The nurse is caring for a patient whose cardiac monitor shows a total absence of electrical impulse as indicated by a flat line. The nurse does not detect a pulse or blood pressure. The nurse would document this as which of the following rhythms?

Atrial fibrillation

Asystole

Ventricular fibrillation

Atrial flutter

Answer and Explanation

The Correct Answer is B

A.   Atrial fibrillation is characterized by rapid, irregular electrical impulses originating from the atria, resulting in a quivering or fibrillating motion of the atria rather than a coordinated contraction.
B.   Asystole is the absence of any electrical activity on the cardiac monitor, resulting in a flat line. It indicates the absence of ventricular contraction and is considered a medical emergency requiring immediate intervention (CPR and advanced cardiac life support).
C.   Ventricular fibrillation is characterized by chaotic, disorganized electrical activity in the ventricles, resulting in ineffective quivering of the ventricles and loss of cardiac output.
D.   Atrial flutter is characterized by rapid but regular electrical impulses originating from the atria, resulting in a sawtooth pattern on the ECG tracing.

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Correct Answer is D

Explanation

A. Facial flushing is not typically associated with end-stage kidney disease and waiting for transport to dialysis. It may be indicative of other conditions such as fever, allergic reactions, or hormonal changes.
B. Hypotension is not a common finding in patients with end-stage kidney disease.

These patients often experience hypertension due to fluid overload and electrolyte imbalances.
C. Diaphoresis, or excessive sweating, is not typically associated with end-stage kidney disease and waiting for transport to dialysis. It may occur in response to other factors such as fever, pain, or anxiety.

D. Peripheral edema, or swelling in the extremities, is a common finding in patients with end-stage kidney disease due to fluid retention and impaired fluid balance regulation.

A. "The pain occurs as a residual pain from cholecystitis." B. "The pain results from lying in one position too long during surgery." C. "The pain is caused from the nitrous dioxide injected into the abdomen." D. "The pain will dissipate if you ambulate frequently."

Correct Answer is D

Explanation

A. Postoperative pain typically resolves after a laparoscopic cholecystectomy since the surgery removes the gallbladder
B. While positioning during surgery can cause discomfort, isolated right shoulder pain is more commonly attributed to the diaphragmatic irritation from residual nitrous oxide in the abdomen.

C. Nitrous dioxide used during laparoscopic procedures is not associated with referred pain to the right shoulder. The pain is due to carbon dioxide gas used during the procedure resulting in the irritation of the diaphragm.
D. This pain is often due to the carbon dioxide used to inflate the abdomen during surgery, which can irritate the diaphragm and refer pain to the shoulder. Ambulation helps to absorb the gas more quickly.

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The nurse is caring for a patient whose cardiac monitor shows a total absence of electrical impulse as indicated by a flat line. The nurse does not detect a pulse or blood pressure. The nurse would document this as which of the following rhythms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has end-stage kidney disease and is waiting for transport to dialysis. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A nurse is collecting data from a client who has leukemia. Which of the following findings has the highest priority?

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The nurse is caring for a patient whose cardiac monitor shows a total absence of electrical impulse as indicated by a flat line. The nurse does not detect a pulse or blood pressure. The nurse would document this as which of the following rhythms?

A patient with a cardiac disorder is having increased premature ventricular contractions and feels "anxious" and short of breath. After vital signs are obtained, what actions should the nurse take? Select all that apply.

A nurse is reinforcing discharge teaching with a client who is postoperative for a traditional cholecystectomy and has a T-tube in place. Which of the following instructions should the nurse include in the teaching?