The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, P-R interval not measurable, ventricular rate 162, R-R interval regular, QRS complex wide and QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as

ventricular tachycardia.

ventricular fibrillation.

sinus tachycardia.

atrial flutter.

Answer and Explanation

The Correct Answer is A

A. Ventricular tachycardia is characterized by a ventricular rate >100 bpm, regular rhythm, no visible P waves, and wide QRS complexes (>0.12 seconds). The findings described—ventricular rate of 162, regular R-R intervals, no visible P waves, and a QRS duration of 0.18 seconds—are consistent with ventricular tachycardia.
B. Ventricular fibrillation shows a chaotic, irregular rhythm with no identifiable QRS complexes, which is not the case here.
C. Sinus tachycardia would have visible P waves and a normal QRS duration.
D. Atrial flutter typically has "sawtooth" flutter waves and a more organized atrial rhythm with a distinct P wave pattern, which is absent in this scenario.

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Correct Answer is D

Explanation

A. Sepsis is a general systemic infection that can arise from many sources but is not the specific concern addressed by prophylactic antibiotics in valve replacement patients.
B. Otitis media (middle ear infection) is unrelated to dental or surgical procedures and not a concern in valve replacement clients.
C. Deep vein thrombosis (DVT) is prevented with anticoagulants and mobility, not antibiotics.
D. Bacterial endocarditis is a serious infection of the heart's inner lining or valves. Clients with valve replacements are at increased risk, especially during procedures like dental work that may introduce bacteria into the bloodstream. Antibiotic prophylaxis is essential to prevent this potentially life-threatening condition.

A. Increased respiratory rate B. Hypotension C. Anuria D. Decreased level of consciousness

Correct Answer is A

Explanation

A. Increased respiratory rate – Tachypnea (increased respiratory rate) is often the earliest compensatory sign of shock as the body attempts to correct metabolic acidosis and hypoxia by increasing oxygen intake and carbon dioxide removal.
B. Hypotension – Occurs later in the shock progression, typically when compensatory mechanisms fail.
C. Anuria – Indicates prolonged or severe shock leading to organ failure, not an early finding.
D. Decreased level of consciousness – A later sign, suggesting impaired cerebral perfusion due to worsening shock.

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Naxlex Comprehensive Predictor Exams

A nurse providing postoperative teaching to a client who has received a valve replacement discusses the importance of antibiotic prophylaxis prior to any dental or surgical procedure. The nurse understands that antibiotic prophylaxis prevents which of the following in these clients?

Correct Answer is D

Explanation

A nurse is caring for a client who is at risk for developing shock. Which of the following findings is the earliest indicator that this complication is occurring?

Correct Answer is A

Explanation

After receiving report on the following clients, which client should the nurse assess first?

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

The nurse is monitoring a client in the post-anesthesia care unit (PACU) following a coronary artery bypass graft, observing a regular ventricular rate of 82 beats/min and "sawtooth" P waves with an atrial rate of approximately 300 beat/min. How does the nurse interpret this rhythm?

A nurse is providing discharge teaching to a client who has a new diagnosis of Class I heart failure. Which of the following instructions should the nurse include in the teaching?

A cardiopulmonary resuscitation (CPR) instructor is presenting a health care provider CPR course. The instructor reviews the ABCDs of basic CPR, which

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is preparing to administer warfarin to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following?