When using an ECG rhythm strip to quickly estimate the ventricular rhythm for a client, the nurse should:

use the 3 second markers to count the number of QRS complexes in 6 seconds and multiply by 10

print a 1-minute EGG strip and count the number of QRS complexes

calculate the number of small squares between one QRS complexes and the next one and divide by 1500

count the number of large squares in the R-R interval and divide by 300

Answer and Explanation

The Correct Answer is A

A) Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10:
The 3-second markers on the ECG strip represent a fixed time interval. By counting the number of QRS complexes in the 6-second interval (i.e., two 3-second markers), you can estimate the heart rate by multiplying the number of QRS complexes by 10. This method is quick and effective for calculating heart rate in an emergency setting, such as in arrhythmias or when time is of the essence.

B) Print a 1-minute ECG strip and count the number of QRS complexes:
While this is another way to assess the heart rate, it is not a quick method, especially in emergency situations. It is more time-consuming because it involves printing out a full strip (or ensuring you have enough data to calculate a full minute). This approach may be useful for detailed analysis but is not optimal for quickly estimating the ventricular rhythm.

C) Calculate the number of small squares between one QRS complex and the next one and divide by 1500:
This method is more complex and is used for calculating the heart rate with a more precise ECG reading. It requires counting the number of small squares between two QRS complexes and dividing by 1500 (the number of small squares in one minute). This method is accurate but not the fastest option for quickly estimating the heart rate during an emergency.

D) Count the number of large squares in the R-R interval and divide by 300:
counting the number of large squares between two R-R intervals and dividing by 300, you get the heart rate. However, this method is less commonly used in emergency situations because it requires more time and may not be as immediate as using the 3-second markers. It is more applicable when doing a detailed analysis of the rhythm.

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Correct Answer is A

Explanation

A) Dyspnea, crackles, hypertension, and edema:
These symptoms suggest a transfusion-related acute lung injury (TRALI) or circulatory overload (TACO), both of which are potentially life-threatening conditions. In cases of TRALI or TACO, the nurse should stop the transfusion immediately but should NOT administer 0.9% normal saline because saline could exacerbate fluid overload and worsen pulmonary edema. Instead, the nurse should focus on managing respiratory distress, ensuring proper oxygenation, and notifying the healthcare provider for further intervention.

B) Low back pain, hypotension, and tachycardia:
These symptoms are typically indicative of a hemolytic transfusion reaction (HTR), which requires immediate intervention. In this case, the transfusion should be stopped immediately, but the nurse should begin administering 0.9% normal saline to help maintain the patient's blood pressure and promote kidney perfusion to prevent renal damage.

C) Urticaria, itching, wheezing, angioedema:
These symptoms are characteristic of a mild allergic reaction to the blood transfusion. In this case, the nurse should stop the transfusion and administer 0.9% normal saline to maintain the patient’s hydration and blood pressure while managing the allergic reaction. The healthcare provider may order antihistamines or corticosteroids to treat the allergic symptoms.

D) Chest tightness, fever, chills/rigors:
These are common symptoms of a febrile non-hemolytic transfusion reaction (FNHTR), which is generally not life-threatening. The nurse should stop the transfusion but can continue administering 0.9% normal saline to support hydration and circulation. FNHTR is often managed with antipyretics (e.g., acetaminophen) to reduce fever and chills, and the transfusion may be resumed if symptoms resolve

A. Blood pressure 102/78 B. Pulse oximetry 95% C. Crackles at bilateral bases D. Heart rate 105 beats per minute

Correct Answer is C

Explanation

A) Blood pressure 102/78:
This blood pressure is within an acceptable range, especially after resuscitation with fluids and blood products. While hypotension is a concern in hypovolemic shock, this blood pressure is stable and does not indicate an immediate need for intervention. Blood pressure monitoring is essential, but this finding is not as urgent as other options.

B) Pulse oximetry 95%:
A pulse oximetry reading of 95% is generally considered within normal limits for a patient who has undergone resuscitation and is stable. Oxygen saturation levels should be monitored, but this finding does not indicate an immediate need for intervention. Values below 90% would be more concerning, especially in trauma patients, but 95% is acceptable.

C) Crackles at bilateral bases:
The presence of crackles at the bilateral lung bases is a sign of pulmonary edema, which can occur as a result of fluid overload, especially after aggressive resuscitation with fluids like lactated Ringer's solution (LR) and blood products. In hypovolemic shock, rapid infusion of fluids can overwhelm the heart's ability to handle the volume, leading to fluid accumulation in the lungs. This finding is concerning because it can indicate a shift from hypovolemic shock to a state of volume overload, which can worsen respiratory function and lead to acute respiratory distress syndrome (ARDS).

D) Heart rate 105 beats per minute:
A heart rate of 105 beats per minute is slightly elevated but can be expected in a patient who has experienced trauma and is undergoing fluid resuscitation. Tachycardia is often seen in hypovolemic shock as the body compensates for decreased circulating volume. While monitoring the heart rate is important, this finding does not indicate an immediate life-threatening concern compared to crackles in the lungs, which suggest pulmonary edema.

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When using an ECG rhythm strip to quickly estimate the ventricular rhythm for a client, the nurse should:

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Naxlex Comprehensive Predictor Exams

The nurse is monitoring a patient receiving a blood transfusion. For Which symptoms would the nurse stop the transfusion but NOT administer 0,9% normal saline?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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