M/S practice questions
The nurse knows that discharge teaching about the management of a new permanent pacemaker has been most effective when the patient states
"I won't lift the arm on the pacemaker side until I see the health care provider."
The nurse evaluates that discharge teaching about the management of a new permanent pacemaker has been effective when the patient states...
"I wont life the arim on the pacemaker side until I see the healthcare provider"
Which topic is most important to inclue in teaching for a 41-year-old patient diagnosed with early alcoholic cirrhosis?
Avoiding all alcohol use
The nurse is caring for a patient who has a massive burn injury and possible hypovolemia. Which assessment data should be of most concern to the nurse?
Blood pressure is 90/40 mm Hg.
The nurse is caring for a client who is postoperative following a pelvic exenteration, and the surgeon changes the client's diet from NPO status to clear liquids. The nurse should check which priority item before administering the diet
Bowel sounds
Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia?
Having the patients family member administer the medication
A patient reports leg cramps during hemodialysis. What action should the nurse take?
Infuse a bolus of normal saline
GERD positioning
Left side, HOB 30 degrees
The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea as is extremely restless. Which is thet priority nursing action?
Notify the PHCP
Which prescribed medication should the nurse expect will have rapid effects on a patient admitted to the emergency department in thyroid storm?
Propanolol
A 53-year-old man is scheduled for an annual physical exam. The nurse will plan to teach the patient about the purpose of?
Prostate-specific antigen (PSA) testing
What is one of the most challenging nursing interventions to promote healing in patients with viral hepatitis?
Providing adequate nutritional intake
The nurse has just auscultated course crackles bilaterally on a patient with a tracheostomy tube in place. If the patient is unsuccessful in coughing up secretions, what action should the nurse take?
Put on sterile gloves and used a sterile catheter to suction
Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient
Risk for aspiration
To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually? Select all the apply
- Blood pressure - Serum creatinine - Urine for microalbuninuria - Monofilament testing of the foot
The client has developed atrial fibrillation, which a ventricular rate of 150 beats per minute. The nurse should assess the client for which associated signs and/or symptoms. Select all the apply
- Syncope - Dizziness - Palpitations
Which patient is the most appropriate for the ICU charge nurse to assign to a registered nurse who has floated from the medical unit?
45-year-old receiving IV antibiotics for meningococcal meningitis
A patient admitted with a possible stroke has been aphasic for 3 hours, and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question?
Administer labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg
Before assisting a patient with ambulation 2 days after total hip arthroplasty, which action is most important for the nurse to take?
Administer prescribed pain medication
The nurse is caring for a client admitted to the emergency department with DKA. In the acute phase, the nurse plans for which priority intervention?
Administer short-duration insulin IV
A patient was admitted with diabetic ketoacidosis has rapid, deep respirations, which action should the nurse take?
Administer the prescribed fluid bolus and insulin
What risk factor will the nurse specifically ask about when a patient is being admitted with acute pancreatitis?
Alcohol use
The nurse is concerned about a postoperative patients risk for injury during an epidose of delirium. What is then nurse's most appropriate action?
Assign UAP to stay with and reorient the patient
The nurse is developing a plan of care for a client who is scheduled for a thyroidectomy. The nurse focuses on psychosocial needs, knowing that which is likely to occur in the client?
Body image changes
The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions?
"I should sleep on my left side"
A patient is admitted to the PACU with a blood pressure of 122/72. 30 minutes after the admission the BP is 114/62 with a pulse of 74 and warm, dry skin. What action by the nurse is most appropriate?
Continue to take vital signs every 15 minutes
A 68-year-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), the nurse will plan to do frequent assessments of the patient's
Breath Sounds
What should the nurse include when teaching older adults at a community recretion center about ways to prevent fractures?
Buy shows that provide good support and are comfortable to wear
Which information should the nurse include in discharge instructions for a patient with communited left foream fractures and a long-arm cast
Call the healthcare provider for numbness of the hand
Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is accurate?
Changes in diet and esercise may control blood glucose levels in type 2 diabetes
During routine hemodialysis, a patient reports nausea and dizziness. Which action should the nurse take first?
Check the blood pressure
When taking the BP on the right arm of a patient who has severe acute pancreatitis, the nurse notices carpal spasms of the patients right hand. Which action should the nurse take next?
Check the calcium level in the chart
A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first?
Check the oxygen saturation
A 70-year-old patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?
Check the respiratory rate and effort
Which patient choice for a snack 3 hours before bedtime indicates that the nurse's teaching about GERD has been effective?
Cherry gelatin with fruit
A client has experienced a pulmonary embolism, the nurse should assess for which symptoms are most commonly reported.
Chest pain that occurs suddenly
A client is admitted with jaundice and suspected hepatitis B. Which intervention does the nurse add to the client's care plan?
Encourage rest during this period
The nurse administered 4 oz of orange juice to an alert patient whose blood glucose level was 62 mg/dL. Fifteen minutes later the blood glucose is 67mg/dL. Which action should the nurse take next?
Give the patient 4 to 6 oz more orange juice
The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. What action should the nurse take next?
Give the patient 4 to 6 oz more orange juice
The nurse is caring for a patient who has just arrived on the telemetry unit after having cardiac catheterization. What task should the nurse delegate to a LPN/LVN?
Give the scheduled aspirin and lipid-lowering medication
An adult male with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. Which laboratory data would the nurse identify as consistent with these symptoms?
Hgb of 8.6 g/dL
The nurse is planning care for a patient with severe heart failure who has developed increased BUN and creatinin levels. What will be the primary treatment goal in the plan?
Maintining cardiac output
During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?
Measure hourly urine output
A patients heart monitor shows sinus rhythm, rate of 64. The PR interval is 0.18 seconds at 0100, 0.22 seconds at 1430, and 0.28 seconds at 1600. Which action should the nurse take first?
Hold the scheduled metoprolol and call the healthcare provider
Which information should the nurse include in discharge teaching for a patient who has had a repair of a fractured mandible?
How and when to cut the immobilizing wires
A patient with burns covering 40% total body surface area is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient?
Milkshake
The nurse is reviewing an ECG rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complex measures 0.06 seconds. The overall heart rate is 64 beats per minute. Which action should the nurse take
Monitor for any rhythm change
An 82-year-old man is admitted with an acute attack of diverticulitis. What should the nurse include in his care?
Monitor for signs of peritonitis
A patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care?
Monitor the patient for SOB
Which assessment finding would the nurse need to report most quickly to the healthcare provider regarding a patient who has acute pancreatitis?
Muscle twitching and finger numbness
The nurse determines that a client requires further teaching after permanent pacemaker insertion if which statement is made?
My pulse rate should be less than what my pacemaker is set at
A patient with left-sided weakness that started 60 minutes earlier is admitted to the ED and diagnostic tests are ordered. Which test should be done first?
Noncontrast computed tomography (CT) scan
The emergency department nurse is evaluating the outcomes for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective?
O2 saturation is >90%
A patient who was admitted with DKA secondary to a UTI has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first?
Obtain a glucose reading using a finger stick
A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess which manifestations of this complication?
Pallor, diminished pulse, and pain in the left hand
Which assessment finding in a patient who has had coronary artery bypass grafting using a right radial artery graft is most important for the nurse to communicate to the healthcare provider?
Pallow and weakness on the right hand
Which assessement finding is of most concern for a patient with acute pancreatitis?
Palpable abdominal mass
The nurse is monitoring a client newly diagnosed with diabetes for signs of complications. Which signs or symptoms, if frequently exhibited in the client, indicate that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed?
Polyuria
A patient with aortic stenosis has acute pain due to decreased coronary blood flow. What would be an appropriate nursing intervention for this patient?
Promote rest to decrease myocardial oxygen demand
The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the HCP?
Purple discoloration of the stoma
The nurse at the eye clinic made a follow-up telephone call to a patient who underwnt cataract extraction and intraocular lens implantation the previous day. Which information is the priority to communicate to the HCP?
The patient reports eye pain rated 5 (on a 0 to 10 scale)
Which information will the nurse include in the teaching plan for a patient newly diagnosed with asthma?
Tremors are an expected side effect of rapidly acting bronchodilators
The nurse is caring for a patient with aortic stenosis. Which assessment data would be most important to report to the healthcare provider
The patient reports chest pressure when ambulating
The nurse is planning to teach a client with GERD about substances to avoid. Which items should the nurse include on this list? Select all the apply
- Coffee - Chocolate - Peppermint - Fried chicken
During the change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first?
55-year-old with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C)
A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. The patient reports that joint discomfort prevents favorite activities such as taking a daily walk and sewing. What problem should be the focus of nursing interventions?
Activity intolerance related to arthralgia
The nurse has provided self-care activity instructions to a client after insertion of an implanted cardioverter-defibrillator (ICD). The nurse determines that further instruction is needed if the client makes which statement?
I can perform activities such as swimming, driving, or operating heavy equipment as I need to.
The nurse assess a patient whith pernicious anemia. Which finding would the nurse expect?
Tender, bleeding gums
What information will the nurse include when teaching a patient scheduled for a radiofrequency catheter ablation to treat atrial flutter?
The procedure will use electrical energy to destroy areas of the conduction system
Hip replacement positioning
- Avoid internal rotation use a wedge pillow - Avoid flexion of hip > 90 degrees - Avoid adduction (leg crosses midline) - Have spouse put on shoes.
The client with obstructive jaundice asks the nurse why his skin is so itchy. Which is the nurse's best response?
"Bile salts accumulate in the skin and cause itching."
A patients CBC shows a Hgb of 19g/dL and a Hct of 54%. Which question should the nurse ask to determine possible causes of this finding?
"Do you hae any history of lung disease?"
The nurse is evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery. Which patient statement indicates that additional teaching is needed?
"I will have incisions in my leg whre they will remove the vein"
Which information will the nurse include when teaching a patient with newly diagnosed gastroesophageal reflux disease (GERD)?
"It will be helpful to keep the head of your bed elevated on blocks."
A client with chronic kidney disease being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious, and the nurse suspects an air embolism. What are the priority nursing actions? Select all that apply
- Administer oxygen to the client - Notify the PCHP and rapid response team - Stop dialysis, and turn the client on the left side with head lower than feet
A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply.
- Assess for airway patency - Administer oxygen as prescribed - Elevate extremities if no fractures are present
The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measure should the nurse include in the plan? Select all that apply
- Avoid activities that require bending over - Take acetaminophen for minor eye discomfort - Place an eye shield on the surgical eye at bed time - Contact the surgeon if a decrease in visual acuity occurs
Which intervention will be included when the nurse is teaching self-management to a patient who is receiving peritoneal dialysis? Select all that apply
- Avoid commercial salt substitutes - Take phosphate binders with each meal - Choose high-protein foods for most meals
A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply.
- Contact the surgeon - Instruct the client to remain quiet - Prepare the client for wound closure - Document the findings and actions taken
The nurse is assessing the functioning of a chest tube drainage system in a client with a chest injury who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply.
- Drainage system maintained below the client chest - 50mL of drainage in the drainage collection chamber - Occulsive dressing in place over the best tube insertion site - Fluctuation of water on the tube in the water seal chamber during inhalation and exhalation
The nurse is planning care for a client with deep vein thrombosis of the right leg. Which interventions would the nurse anticipate the physician to most likely prescribe? Select all that apply.
- Elevation of the right leg - Administration of acetaminophen - Application of moist heat to the right leg - Monitoring for signs of pulmonary embolism
Fistulas
- Feel for the thrill and bruit - Lower risk of clots compared to a graft
A client with a diagnosis of Addisonian crisis is being admitted to the ICU. which findings will the interprofessional healthcare team focus on? Select all the apply
- Hypotension - Hyperkalemia
A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is melanoma. The nurse understands that melanoma has which characteristics? Select all the apply
- Lesion is highly metastatic - The lesion is a nevus that has changes in color
The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply
- Loosen restrictive clothing - Remove the pillow and raise padded side rails - Position the client to the side, if possible, with the head flexed forward
A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions? (Put a comma and a space between each answer choice [A, B, C, D]).
1. Administer IV antibiotics. 2. Administer acetaminophen (Tylenol). 3. Sponge the patient with cool water. 4. Perform wet-to-dry dressing change.
Which assessment finding in a 36-year-old patient is most indicative of a need for further evaluation?
A breast nodule that is 1cm in size, non-tender, and fixed
The nurse employed in a cardiac unit determines that which client is the least likely to have an implanted cardioverter-defibrillator (ICD) inserted?
A client with an episode of cardiac arrest related to myocardial infarction
The nursing instructor asks a nursing student to identify the risk factors associated with the development of thyrotoxicosis. The student demonstrates understanding of the risk factors by identifying an increased risk for thyrotoxicosis in which client?
A client with graves disease who is having surgery
The nurse is assessing health fair participants for risks for hepatitis. Does the nurse recognize which client as being at the greatest risk for developing hepatitis B?
A college student who has had several sexual partners
A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft?
A fistula is much less likely to clot
A patient is scheduled for a cardiac catheterization with coronary angiography. What information should the nurse provide before the procedure?
A flushed feeling is common when the contrast dye is injected
After receiving change-of-shift report on four patients, which patient should the nurse assess first?
A patient with acute aortic regurgitation whose blood pressure is 86/54 mmHg
A young adult patient who denies any history of smoking is seen in the clinic with a new diagnosis of COPD. What topic should the nurse plan to teach the patient?
A1-antitrypsin testing
A patient with acute pancreatitis is NPO and has a NG tube to suction. Which information obtained by the nurse indicates that these therapies have been effective?
Abdominal pain is decreased
The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority?
Activation status of the device, heart rate cutoff, and number of shock it is programmed to deliver
A 40-year-old male patient has had a herniorrhaphy to repair an incarcerated inguinal hernia. Which patient teaching will the nurse provide before discharge?
Apply scrotal support and ice to reduce swelling
A patient will attempt oral feedings for the first time after having a stroke. After assessing the gag reflex, what action should the nurse take?
Assist the patient into a chair
A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care?
Assist the patient to eat with the right hand
The nurse should instruct a patient with a nondisplaced fractured left radius that the cast will need to remain in place what what amount of time?
At least 6 weeks
The nurse notes that a client's cardiac rhythm shows absent P waves, no PR interval and an irregular rhythm. How should the nurse interpret this rhythm
Atrial fibrillation
Which information about a patient with Goodpasture syndrome requires the most rapid action by the nurse
Audible crackles bilaterally over the posterior chest to the midscapular level
A client has just been admitted to the nurse unit following a thyroidectomy. Which assessment is the priority for this client?
Audible stridor
Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after the insertion of a centrally inserted IV catheter?
Auscultate the patient's breath sounds
A patient is scheduled for transsphenodial hypophysectomy to treat a pituitary ademona. What should the nurse include in preoperative teaching?
Avoid brushing teeth for at least 10 days after the surgery
Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure?
BNP
The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included?
Bed rest with elevation of the affected extremity
A client is admitted with end-stage cirrhosis and severe vomiting. Which problem should the nurse monitor the client most carefully for?
Bleeding esophageal varices
The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?
Blood pressure is 90/40mmHg
An active 32-year-old male who has type 1 diabetes is being seen in the endocrine clinic. Which finding indicates a need for the nurse to discuss a possible change in therapy with the HCP?
Blood pressure of 140/88
A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect?
Bloody
A patient who has been in the intesive care unit for 4 days has disturbed sensory perception from sleep deprivation. Which action should the nurse include in the plan of care?
Cluster nursing activities so that the patient has uninterrupted rest periods
Which finding by the nurse will be most helpful in determining whether a 67-year-old patient with BPH has a upper UTI?
Costovertebral tenderness
A patient has a magnesium level of 1.3mg/dL. Which assessment would help the nurse identify a likely cause of this value.
Daily alcohol intake
A patient with multiple draining wounds is admitted for hypovolemia. What would be the most accurate way for the nurse to evaluate fluid balance?
Daily weight
The nurse is assessing a male patient diagnosed with a pituitary tumor causing panhypopituitarism. Which assessment finding is consistent with panhypopituitarism?
Decreased facial hair
The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient's condition has improved?
Decreased peripheral edema
What concern should the nurse anticipate for a patient who has a right hemisphere stroke?
Denial of deficits and impulsiveness
A patient being admitted with a stroke has right-sided facial drooping and right-sided arm and leg paralysis. Which finding should the nurse expect?
Difficulty comprehending instructions
Which problem should the nurse anticipate for a patient admitted to the hospital with diabetes insipidus?
Distubered sleep pattern
During the physical examination, the nurse cannot feel the patient's thyroid gland. What action should the nurse take?
Document that the thyroid was nopalpable
A patient has a sinus rhythm and a heart rate of 72 beats/min. The nurse determines that the PR interval is 0.24 seconds. What action should the nurse take?
Document the finding and monitor the patient
Which test should the nurse anticipate discussing with a patient who has a possible seizure disorder?
Electroencephalophalography (EEG)
The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a post-operative plan of care for the client and should include which intervention in the plan?
Elevate and immobilize the grafted extremity
The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing?
Encouraging active range-of-motion exercises
The nurse is caring for a patient who is using bucks traction after a hip fracture. Which action can the nurse delegate to experienced UAP?
Ensure the weight for the traction is hanging freely
The registered nurse (RN) is educating a new nurse about aortic regurgitation. Which statement by the new nurse indicates that the teaching has been effective?
Failures of the aortic valve to close completely allows blood to flow retrograde through the aorta to the left ventricule
What potential cause of infection will the nurse consider in the plan of care for a patient immediately after a perineal radical prostatectomy?
Fecal wound contamination
The nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which signs or symptoms, if noted in the client, will alert the nurse to the presence of this crisis?
Fever and tachycardia
A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. The nurse should know that this history is consistent with what type of seizure?
Focal-onset
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth?
Full-thickness skin destruction
A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from noe. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient?
Glycosylated hemoglobin
The nurse is instructing a client with diabetes about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication?
Hyperglycemia
A patient who has GERD is experiancing increasing discomfort. Which patient statement to the nurse indicates that addition teaching about GERD is needed?
I eat small meals and have a bedtime snack
When assessing a patient who has a right frontal lobe tumor, what finding should the nurse expect?
Impaired judgement
A patient has just been admitted with a 40% TBSA burn injury. To maintain adequate nutrition the nurse should plan to take which action?
Insert a feeding tube and initiate enteral nutrition
The day shift nurse at the long-term care facility learns during the morning report that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which action should the nurse take?
Keep blinds open during the daytime hours
Which information will the nurse provide for a patient with newly diagnosed GERD?
Keep the head of your bed elevated on blocks
Which information about a patient with a lumbar vertebral compression fracture should the nurse immediately report to the healthcare provider?
Patient has been incontinent of urine and stool
After recieving change-of-shift report, which patient should the nurse assess first?
Patient with serum magnesium level 1.1 mEq/L who has tremors and hyperactive reflexes
The home health registered nurse is planning for a patient with seizure disorder related to a recent head injury. Which action can the nurse delegate to a LPN/LVN?
Place medications in the home medication organizer
A patient is being scheduled for ERCP as soon as possible. Which prescribed action should the nurse take first?
Place the patient on NPO status
A 27-year-old patient admitted with DKA has a serum glucose level of 732 mg/dL and a potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse take first?
Place the patient on a cardiac monitor
A patient admitted with AKI due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed action should the nurse take first?
Place the patient on a cardiac monitor
Which menu choice by the patient who is receiving hemodialysis indicates that the nurse's teaching has been successful
Poached eggs, whole-wheat toast, and apple juice
A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take?
Prepare the patient for a skin biopsy
Which assessment finding should the nurse expect when a patient with AKI has an arterial blood pH of 7.30?
Rapid, deep respirations
What should the nurse ask the patient about to determin possible causes of acute glomerulonephritis?
Recent sore throat and fever
After the insertion of an arteriovenus graft in the right forearm, a patient reports pain and coldness of the right fingers. Which action should the nurse take?
Report the patients symptoms to the HCP
A hospitalized patient who is diabetic recieved 38 U of NPH insulin at 0700. At 1300 the patient has been away from the nursing unit for 2 hours, missing lunch delivery while awaiting a chest x-ray. What is the best action by the nurse to prevent hypoglycemia?
Request that if testing is further delayed, the patient will eat lunch first
The nurse will assess an older patient who takes diuretics and has a possible urinary tract infection (UTI). Which action should the nurse take first?
Request the patient empty the bladder.
The home health nurse is caring for an 81-year-old who had a stroke 2 months ago. Based on the information shown in the accompanying figure from the history, physical assessment, and physical therapy/occupational therapy, which nursing diagnosis is the highest priority for this patient?
Risk for caregiver role strain
Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain?
ST-segment elevation
A patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate?
Schedule the patient for HCV genotype testing.
Which assessment finding alerts the nurse to provide patient teaching about cataract development?
Sensitivity to light
A client with type 1 diabetes mellitus is admitted to the emergency department with suspected diabetic ketoacidosis (DKA). Which laboratory result would be expected with this diagnosis?
Serum potassium is 6.8
A client's ECG strip shows atrial and ventricular rates of 110 beats per minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse interpret this rhythm
Sinus tachycardia
A patient is admitted to the ED with a left lower femur fracture. Which assessment finding by the nurse is most important to report to the HCP?
Slow capillary refill of the left foot
The nurse is listening to a lecture about angina. Which statement by the nurse indicates that the teaching has been effective?
Stable angina is chronic
During assessment of the patients skin, the nirse obserces a similar pattern of discrete, small, raised lesions on the left and right upper back areas. Which term should the nurse use to document the distribution of these lesions?
Symmetric
A patient who has hyperthyroidism is treated with radioactive iodine. What information should the nurse include in discharge teaching?
Symptoms of hypothyroidism will occur as the RAI therapy takes effect
A female patient with a suspected UTO is to provide a clean-catch urine specimen for culture and sensitivity testing. What should the nurse do to obtain the specimen?
Tell the patient to clean the uretheral area, void a small amount into the toilet, then void directly into a sterile container
Following a thyroidectomy, a patient reports "a tingling feeling around my mouth" which assessment should the nurse complete first?
Test for presence of chovosteks sign
The nurse is reviewing the 12-lead electrocardiograph for a healthy older adult patient who is having an annual physical examination. What finding should be of most concern to the nurse?
The heart rate is 41 beats/min
The charge nurse observes a newly hired nurse performing all the following interventions for a patient who has just undergone right cataract removal and an intraocular lens implant. Which action requires that the charge nurse intervene?
The nurse encourages the patient to cough
Which action by a nurse caring for a patient after an implantable cardioverter-defibrillaror (ICD) insertion indicates a need for more teaching about the care of patients with ICDs?
The nurse encourages the patient to do active range-of-motion esercises for all extremities
When admitting a patient for a cardiac catheterization and coronary angiogram, which information about the patient is important for the nurse to communicate to the health care provider before the test?
The patient is allergic to shellfish
The nurse is caring for a patient admitted with DI. Which information is most important to report to the health care provider
The patient is confused and lethargic
The nurse teaches a patient about pursed lip breathing. Which action by the patient indicates a need for further teaching of pursed-lip breathing?
The patient puffs up the cheeks while exhaling
A patient who had a total laryngectomy has previously expressed hopelessness about the loss of control over personal care. Which information obtained by the nurse indicates that this identified problem is resolved?
The patient asks to learn how to clean the tracheostomy stoma
Which action by a patient who is using peritoneal dialysis indicates that the nurse should provide more teaching about PD?
The patient cleans the catheter while in the bathtub each day
The nurse teaches a patient who has asthma about peak flowmeter use. Which action by the patient indicates that teaching was successful?
The patient uses albuterol for peak flows in the yellow zone
A 62-year-old femal patient has been hospilitized for 4 days with AKI caused by dehydration. Which information will be most important for the nurse to report to the health care provider?
Urine output over an 8 hour period is 2500mL
Which action will help the nurse determine whether a new patient's confusion is caused by dementia or delirium?
Use the confusion assessment method tool
The nurse is assessing a 22-year-old patient experiancing the onset of symptoms of type 1 diabetes. To which question would the nurse anticipate a positive response
"Have you lost any weight lately"
Which patient statement to the nurse indicates that the patient understands self-care for pernicious anemia?
"I could choose nasal spray rather that injections of vitamin B12"
Which statement made by a 50-year-old female patient indicates to the nurse that further assessment of thyroid function may be need
"I feel a lump in my throat when I swallow"
The nurse admits a patient to the hospital in Addisonian crisis. Which patient statement supports the need to plan additional teaching?
"I had the flu earlier this week, so I couldn't take the hydrocortisone."
Which information from a patient hellps the nurse confirm the pervious diagnosis of chronc stable angina?
"The pain goes awat after a nitroglycerin tablet"
The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all the apply
- Check the level of the drainage bag - Reposition the client to her or his side - Place the client in good body alignment - Check the peritoneal dialysis system for kinks
A client with a diagnosis of DKA is being treated in the emergency department. Which finding supports this diagnosis? Select all that apply
- Comatose state - Deep, rapid breathing - Elevated blood glucose level
When caring for a client with an internal radiation implant, the nurse should observe which principles? Select all that apply
- Keeping pregnant women out of the clients' room - Placing the client in a private room with a private bath - Wearing a lead shield when providing direct client care
The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply
- Maintain NPO status - Encourage coughing and deep breathing - Give hydromorphone IV as prescribed for pain
The nurse is developing a plan of care for a client with Addison's disease. The nurse has identified a problem of risk for deficient fluid volume and identifies nursing interventions that will prevent this occurrence. Which nursing interventions should the nurse include in the plan of care? Select all that apply.
- Monitor for changes in mentation - Encourage fluid intake of at least 3000mL per day - Monitor vital signs, skin turgor, and intake and output
A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room? Select all that apply
- Side rail pads - Oxygen mask - Suction tubing
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply.
- The client is aphasic - The client has weakness on the right side of the body - The client has weakness on the right side of the face and tongue
A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment finding would be consistent with acute pancreatitis? Select all that apply
- The grey-blue color on the flank - cullen's sign - Abdominal guardian and tenderness - Left upper quadrant pain with radiation to the back
The nurse is monitoring a client who has been diagnosed with type 1 diabetes and is being treated with NPH and regular insulin. Which manifestation would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply
- Tremors - Irritability - Nervousness
After being hospitilized for 3 days with a right femur fracture, a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" which action should the nurse take first?
Administer prescribed PRN O2 at 4 L/min
A patient is admitted with diabetes insipidus. Which action will be appropriate for the RN to delegate to an experienced LPN/LVN?
Administer prescribed subcutaneous DDVAP
Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens implementation?
Administration of corticosteroid drugs
Which care activity for a patient with a paralytic ileus is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)?
Applying petroleum jelly to the lips
A patient who has a history of COPD was hospitalized for increasing SOB and chronic hypoxemia. In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching?
Arrange for the patient's caregiver to be present during the teaching
A 30-year-old patient has a new diagnoses of type 2 diabetes. When should the nurse recommend the patient schedule a dilated eye examination?
As soon as available
Which action will the nurse include in the plan of care to maintain the patency of a patient's left arm AV fistula?
Ascultate for a bruit at the fistula site
A female patient who had a stroke 24 hours ago has expressive aphasia. What is an appropriate nursing intervention to help the patient comminicate?
Ask questions that the patient can answer with "yes" or "no"
The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence
Ask the client to extend the arms
A 22-year-old patient seen at the health clinic with severe migraine headache tells the nurse about having similar headaches recently. Which initial action should the nurse take?
Ask the patient to keep a headache diary
A patient whi has begun to awaken after 30 minutes in the PACU is restless and shouting at the nurse. The patients oxygen saturation is 96% and recent laboratory results are all normal. Which action by the nurse is most appropriate?
Assess for bladder distention
What should be the nurse's initial action for a patient with moderate dementia who develops increased restlessness and agitation?
Assess for factors that might be causing discomfort
Which action should the nurse take to evaluate the effectiveness of Buck's traction for a patient who has an intracapsular fracture of the right femur?
Assess for hip pain
Which action by the nurse will determine if the therapies ordered for a patient with chronic constrictive pericarditis are effective?
Assess for the presence of jugular venous distention (JVD).
The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which action should the nurse take first?
Assess patient orientation
The nurse notes frank red blood in the drainage container from the nasogastric (NG)tube of a client who is 2 days post-esophagogastrostomy. Which is the nurse's priority intervention?
Assess the client's vital signs and abdomen
A long-term care patient with moderate dementia develops increased restlessness and agitation. The nurse's action should be too?
Assess the patient for anything that might be causing discomfort
When performing a skin assessment, the nurse notes anfiomas on the chest of an older patient. Which action should the nurse take next?
Assess the patient for educence of liver disease
The nurse is preparing to teach a 43-year-old man who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first?
Assess the patient's perception of what it means to have diabetes
A patient has just arrived on the unit after a thyroidectomy. Which action should the nurse take first?
Assess the patients respiratory effort
A pedestrian who was hit by a car and admitted to the ED with possible right lower leg fractures. What initial action should the nurse take?
Assess the pedal pulses
A 71-year-old patient had an abdominal-perineal resection for colon cancer. Which nursing action is most important to include in the plan of care for the day after surgery?
Assess the perineal drainage and incision
Nursing staff on a hospital unit are reviewing rates of healthcare associated infections (HAI) of the urinary tract. Which nursing action will be most helpful in decreasing the risk for urinary HAI in patients admitted to the hospital
Avoiding unnecessary urinary catheterization
A 68-year-old patient with a stroke is unconscuous and unresponsive to stimuli. After learning that the patient has a history of GERD, what should the nurse plan to assess more frequently that is routine?
Breath sounds
During the early post-op period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the intitial nursing action?
Call the surgeon
A nurse is caring for a patient who has burns on the ears, head, neck, and right arm and hand. The nurse should place the patient in which position?
Elevate the right arm and hand on pillows and extend the fingers
The nurse is monitoring a client with diabetes mellitus for signs of hypoglycemia. Which manifestations are associated with this complication?
Elevated pulse; shakiness; cool, clammy skin
A patient who had a total hip replacement has an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect?
Elevated reticulocyte count
A patient is hospitalized with AKI. Which information will be most useful to the nurse in evaluating improvement in kidney function?
GFR
A patient on the telemetry unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the agency dysrhythmia protocol should the nurse do first?
Give supplemental O2 at 2 to 3 L/min via nasal cannula
An older adult patient presents with a broken arm and visible scattered bruises healing at different stages. Which action should the nurse take first?
Have the family member stay in the waiting area while the patient is assessed.
Which question from the nurse during a patient interview will provide focused information about a possible thyroid disorder?
Have you had a recent unplanned weight gain or loss
The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered?
Hemoglobin level
Which statement by the patient who has newly diagnosed type one diabetes indicates a need for additional instruction from the nurse?
I can choose any foods, as long as i use enough insulin to cover the calories
The home health nurse makes a home visit to a client who has an implanted cardioverter-defibrillator (ICD) and reviews the instructions concerning pacemakers and dysrhythmias with the client. Which client statement indicates that further teaching is necessary?
I can stop taking my antidysrhythmic medicine now because I have a pacemaker
The nurse admits a patient to the hospital in addisonian crisis. Which patinet statement supports the need to plan additional teaching?
I had the flu earlier this week, so i couldnt take the hydrocortisone
Which patient statment indicates understanding of the nurses teaching about a new short-arm synthetic cast?
I will apply an ice pack to the cast over the fracture site on and off for 24 hours
The nurse should determine that teaching about migraine headaches has been effective when the patient says which of the following?
I will lie down someplace dark and quiet when the headaches begin
A nurse has provided dietary instructions to a client with Addison's disease. Which statement made by the client indicates that the client understands the instructions?
I will maintain a normal sodium intake in my diet
A nurse is providing home care instructions to a client with a diagnosis of Addison's disease. Which statement by the client indicates a need for further instruction
I will need to take daily medications until my symptoms decrease
The nurse provides instructions to a client newly diagnosed with type 1 diabetes. The nurse recognizes an accurate understanding of measures to prevent DKA when the client makes which statement?
I will notify my primary healthcare provider if my blood glucose level is higher than 250 mmol/L
The nurse admits a patient who has a diagnosis of acute asthma. Which statement indicates that the patient may need teaching regarding medication use?
I've been using my albuterol inhaler frequently over the last 4 days
The nurse has taught the client about an upcoming ERCP procedure. The nurse determines that the client needs further information if the client makes which statement?
Im glad I dont have to lie still for this procedure
The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence?
Inability to pass flatus
The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem?
Inadequate fluid volume
The appropriate collaborative therapy for the patient with acute diarrhea caused by a viral infection is to
Increase fluid intake
While caring for a patient who has been admitted with a PE, the nurse notes a change in this patient's oxygen saturation from 94% to 88% which action should the nurse take?
Increase the prescribed o2
On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2, K 4.9, and Na 135. Which of the following actions should be the nurse's priority?
Increase the rate of the ordered IV solution
A young adult patient is being seen in the clinic with increased secretion of the anterior pituitary hormones. The nurse would expect the laboratory test results to show?
Increased urinary cortisol
A young adult patient who is being seen in the clinic has exessive secretion of the the anterior pituitary hormone. Which laboratory test result should the nurse expect?
Increased urinary cortisol
A patient has just arrived in the PACU after a thyroidectomy. Which information about the patient is most important to communicate to the surgeon?
Increasing neck swelling
A patiinet with diabetic ketoacidosis is brought to the emergency department. Which prescribed action should the nurse implement first?
Infuse 1 L of normal saline per hour
After obtaining the information shown in the accompanying figure regarding a patient with Addison's disease, which prescribed action will the nurse take first?
Infused 5% dextrose and 0.9% saline
A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia
It can develop into ventricular fibrillation at any time
The nurse is caring for a client after thyroidectomy. The client expresses concern about the postoperative voice hoarseness she is experiencing and asks if the hoarseness will subside. The nurse should provide the client with which information?
It is normal during this time and will subside
A patient with cancer of the stomach at the lesser curvature undergoes a total gastrectomy with an esophagojejunostomy. postop, what would the nurse teach the patient to expect?
Lifelong administration of cobalamin
The nurse is caring for a client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. Which activity will assist with preventing dislodgement of the pacing catheter?
Limiting both movement and abduction of the right arm
Which laboratory test result will the nurse monitor to evaluate the effects of therapy for a patient who has acute pancreatitis?
Lipase
A patient is disgoned with moderate dementia after multiple strokes. What would the nurse expect to find during assessment of the patient?
Loss of recent and long-term memory
The nurse is reviewing the lab results for a patient with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be prescribed for this patient?
Low-protein
Nursing management of the patient with chronic gastritis includes teaching the patient to?
Maintain a nonirritating diet with six small meals a day
The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse would include which intervention in the plan?
Maintain activity level as prescribed
The nurse is planning care for a patient with acute severe panccreatitis. What is the highest priority patient outcome?
Maintaing normal respiratory function
What treatment measure is used in the management of the patient with acute pancreatitis?
Nasogastric (NG) suction to prevent gastric contents from entering the duodenum
Which finding by the nurse when assessing a patient with a large pituitary adenoma is most important to report to the healthcare provider?
Nausea and projectile vomiting
A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased, and no wheezes are audible. What action should the nurse take?
Notify the HCP and prepare for intubation
A patient with COPD has been eating very little and has lost weight. Which intervention would be most appropriate for the nurse to include in the plans of care?
Offer high-calorie protein snacks between meals and at bedtime
The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client?
On the nonoperative side with the legs abducted
The healthcare provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with venus thromboembolism of the left lower leg. Which action by the nurse is best?
One pillow is placed under the thighs and 2 pillow are under the lower legs
The nurse is assessing the patency of a client's left arm AV fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent?
Palpation of a thrill over the fistula
The intensive care unit (ICU) nurse educator will determine that teaching about arterial pressure monitoring for a new staff nurse has been effective when the nurse?
Positions the zero-reference stopcock line level with the phlebostatic axis.
The nurse assesses a circular, flat, reddened lesion about 5cm in diameter on a middle-aged patients ankle. How should the nurse determine if the lesion is related to intradermal bleeding?
Press firmly on the lesion
A patient who has a C7 spinal cord injury 1 week ago has a weak cough effort and crackles. The initial intervention by the nurse should be too?
Push upward on the epigastric area as the patient coughs
Which finding from a newly admitted adult patient;'s ECG requires futher investigation by the nurse?
QRS interval of 0.14 second
What intervention will the nurse include in the plan of care for a patient with moderate dementia who is admitted for other health problems?
Remind the patient frequently about being in the hospital
The nurse assesses a patient with COPD who has been admitted after increasing dyspnea over the past 3 days. Which finding is important for the nurse to report to the healthcare provider?
Respirations are 36 breaths/minute
Which intervention will be included in the plan of care for a patient with AKI who has temporty vascular access catheter in the left femoral vein
Restrict physical activity to bed rest
Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)?
Review the patient's current medication list
Which nursing action will be included in the plan of care for a patient who has recently been diagnosed with asymptomatic nonalcohol fatty liver disease (NAFLD)
Review the patient's current medication list
An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on a 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next?
Set up the patient-controlled analgesia (PCA) and administer the loading dose of morphine.
The nurse is caring for a client with a diagnosis of addison's disease and is monitoring the client for signs of addisonians crisis. The nurse should assess the client for which manifestation that would be associated with this crisis
Severe abdominal pain
The nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis. The nurse will direct the assessment to look for which as a hallmark sign of this disorder?
Severe abdominal pain that is unrelieved by vomiting
A registered nurse is caring for a patient with a goiter and possible hyperthyroidism. Which action by the RN indicates that the charge nurse needs to provide the RN with additional teaching?
The RN palpates the neck to assess thyroid size
The nurse teaches a patient about pursed-lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed?
The patient puffs up the cheeks while exhaling
The nurse at the outpatient surgery unit obtains the following information about a patient who is scheuled for cataract extracation and implantation of an intraocular lens. Which information is important to report to the HCP before the procedure?
The patient takes antihypertensive medications
A patient hospitilized with pneumonia is disorientated and confused 3 days after admission. Which information indicates that the patient is experiancing delirium rather than dementia?
The patient was oriented and alert when admitted
The nurse completes an admission assessment on a patient with asthma. Which information given by the patient indicates a need for a change in therapy?
The patient's only medications are albuterol (Ventolin HFAl) and salmeterol
The nurse is caring for a patient who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern?
The patients hands flap back and fourth when the arms are extended
The nurse completes an admission assessment on a patient with asthma. WHich information indicates a need for a change in therapy?
The patients only medications are albuterol and salmeterol
Which stroke risk factor for a 48-year-old male in the clinic is most important for the nurse to address?
The patients usual blood pressure is 170/94
Which finding for a patient admitted with glomerulonephritis indicates to the nurse that treatment has been effective?
The periorbital and peripheral edema are resolved
A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?
There are fine crackles throughout both lung fields
The nurse is participating in a class on rhythm strip interpretation. Which statement by the nurse indicates an understanding of a PR interval of 0.20?
This is a normal finding
Which laboratory value should the nurse review to determine whether a patients hypothyroidsim is caused by a problem with the anterior pituitary gland?
Thyroid-stimulating hormone (TSH)
While the nurse is transporting a patient on a strecher to the radiology department, the patient begins to have a tonic-clonic seizure. Which actions should the nurse take?
Time and observe and record the details of the seizure and the postictaial phase
The nurse is monitoring a client for signs of hypocalcemia after thyroidectomy. Which sign or symptom, if noted in the client, would most likely indicate the presence of hypocalcemia?
Tingling around the mouth
The nurse is caring for a client after thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which purpose?
To treat hypocalcemic tetany
A nurse is caring for a client after a thyroidectomy. Which specific emergency equipment should the nurse have available as it relates to this procedure?
Tracheostomy tray
Which action will be included in the plan of care when the nurse is caring for a patient who is receiving nicardipine (Cardene) to treat a hypertensive emergency?
Use an automated noninvasive blood pressure machine to obtain frequent blood pressure (BP) measurements.
The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, and QRS complex wide and distorted, and QRS duration of 0.18 second. Does the nurse interpret the patient's cardiac rhythm?
V-Tach
The nurse notes that a client with sinus rhythm has a PVC that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How should the nurse interpret this rhythm?
Ventricular fibrillation
The nurse is watching the cardiac monitor and notices that a client's rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats per minute. The nurse determines that the client is experiencing dysrhythmia
Ventricular tachycardia
The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, QRS complex wide and distorted, and QRS duration of 0.18 second. How should the nurse interpret this cardiac rhythm?
Ventricular tachycardia
