A nurse is analyzing a client’s electrocardiogram (ECG) strip and identifies the following information: Heart rate: 92/min.

Rhythm: Irregular.

P wave: Unable to identify.

PR interval: Unable to measure. QRS duration: 0.10 seconds.

Based upon this information, the nurse should interpret the client’s rhythm as indicating which of the following?

Supraventricular tachycardia.

Atrial fibrillation.

Sinus bradycardia.

First-degree heart block.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Supraventricular tachycardia (SVT) is characterized by a rapid heart rate originating above the ventricles, typically with a regular rhythm and identifiable P waves. The described ECG strip shows an irregular rhythm and an inability to identify P waves, which is not consistent with SVT5.
Choice B rationale
Atrial fibrillation (AF) is characterized by an irregularly irregular rhythm, absence of identifiable P waves, and variable PR intervals. The ECG findings of an irregular rhythm, inability to identify P waves, and a QRS duration of 0.10 seconds are consistent with AF6.
Choice C rationale
Sinus bradycardia is characterized by a regular rhythm with a heart rate less than 60 beats per minute and identifiable P waves preceding each QRS complex. The described ECG strip shows an irregular rhythm and an inability to identify P waves, which is not consistent with sinus bradycardia.
Choice D rationale
First-degree heart block is characterized by a prolonged PR interval with a regular rhythm. The described ECG strip shows an irregular rhythm and an inability to measure the PR interval, which is not consistent with first-degree heart block.

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Correct Answer is A

Explanation

Choice A rationale
Hypovolemic shock occurs due to a significant decrease in circulating blood volume, leading to inadequate tissue perfusion. Blood loss, such as the 800 mL lost during surgery, is a common cause of hypovolemic shock. The steadily decreasing blood pressure is consistent with this type of shock.
Choice B rationale
Septic shock results from a systemic inflammatory response to infection, leading to vasodilation and maldistribution of blood flow. There is no indication of infection in this scenario.
Choice C rationale
Neurogenic shock results from a loss of sympathetic tone, leading to vasodilation and relative hypovolemia. It is often associated with spinal cord or severe head injury, which is not indicated in this scenario.
Choice D rationale
Obstructive shock occurs when there is an obstruction to blood flow within the cardiovascular system, such as a pulmonary embolism or cardiac tamponade. There is no evidence of such an obstruction in this scenario.

A. Bubbling of the water in the water seal chamber with exhalation. B. Eyelets are not visible. C. Movement of the trachea toward the unaffected side. D. Crepitus in the area above and surrounding the insertion site.

Correct Answer is C

Explanation

Choice A rationale
Bubbling of the water in the water seal chamber with exhalation. This statement is incorrect. Bubbling in the water seal chamber with exhalation can be normal and indicates that air is being expelled from the pleural space. It is not necessarily a cause for concern.
Choice B rationale
Eyelets are not visible. This statement is incorrect. The visibility of eyelets on the chest tube is not a standard indicator for notifying the provider. The focus should be on the function of the chest tube and the patient’s clinical status.
Choice C rationale
Movement of the trachea toward the unaffected side. This statement is correct. Tracheal deviation toward the unaffected side can indicate a tension pneumothorax, a life-threatening condition that requires immediate medical attention. It suggests that pressure is building up in the pleural space, compressing the lung and shifting the trachea.
Choice D rationale
Crepitus in the area above and surrounding the insertion site. This statement is incorrect. Crepitus, or subcutaneous emphysema, can occur when air leaks into the subcutaneous tissue around the chest tube insertion site. While it should be monitored, it is not necessarily an emergency requiring immediate notification of the provider.

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Naxlex Comprehensive Predictor Exams

A nurse is providing postoperative care to a client who lost 800 mL of blood during surgery. The client’s blood pressure has been steadily decreasing over the past 2 hours. Which of the following categories of shock should the nurse recognize is occurring?

Correct Answer is A

Explanation

A nurse is assessing a client who has a pneumothorax with a chest tube in place For which of the following findings should the nurse notify the provider?

Correct Answer is C

Explanation

A nurse is providing discharge teaching for a client who has a new prescription for warfarin. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparin’s effects?

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?

A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to?

A nurse is caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa. Which of the following laboratory results should the nurse review for an indication of a therapeutic effect of the medication?

Increased heart rate. Discomfort at the puncture site. A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately?

A nurse is providing teaching to a client who has atrial fibrillation and reports dizziness and palpitations. Which of the following should the nurse understand is the cause of these manifestations?