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.

Nursing Test Bank

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Correct Answer is B

Explanation

Choice A rationale
Asking appropriate questions about suctioning indicates interest and understanding but does not demonstrate the ability to perform the procedure.
Choice B rationale
Performing the procedure independently shows that the partner has the necessary skills and confidence to care for the client at home.
Choice C rationale
Attending a class about tracheostomy care is beneficial but does not demonstrate the ability to perform the procedure independently.

Choice D rationale
Verbalizing all steps in the procedure indicates knowledge but does not demonstrate the practical ability to perform the procedure.

A. Breast cancer can occur in any part of the breast, but ductal breast cancer is most common. B. Breastfeeding increases the risk of breast cancer in women over 40 years of age. C. Clients who have BRCA1 or BRCA2 gene changes have a decreased risk of breast cancer. D. Clients should begin screening mammography annually by the age of 50 years old.

Correct Answer is A

Explanation

Choice A rationale

Breast cancer can occur in any part of the breast, but ductal breast cancer is most common. This statement is correct because the majority of breast cancers originate in the ducts that carry milk to the nipple. Ductal carcinoma in situ (DCIS) and invasive ductal carcinoma (IDC) are the most common types of breast cancer, accounting for about 80% of all cases.
Choice B rationale
Breastfeeding increases the risk of breast cancer in women over 40 years of age. This statement is incorrect. In fact, breastfeeding is known to reduce the risk of breast cancer. The longer a woman breastfeeds, the greater the protective effect. This is thought to be due to hormonal changes that occur during lactation, which may delay the return of menstrual periods and reduce a woman’s lifetime exposure to hormones like estrogen that can promote breast cancer cell growth.
Choice C rationale
Clients who have BRCA1 or BRCA2 gene changes have a decreased risk of breast cancer. This statement is incorrect. Mutations in the BRCA1 and BRCA2 genes significantly increase the risk of developing breast cancer. Women with these mutations have a 45-65% chance of developing breast cancer by age 70, compared to about 12% for women in the general population. These genes normally help repair DNA damage, but when they are mutated, they can lead to the development of cancer.
Choice D rationale
Clients should begin screening mammography annually by the age of 50 years old. This statement is partially correct but not entirely accurate. The American Cancer Society recommends that women with an average risk of breast cancer should start annual mammograms at age 45 and can switch to biennial screening at age 55. However, women should have the option to start screening as early as age 40 if they choose.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a tracheostomy. The client’s partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client’s discharge?

Correct Answer is B

Explanation

A nurse is educating clients about breast cancer at a community health event. Which of the following statements should the nurse include in the training?

Correct Answer is A

Explanation

A nurse is caring for a client who has brain cancer and is undergoing radiation therapy. Which of the following manifestations should the nurse report immediately?

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 75-year-old male client who is experiencing difficulty breathing and shortness of breath. Exhibits The nurse is caring for the client following a thoracentesis. (Select the 3 findings that require immediate follow-up.)

A nurse is planning care for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following manifestations is most appropriate for the nurse to monitor?

A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client?

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?