A nurse is caring for a client in a cardiac unit. Using the five criteria for ECG analysis information, the nurse interprets the client's ECG as which of the following rhythm interpretations?

Heart Rate: 59 bpm

Rhythm: Regular

Presence of P waves: One P wave for every QRS complex

PR interval: 0.20 seconds

QRS complex duration: 0.10 seconds

Ventricular tachycardia

Sinus tachycardia

Sinus bradycardia

Normal sinus rhythm

Answer and Explanation

The Correct Answer is C

A) Ventricular tachycardia: Ventricular tachycardia is characterized by a rapid heart rate exceeding 100 bpm, typically arising from abnormal ventricular activity. In this case, the heart rate is 59 bpm, which does not support this interpretation. Additionally, ventricular tachycardia usually presents with wide QRS complexes and no discernible P waves, neither of which is true in this scenario.

B) Sinus tachycardia: Sinus tachycardia is defined by a heart rate exceeding 100 bpm originating from the sinoatrial (SA) node, with a regular rhythm and normal P waves. The heart rate of 59 bpm in this client is too low for a diagnosis of sinus tachycardia, making this option incorrect.

C) Sinus bradycardia: Sinus bradycardia occurs when the heart rate is less than 60 bpm, with a regular rhythm and a normal PR interval and QRS duration. The provided data shows a heart rate of 59 bpm, a regular rhythm, one P wave for every QRS complex, a PR interval of 0.20 seconds, and a QRS duration of 0.10 seconds, which aligns perfectly with the criteria for sinus bradycardia.

D) Normal sinus rhythm: Normal sinus rhythm typically presents with a heart rate of 60-100 bpm, a regular rhythm, and appropriate P waves for each QRS complex. Given the heart rate of 59 bpm, this does not meet the criteria for normal sinus rhythm, as it falls below the acceptable range.

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Correct Answer is D

Explanation

Correct Answer: D. Stage 1 hypertension

Rationales

A. Within the expected reference range.
Normal blood pressure is defined as a systolic less than 120 mm Hg and a diastolic less than 80 mm Hg. Since this client’s reading is 130/82 mm Hg, it exceeds the normal range, so it cannot be classified as expected.

B. Elevated.
Elevated blood pressure is defined as systolic 120–129 mm Hg and diastolic less than 80 mm Hg. While the systolic pressure of 130 is only slightly above this range, the diastolic value of 82 exceeds the “less than 80” requirement. Therefore, this reading does not qualify as elevated.

C. Stage 2 hypertension.
Stage 2 hypertension is defined as systolic pressure of 140 mm Hg or higher or diastolic pressure of 90 mm Hg or higher. This client’s values do not meet those thresholds, so stage 2 does not apply.

D. Stage 1 hypertension.
Stage 1 hypertension is defined as systolic 130–139 mm Hg or diastolic 80–89 mm Hg. Since the client’s reading is 130/82 mm Hg, both values fall within this category, making stage 1 hypertension the correct classification.

A. Apply cold therapy to the affected leg. B. Monitor Homan's sign. C. Obtain a venous duplex ultrasound. D. Obtain impedance plethysmography.

Correct Answer is C

Explanation

A) Apply cold therapy to the affected leg: Cold therapy may be used for certain conditions to reduce swelling and pain, but in the case of suspected deep vein thrombosis (DVT) indicated by redness, warmth, tenderness, and pain in the calf, cold therapy is not appropriate. Instead, the focus should be on confirming the diagnosis before applying any treatment.

B) Monitor Homan's sign: Homan's sign involves dorsiflexion of the foot to assess for pain in the calf, which can suggest DVT. However, it is no longer considered a reliable diagnostic tool. Instead, confirmation through imaging or other diagnostic measures is preferred, so simply monitoring this sign would not be sufficient in this situation.

C) Obtain a venous duplex ultrasound: A venous duplex ultrasound is the gold standard for
diagnosing DVT. Given the client’s symptoms—redness, warmth, tenderness, and pain in the calf—the appropriate order is to obtain this ultrasound to confirm the presence of a thrombus. This imaging study provides critical information for diagnosis and subsequent management.

D) Obtain impedance plethysmography: While impedance plethysmography can assess venous flow and help diagnose DVT, it is less commonly used than venous duplex ultrasound. The more direct and widely accepted method for diagnosing DVT in this scenario is the ultrasound, making this option less suitable as the initial order.

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Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that his blood pressure of 130/82 mm Hg places him in which of the following categories?

Correct Answer is D

Explanation

Correct Answer: D. Stage 1 hypertension

Rationales

A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding?

Correct Answer is C

Explanation

A nurse is caring for a client who is being administered spironolactone (Aldactone). Which of the following laboratory values should be monitored due to taking this medication?

A nurse is preparing to administer hydrochlorothiazide 25 mg PO daily to a client. Available is hydrochlorothiazide 50 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client who is taking enalapril (Vasotec). Which of the following outcomes indicates a therapeutic effect of the medication?

A nurse is reviewing the medication list for a client who has a new prescription for warfarin. The nurse should recognize which is incompatible with warfarin?

A nurse is planning to assign tasks for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? (Select all that apply.)

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