A nurse is reviewing the cardiac monitor strip for a client who is recovering from an acute myocardial infarction. Which of the following findings should the nurse report to the provider immediately?

Sinus tachycardia rate 104/min

Two premature ventricular contractions per minute

First degree heart block

A new onset of atrial fibrillation

Answer and Explanation

The Correct Answer is D

A. Sinus tachycardia rate 104/min: Mild sinus tachycardia may occur in response to pain, anxiety, or hypovolemia and is usually not immediately life-threatening. While it should be monitored, it does not require urgent reporting unless it worsens or is accompanied by other concerning signs.

B. Two premature ventricular contractions per minute: Occasional PVCs can be benign, especially in a post-MI patient, and may not require immediate intervention. Frequent or paired PVCs, or those occurring in runs, are more concerning for ventricular arrhythmias.

C. First degree heart block: This is characterized by a prolonged PR interval but generally does not compromise cardiac output. It is often stable and can be monitored rather than reported as an urgent finding.

D. A new onset of atrial fibrillation: New-onset atrial fibrillation following a myocardial infarction increases the risk of decreased cardiac output, thromboembolism, and hemodynamic instability. This arrhythmia requires immediate notification of the provider for assessment and initiation of appropriate interventions such as rate or rhythm control and anticoagulation.

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Correct Answer is A

Explanation

A. Mastitis: Mastitis is an infection of the breast tissue, often caused by bacteria entering through a cracked nipple. It presents with localized redness, warmth, tenderness, swelling, and systemic symptoms such as fever and chills. These signs align with the client’s sudden onset of chills and a tender, red area on the breast, indicating an acute infectious process.

B. Engorgement: Engorgement occurs when the breasts are overfilled with milk, leading to generalized swelling, firmness, and mild discomfort. It usually develops gradually rather than suddenly and is not associated with systemic symptoms like chills or fever.

C. Blocked milk duct: A blocked duct can cause localized firmness and tenderness, often forming a small, palpable lump. Unlike mastitis, it typically does not produce systemic symptoms such as chills or fever, and the redness is usually limited to the area over the blockage rather than indicating infection.

D. Thrush: Thrush is a fungal infection caused by Candida species, affecting the nipple or infant’s mouth. It presents with pain during breastfeeding, itching, or burning, and may show white patches on the nipple or tongue. Thrush does not cause localized redness, tenderness, or systemic symptoms such as chills.

A. Ceftriaxone 50 mg/kg/dose IV every 24 hr B. Loperamide PO 1 mg twice daily C. Check urine specific gravity every 4 hr. D. Dextrose 5% sodium chloride IV infusion 60 mL/hr over 6 hr E. Obtain arterial blood gases. F. Oral rehydration solution 50 mL/kg over 4 hr

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

• Ceftriaxone 50 mg/kg/dose IV every 24 hr: The stool sample is positive for Escherichia coli, indicating a bacterial gastroenteritis that may require IV antibiotics due to dehydration and systemic involvement. Ceftriaxone provides broad-spectrum coverage appropriate for pediatric patients with moderate to severe infection. IV administration ensures adequate therapeutic levels while the child is unable to tolerate oral intake.

• Check urine specific gravity every 4 hr: The child shows signs of dehydration: weight loss, concentrated urine, sunken eyes, and poor skin turgor. Monitoring urine specific gravity frequently provides an objective measure of hydration status and kidney perfusion. It allows the nurse to evaluate response to fluid therapy.

• Loperamide PO 1 mg twice daily: Antidiarrheal medications like loperamide are contraindicated in pediatric infectious diarrhea, especially with E. coli. Loperamide slows intestinal motility, which can prolong infection and increase the risk of complications such as hemolytic uremic syndrome. In children, it can also cause central nervous system depression.

• Dextrose 5% sodium chloride IV infusion 60 mL/hr over 6 hr: IV fluid replacement is essential for a child with significant fluid loss from vomiting and diarrhea. Dextrose with sodium chloride provides both hydration and caloric support, correcting dehydration and electrolyte imbalances. Infusion rate is calculated to safely restore intravascular volume without causing fluid overload.

• Obtain arterial blood gases: Arterial blood gas analysis is not necessary in a child with mild to moderate dehydration and stable oxygenation. Vital signs and urine output provide adequate monitoring of perfusion and acid-base status in this context. ABGs are reserved for cases of severe dehydration with respiratory compromise or suspected metabolic derangements.

• Oral rehydration solution 50 mL/kg over 4 hr: Once the child is stable and able to tolerate oral intake, oral rehydration is recommended to maintain fluid and electrolyte balance. ORS replenishes lost sodium and water efficiently and reduces the risk of ongoing dehydration. It is evidence-based for mild to moderate dehydration in pediatric gastroenteritis.

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A nurse is reviewing the cardiac monitor strip for a client who is recovering from an acute myocardial infarction. Which of the following findings should the nurse report to the provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is breastfeeding and reports a sudden onset of chills and a tender, red area on the right breast. The nurse should identify that these manifestations indicate which of the following conditions?

Correct Answer is A

Explanation

A nurse is assisting with the care of a 2-year-old child. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the child.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

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