How should the nurse identify the rhythm shown in the diagram?

ventricular tachycardia

asystole

normal sinus rhythm

ventricular fibrillation

Answer and Explanation

The Correct Answer is A

A. Ventricular tachycardia: Ventricular tachycardia (VT) is identified by a regular, fast rhythm with wide QRS complexes, typically without visible P waves. This rhythm often appears as consecutive, large, uniform waves, which is consistent with what is seen in the diagram.

B. Asystole: Asystole is characterized by a flat line, indicating no electrical activity, which is not present in this strip.

C. Normal sinus rhythm: Normal sinus rhythm would show identifiable P waves, a normal QRS complex, and a regular rate, which are not observed here.

D. Ventricular fibrillation: Ventricular fibrillation appears as chaotic, irregular waveforms with no clear QRS complexes or organization, which does not match the rhythm shown.

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Correct Answer is C

Explanation

A. Restlessness is an objective sign that may indicate pain, but it is not a subjective report from the client.

B. Pupil dilation is an objective physiological response often associated with pain or stress, not a subjective indicator.

C. A report of a burning sensation is a subjective indicator because it is based on the client’s own description of their pain experience.

D. Grimacing is an objective observation by the nurse, not a subjective report from the client.

A. PICC line insertion site B. Breath sounds C. Temperature D. Heart rate

Correct Answer is ["A","C","D"]

Explanation

A. PICC line insertion site: The client reports pain, redness, and edema at the PICC line insertion site, which are signs of a possible infection. This finding requires immediate follow-up to prevent complications like bloodstream infection or sepsis.

B. Breath sounds: The client’s breath sounds are clear and unchanged from Day 1, so this finding does not require immediate follow-up.

C. Temperature: The client's temperature has risen to 39 °C (102.2 °F) from 37.2 °C (99 °F) on Day 1. Such a significant increase in temperature indicates a possible infection and needs prompt intervention.

D. Heart rate: The client’s heart rate has increased to 108/min from 66/min, suggesting tachycardia. This could be a response to infection, potentially linked to sepsis, and warrants immediate follow-up.

E. Albumin level: The albumin level has increased to within the normal range, which is a positive trend and does not require urgent intervention.

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How should the nurse identify the rhythm shown in the diagram?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client for manifestations of pain. Which finding is a subjective indicator of pain?

Correct Answer is C

Explanation

Select the 3 findings on day 3 that require immediate follow-up. Exhibits

Correct Answer is ["A","C","D"]

Explanation

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