The nurse is evaluating the following rhythm strip on a client in the telemetry unit. The client is alert and oriented but complains of slight nausea after eating breakfast. What is the nurse's best action?

Perform a 12 lead EKG and request an order for bumetanide 0.5 mg IV

Administer pantoprazole sodium 40 mg by mouth to decrease GI distress

Administer carvedilol 10 mg by mouth and reassess in 30 minutes

Complete the remainder of the assessment and continue to monitor

Answer and Explanation

The Correct Answer is D

A.   The 12-lead EKG might be unnecessary right now, especially since the client has no other alarming symptoms. Bumetanide is also not indicated for nausea or tachycardia in this scenario.
B.   There is no clear indication that the nausea is related to acid reflux or GI distress that would justify pantoprazole.
C.   The tachycardia could be physiological, and treating it with a beta-blocker is unnecessary unless there is a more concerning underlying cause (like heart failure or ischemia). The priority here is not pharmacological intervention but monitoring the client's overall condition.
D.   This action allows for appropriate monitoring of the client's condition. Sinus tachycardia may resolve on its own without intervention, and the client doesn't exhibit severe symptoms requiring immediate pharmacologic treatment.

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Correct Answer is C

Explanation

A. This test set is incomplete for diagnosing DIC. While PT and fibrinogen are important, the eosinophil count is not a key test for DIC.
B. While fibrin degradation products are useful, lactic acid is not specific for DIC and may indicate other issues. A complete blood count is helpful but not definitive for diagnosing DIC.
C. These are key markers for DIC. An elevated D-dimer indicates clot formation and breakdown, while fibrinogen and fibrin degradation products are used to assess clotting and fibrinolysis, both of which are abnormal in DIC.
D. Complete blood count, complete metabolic panel, and prothrombin time are general tests and can give some clues, but they are not definitive for diagnosing DIC.

A. count the number of large squares in the R-R interval and divide by 30C B. print a 1-minute ECG strip and count the number of ORS complexes, C. count the number of QRS complexes in 6 seconds and multiply by 10. D. calculate the number of small squares between one QRS complex and the next one and divide by 1500.

Correct Answer is C

Explanation

A. Counting the number of large squares between R-R intervals and dividing by 30 is not the correct method for estimating the ventricular rate on an ECG strip.
B. Printing a 1-minute ECG strip and counting the QRS complexes (option B) is accurate but unnecessary for a quick estimation.
C. The most common and efficient method for estimating the ventricular rate quickly is to count the number of QRS complexes in a 6-second strip (often marked by two dashed lines) and multiply by 10. This gives an estimate of the heart rate per minute.
D. Counting the number of small squares between QRS complexes and dividing by 1500 is the most accurate method but requires more time and precision than counting QRS complexes in 6 seconds.

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The nurse is evaluating the following rhythm strip on a client in the telemetry unit. The client is alert and oriented but complains of slight nausea after eating breakfast. What is the nurse's best action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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