When using an ECG rhythm strip to quickly estimate the ventricular rate for a client, the nurse should:

count the number of large squares in the R-R interval and divide by 30C

print a 1-minute ECG strip and count the number of ORS complexes,

count the number of QRS complexes in 6 seconds and multiply by 10.

calculate the number of small squares between one QRS complex and the next one and divide by 1500.

Answer and Explanation

The Correct Answer is C

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

Explanation

A. Increased respiratory rate - Fluid overload can lead to pulmonary edema, which causes difficulty breathing and an increased respiratory rate.
B. Increased temperature - Fluid overload does not typically cause a temperature increase. A fever may indicate infection rather than fluid overload.
C. Increased heart rate - The body compensates for fluid overload by increasing the heart rate to maintain cardiac output.
D. Increased blood pressure - Fluid overload leads to increased blood volume, which results in elevated blood pressure.
E. Increase hematocrit - Hematocrit usually decreases with fluid overload, as it is diluted by the extra fluid volume.

A. prepare to place the client in a single room. B. ask the client if they wish to speak to a spiritual advisor. C. explore the possibility of suicidal thoughts with the client. D. explain to the client that they will not die for a long time.

Correct Answer is C

Explanation

A. While privacy may be important for a patient who is emotionally distressed, the priority is addressing
the client’s emotional state, not the physical environment.
B. This might be helpful later, but the priority is to explore the patient's feelings and concerns regarding their condition first. Immediate emotional support is more important at this stage.
C. When a patient expresses feelings of hopelessness, as in this case, the nurse must assess for potential suicidal ideation. This is a priority to ensure patient safety and to provide necessary psychological support or intervention.
D. While reassurance is important, providing false or unrealistic expectations can lead to further disappointment. The nurse should focus on addressing emotional distress and offering realistic support rather than giving definitive assurances.

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When using an ECG rhythm strip to quickly estimate the ventricular rate for a client, the nurse should:

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

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

Explanation

The physician has just informed a client with advanced heart failure that a left ventricular assist device (LVAD) will be needed. The client is crying and says to the nurse, "I just know that I am going to die. What's the point of treatment?" The priority nursing action is to:

Correct Answer is C

Explanation

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