Nursing Elites

1. Based on this strip, what is the correct interpretation of this rhythm?

• A. Atrial fibrillation.
• B. Premature atrial fibrillation.
• C. AV block.
• D. Ventricular tachycardia.

Correct answer: A

Rationale: The correct interpretation of the rhythm strip is atrial fibrillation. This arrhythmia is characterized by an irregular heartbeat and the absence of distinct P waves. Choice B, premature atrial fibrillation, is incorrect as there is no indication of premature beats in the strip. Choice C, AV block, is also incorrect as there is no evidence of conduction delays between the atria and ventricles. Choice D, ventricular tachycardia, is not supported by the absence of wide QRS complexes typically seen in this arrhythmia.

2. Based on the interpretation of this strip, what action should be implemented first?

• A. Call a code.
• B. Start CPR.
• C. Administer IV fluids.
• D. Apply oxygen.

Correct answer: A

Rationale: The correct answer is A: 'Call a code.' In the context of ventricular fibrillation (V-Fib), immediate defibrillation is crucial. Calling a code is the first step to activating the emergency response team, including individuals trained to provide defibrillation. Starting CPR (Choice B) may be necessary but should follow defibrillation. Administering IV fluids (Choice C) and applying oxygen (Choice D) are important interventions in cardiac arrest cases, but in V-Fib, the priority is defibrillation to restore normal heart rhythm.

3. A client with chronic heart failure is being discharged with a new prescription for furosemide. Which instruction should the nurse include in the discharge teaching?

• A. Increase your intake of potassium-rich foods.
• B. Restrict your fluid intake to 1 liter per day.
• C. Avoid salt substitutes containing potassium.
• D. Weigh yourself once a week.

Correct answer: A

Rationale: The correct answer is to instruct the client to increase their intake of potassium-rich foods. Furosemide is a loop diuretic that can lead to potassium loss due to increased urinary excretion. Potassium-rich foods can help prevent hypokalemia, a potential side effect of furosemide. Restricting fluid intake (choice B) may not be suitable for all patients with heart failure, and a general restriction of 1 liter per day is not typically recommended. Avoiding salt substitutes containing potassium (choice C) is not a priority teaching point in this scenario. Weighing oneself once a week (choice D) is important for monitoring fluid status, but increasing potassium-rich foods is more directly related to the potential side effects of furosemide.

4. A client with fluid volume excess has gained 6.6 pounds. The nurse recognizes that this is equivalent to what volume of fluid?

• A. Two liters.
• B. Three liters.
• C. Four liters.
• D. Five liters.

Correct answer: B

Rationale: A weight gain of 6.6 pounds is approximately equivalent to 3 liters of fluid. It is important to remember that 1 liter of fluid is equal to 1 kg, which is approximately 2.2 pounds. Therefore, when the client gains 6.6 pounds, it translates to 3 liters of fluid. Choices A, C, and D are incorrect as they do not align with the conversion rate of 1 liter of fluid to 2.2 pounds.

5. A client who experienced partial-thickness burns with over 50% body surface area (BSA) 2 weeks ago suddenly becomes restless and agitated.

• A. Increase the room temperature.
• B. Assess the oxygen saturation.
• C. Continue to monitor vital signs.
• D. Notify the rapid response team.

Correct answer: D

Rationale: In a burn patient with sudden restlessness and agitation, it is crucial to consider hypoxia or other critical conditions. As such, notifying the rapid response team is the most appropriate action to ensure prompt assessment and intervention. Increasing room temperature (Choice A) is not the priority in this scenario. While monitoring vital signs (Choice C) is important, the sudden change in behavior warrants immediate action. Assessing oxygen saturation (Choice B) is a step in the right direction, but involving the rapid response team ensures a comprehensive evaluation and timely management of the patient's condition.

Similar Questions