Question

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?

Answer 1

Correct Answers:

The P wave falls before the QRS complex.

Rationale :

🟢 The P wave initiates the electrical signal from the sinoatrial (SA) node, indicating atrial depolarization.

🟢 In a normal sinus rhythm, every P wave is followed by a QRS complex, showing a consistent rhythm.

🟢 A PR interval between 0.12–0.20 seconds is considered normal, so 0.22 sec (choice A) is prolonged.

🟢 A normal T wave is upright; inversion may indicate ischemia or other cardiac issues.

🟢 The QRS complex duration should be less than 0.12 seconds—a duration of 0.20 seconds suggests a conduction delay.

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Answer 2

Correct Answers:

Fever and chills
Nuchal rigidity
Severe headache
Brudzinski's sign

Rationale :

🔶 Fever and chills are hallmark signs of infection due to inflammation of the meninges.

🔶 Nuchal rigidity (stiff neck) is a classic indicator of meningeal irritation and often prompts urgent evaluation.

🔶 A severe headache results from increased intracranial pressure and inflammation within the meninges.

🔶 Brudzinski’s sign is a positive neurological indicator—flexion of hips/knees when the neck is flexed.

🔶 These symptoms reflect CNS infection and require rapid intervention to prevent neurologic sequelae.

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Answer 3

Correct Answers:

Packed RBCS

Rationale :

🔴 In hypovolemic shock, oxygen-carrying capacity and blood volume must be restored, making packed RBCs appropriate.

🔴 Packed red cells improve tissue perfusion and correct anemia caused by blood loss.

🔴 Cryoprecipitates are for clotting factor deficiencies, not primary volume replacement.

🔴 Albumin helps with oncotic pressure but doesn't provide oxygen-carrying capacity.

🔴 Platelets are used in thrombocytopenia or bleeding due to platelet dysfunction—not for hypovolemia.

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Answer 4

Correct Answers:

Flexion and internal rotation of upper extremities

Rationale :

🟢 Decorticate posturing occurs due to damage above the brainstem, involving the cerebral hemispheres.

🟢 It is characterized by flexed arms, clenched fists, and extended legs—suggesting severe brain injury.

🟢 Internal rotation of the upper limbs is a hallmark feature.

🟢 This differs from decerebrate posturing, which shows extension of both arms and legs.

🟢 Decorticate posture is often seen in traumatic brain injury and has serious neurological implications.

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Answer 5

Correct Answers:

Atrial fibrillation

Rationale :

🔵 Atrial fibrillation (AF) presents with a rapid and irregular heart rate, often causing palpitations and dizziness.

🔵 A pulse deficit occurs when not all heartbeats result in a palpable peripheral pulse—common in AF.

🔵 ECG findings include absent P waves and irregularly irregular rhythm.

🔵 AF increases the risk for clots and stroke, especially in long-standing cases.

🔵 Early recognition allows for timely rate control or rhythm conversion interventions.

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Answer 6

Correct Answers:

Excessive thrombosis and bleeding

Rationale :

🟡 DIC (Disseminated Intravascular Coagulation) is a paradoxical condition with simultaneous clotting and bleeding.

🟡 Widespread microthrombi consume clotting factors, causing secondary hemorrhage.

🟡 It may follow sepsis, trauma, or obstetric complications.

🟡 Expect labs to show low platelets, elevated PT/PTT, and fibrin degradation products.

🟡 The nurse must monitor for bruising, oozing from IV sites, and organ dysfunction.

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Answer 7

Correct Answers:

Hypotension

Rationale :

🟣 Verapamil is a calcium channel blocker that reduces myocardial contractility and conduction, lowering BP.

🟣 IV bolus administration can cause vasodilation, resulting in rapid drop in blood pressure.

🟣 The nurse must monitor ECG and vital signs closely during administration.

🟣 Other side effects may include bradycardia or AV block, but hypotension is most common.

🟣 Verapamil should be administered slowly with resuscitation equipment available.

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Answer 8

Correct Answers:

Elective cardioversion

Rationale :

🔶 In stable ventricular tachycardia (VT), elective synchronized cardioversion is the treatment of choice.

🔶 The goal is to restore sinus rhythm while avoiding hemodynamic collapse.

🔶 Defibrillation is reserved for pulseless VT or VF, not stable presentations.

🔶 Radiofrequency ablation is used for recurrent episodes but not during acute management.

🔶 CPR is only initiated if the patient is unresponsive and pulseless.

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Answer 9

Correct Answers:

Position the child laterally.

Rationale :

🔴 Lateral positioning helps maintain a patent airway and prevents aspiration during a seizure.

🔴 Restraining the arms can cause injury and is contraindicated.

🔴 A tongue blade should never be inserted, as it poses a choking risk and may damage teeth.

🔴 The priority is airway protection, not stopping the seizure forcefully.

🔴 Lateral safety positioning is part of seizure precautions in pediatric clients.

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Answer 10

Correct Answers:

Ability to self-feed with the use of adaptive equipment

Rationale :

🟢 A C5 spinal cord injury affects upper limb function but allows limited shoulder and bicep use.

🟢 With adaptive tools, clients may achieve independence in feeding and grooming tasks.

🟢 Bowel and bladder control is not typically regained in complete spinal cord transection.

🟢 Transfers and wheelchair control usually require assistive devices or caregiver support at this level.

🟢 Setting realistic goals promotes independence while managing expectations based on the injury level.

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QLexNursing

1 :
A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?

2 :
What are the anticipated signs and symptoms for a client who has meningitis? (Select all that apply.)

3 :
A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?

4 :
A client is experiencing decorticate posturing. Which assessment finding would the nurse expect to observe in this client?

5 :
A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

6 :
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

7 :
A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?

8 :
A nurse is caring for a client who reports heart palpitations that come and go. An ECG confirms the client is experiencing episodes of ventricular tachycardia (VT). The client is stable. The nurse should anticipate the need for taking which of the following actions?

9 :
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

10 :
A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care?

QLexNursing

1 : A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?

2 : What are the anticipated signs and symptoms for a client who has meningitis? (Select all that apply.)

3 : A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?

4 : A client is experiencing decorticate posturing. Which assessment finding would the nurse expect to observe in this client?

5 : A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

6 : A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

7 : A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?

8 : A nurse is caring for a client who reports heart palpitations that come and go. An ECG confirms the client is experiencing episodes of ventricular tachycardia (VT). The client is stable. The nurse should anticipate the need for taking which of the following actions?

9 : A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

10 : A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care?

1 :
A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?

2 :
What are the anticipated signs and symptoms for a client who has meningitis? (Select all that apply.)

3 :
A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?

4 :
A client is experiencing decorticate posturing. Which assessment finding would the nurse expect to observe in this client?

5 :
A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

6 :
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

7 :
A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?

8 :
A nurse is caring for a client who reports heart palpitations that come and go. An ECG confirms the client is experiencing episodes of ventricular tachycardia (VT). The client is stable. The nurse should anticipate the need for taking which of the following actions?

9 :
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

10 :
A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care?