The nurse calls a code when which of the following rhythms is noted on the cardiorespiratory monitor?
1.
2.
3.
4.
3
Rationale: Rhythm strip 3 demonstrates ventricular fibrillation, a fatal rhythm if not immediately reversed with defibrillation and medications. Answer option 2 demonstrates supraventricular tachycardia, which needs treatment but does not require the code team. Rhythm strip 2 shows atrial flutter, which is a serious but not fatal arrhythmia. Rhythm strip 4 demonstrates ventricular tachycardia, and requires immediate assessment of the client. If the client is pulseless and unconscious, the code is called; however, if the client is alert and without symptoms, the nurse should notify the physician or RN supervisor immediately, because emergent treatment is required. All changes in rhythm should be immediately reported, but only fatal rhythms require the nurse to call a code.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Chapter 33
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. A patient who has recently been diagnosed with an aneurysm and been placed on aneurysm precautions will have which of the following incorporated into his plan of care?
A) Elevate the head of the bed to 45 degrees. B) Maintain the patient on complete bed rest. C) Administer enemas when the patient is constipated. D) Avoid use of thigh-high elastic compression stockings.
The nurse is reviewing the postsurgical laboratory values of an older adult client. The client's erythrocyte sedimentation rate (ESR) is 20 mm/hr. The nurse initially responds to this data by:
a. asking the client if he or she has been di-agnosed with any chronic inflammatory diseases. b. recognizing that the value is normal for older adults. c. notifying the client's health care provider immediately. d. requesting that the laboratory rerun the test.
Anticipatory guidance for the family of a preadolescent with a cognitive dysfunction should include information about:
a. institutional placement. b. sexual development. c. sterilization. d. clothing.
A nurse considers how the environment outside of the family influences the development of a child when planning care for a family. Which of the following theories is being used by the nurse?
a. Bioecological systems theory b. Family systems approach c. Family developmental theory d. Interactionist theory