A new nurse is reviewing a rhythm on a telemetry monitor and believes it might be ventricular fibrillation. Which of the following characteristics is the nurse most likely observing? Select all that apply.
a. P:QRS ratio that is not measurable
b. Large and tall P waves
c. Normal PR interval
d. Irregular rhythm
e. Ventricular heart rate of 150-250 bpm
a. P:QRS ratio that is not measurable
d. Irregular rhythm
rationale: Irregularity is a characteristic of V-fib. Ventricular fibrillation is an irregular rhythm and the P: QRS ratio is nonmeasurable.
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What intervention should the nurse implement to prevent an increase in intracranial pressure (ICP) of a comatose patient who has suffered a closed head injury?
A) Suction the airway every hour and as needed. B) Elevate the head of the bed 15 to 30 degrees. C) Turn the patient and change his position every 2 hours. D) Maintain a well-lit room.
The nurse, reviewing the similarities and differences between the nursing process and the teaching-learning process, realizes that:
a. there is little similarity between the two. b. the teaching-learning process is less complex than the nursing process. c. the two are very similar. d. they exist independently of each other.
The nurse is performing a nutrition assessment on the client. Which of the following may be documented by the nurse regarding laboratory results?
1. "Client lost 20 pounds during last 2 months.". 2. "Dental caries and poor oral health noted.". 3. "Leukocytosis.". 4. "Client using St. John's worst daily.".
While working with clients who are experiencing a significant degree of stress, the nurse knows that which one of the following is a priority assessment area?
a. The client's primary physical needs b. What else is happening in the client's life c. How the stress has influenced the client's activities of daily living d. Whether the client is thinking about harming himself or others