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Questions 149

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Question 1 of 5

The nurse is assessing an ECG strip of a 42-year-old client and finds a regular rate greater than 100, a normal QRS complex, a normal P wave in front of each QRS, a PR interval between 0.12 and 0.20 seconds, and a P: QRS ratio of 1:1. What is the nurse's interpretation of this rhythm?

Correct Answer: B

Rationale: A regular rate >100 with normal P waves, QRS complexes, and PR interval indicates sinus tachycardia, a common response to stress, fever, or hypoxia.

Question 2 of 5

The nurse is supervising a student nurse on the oncology unit who is providing care for a client with neutropenic precautions. Which action by the student nurse requires intervention by the supervising nurse?

Correct Answer: C

Rationale: Potted plants pose an infection risk (e.g., mold) for neutropenic clients and are prohibited. Other actions are appropriate.

Question 3 of 5

The nurse is performing a neurological assessment on a client. She asks the client to smile, close both eyes, and frown. Which cranial nerve (CN) is the nurse testing?

Correct Answer: B

Rationale: Cranial nerve VII (facial) controls facial movements like smiling, frowning, and closing eyes.

Question 4 of 5

The nurse has an order to give 1,000 mL of 0.9% NS with 20 meQ of potassium chloride over 8 hours. The IV set has a drop factor of 15. How many gtts/min should the client receive?

Correct Answer: 31

Rationale: Rate = 1,000 mL ÷ 8 hr = 125 mL/hr. Drops/min = (125 mL/hr × 15 gtts/mL) ÷ 60 min = 31.25 gtts/min, rounded to 31 gtts/min.

Question 5 of 5

The nurse working the organ transplant unit is caring for a client with a white blood cell count of 450. During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?

Correct Answer: D

Rationale: A white blood cell count of 450 indicates severe immunosuppression, so the fruit should be removed to prevent infection from potential contaminants.

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