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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

Four 6-month-old children arrive at the clinic for diphtheria-pertussis-tetanus immunization. Which child can safely receive the immunization at this time?

Correct Answer: A

Rationale: A mild runny nose is not a contraindication for the DTaP vaccine, whereas seizures, severe allergic reactions, or fever indicate a need to delay immunization.

Question 3 of 5

The diagnostic work-up of a client hospitalized with complaints of progressive weakness and fatigue confirm a diagnosis of myasthenia gravis. The medication used to treat myasthenia gravis is:

Correct Answer: A

Rationale: Neostigmine (Prostigmine) is a cholinesterase inhibitor used to improve muscle strength in myasthenia gravis.

Question 4 of 5

Which assessment finding would the nurse expect in a client with long-term venous insufficiency with the presence of a venous ulcer?

Correct Answer: B

Rationale: Venous insufficiency causes stasis ulcers, typically over the medial malleolus, due to venous pooling and tissue breakdown.

Question 5 of 5

A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:

Correct Answer: A

Rationale: Monthly Protime tests monitor the therapeutic effect of warfarin and prevent bleeding complications.

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