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Question 1 of 5

The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:

Correct Answer: C

Rationale: Assuming a wide, regular, rapid rhythm (common in critical scenarios), ventricular tachycardia is the most likely arrhythmia, requiring immediate intervention.

Question 2 of 5

A pregnant woman undergoes a 40-minute nonstress test for evaluation of the fetal heart rate (FHR) and accelerations. Which of the following test results is normal (reactive)?

Correct Answer: C

Rationale: A reactive nonstress test requires at least two accelerations of FHR by 15 bpm for 15 seconds within 20-40 minutes. No accelerations (
C) is considered normal (reactive) if other criteria are met, but typically, accelerations are expected. Options A, B, D do not meet standard reactive criteria.

Question 3 of 5

A client is to wear a Holter monitor for continuous cardiac monitoring for 48 hours. The nurse should advise the client to avoid which of the following activities during the monitoring period? Select all that apply.

Correct Answer: C,D

Rationale: Holter monitors can be affected by electromagnetic interference from wireless devices like iPads (
C), so these should be avoided. Showering and bathing (
D) can damage the monitor or electrodes. Watching TV (
A), using a remote control (
B), drinking caffeine (E), and exercising (F) typically do not interfere with monitoring, though exercise should be noted in the activity log.

Question 4 of 5

The nurse is caring for a client who is at risk for altered fluid balance. Which signs and symptoms of dehydration would the nurse expect to find in this client? Select all that apply.

Correct Answer: B, C

Rationale: Increased hematocrit and orthostatic hypotension are signs of dehydration due to reduced plasma volume, while bounding pulses and decreased urine specific gravity are not typical.

Question 5 of 5

A client comes to the emergency department with scalding burns covering his entire left arm, anterior and posterior surfaces. Using the rule of nines, how much total body surface area (TBSA) has been burned? Record your answer using a whole number.

Correct Answer: 18

Rationale: Rule of nines: Entire arm (anterior and posterior) = 9% per arm. Left arm burn = 9% X 2 surfaces = 18% TBSA.

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