Answer to Question 1
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
Answer to Question 2
3
Rationale: The body needs complex carbohydrates to meet its energy needs. The client who exercises regularly should increase the intake of complex carbohydrates to maintain energy levels. Water will not increase energy in the body, although it plays an important role in the body. The second source of energy for the body is fat. The client who has high energy needs should take in enough quality fat to help the body meet its energy needs. Protein is needed to build and repair cells, and can be a source of energy, but is not the best source.
NUrse
Nurse-patient interaction; nonverbal communication
Nurse Sandy
A nurse communicates with her non–English-speaking patient through an interpreter
To check pupillary reflexes the nurse first holds the penlight