What is the rate on the rhythm strip in the image below?
90
110
73
50
The Correct Answer is A
A. To determine the heart rate from a rhythm strip, you can count the number of R-R intervals in a set time frame (typically 6 seconds) and multiply by 10 to convert to beats per minute. If the rhythm is regular, you can also use the 300 method by dividing 300 by the number of large squares between R waves. In this case, the rate is calculated to be 90 beats per minute.
B. A heart rate of 110 beats per minute would be classified as tachycardia and is not supported by the observed intervals.
C. A heart rate of 73 beats per minute would be a normal resting heart rate but does not match the calculation from the rhythm strip.
D. A heart rate of 50 beats per minute would indicate bradycardia, which is not reflected in this rhythm strip.
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Correct Answer is A
Explanation
A. Asking the client to identify scented aromas assesses cranial nerve I (olfactory nerve), which is responsible for the sense of smell.
B. Reading a Snellen chart assesses cranial nerve II (optic nerve), which is related to vision.
C. Listening to the client's speech evaluates the function of cranial nerves V (trigeminal) and XII (hypoglossal), which are related to mastication and tongue movement, respectively.
D. Asking the client to clench his teeth tests cranial nerve V, which innervates the muscles of mastication.
Correct Answer is D
Explanation
A. Petechiae are small, pinpoint hemorrhages and are considered objective data that can be observed and documented by the nurse.
B. Blood pressure is a vital sign and objective data that can be measured using a sphygmomanometer.
C. Cyanosis is a physical sign indicating low oxygenation in the blood and is objective data that can be observed.
D. Nausea is a subjective symptom reported by the client, reflecting their internal experience and cannot be measured or observed directly.