A client has a normal cardiac rhythm and a heart rate of 72 beats/minute. The nurse determines the P-R interval is 0.20 seconds. The most appropriate intervention by the nurse would be to

Notify the health care provider immediately.

Document the finding and continue to monitor the patient.

Prepare the patient for temporary pacemaker insertion.

Give atropine per agency dysrhythmia protocol.

Answer and Explanation

The Correct Answer is B

A. Notifying the health care provider immediately is not necessary, as the PR interval is at the upper limit of normal (0.20 seconds) and the client is stable.
B. Document the finding and continue to monitor the patient – A PR interval of 0.20 seconds with a normal heart rate and rhythm does not require intervention; just ongoing observation.
C. Prepare the patient for temporary pacemaker insertion – This is used for serious conduction blocks or symptomatic bradycardia, which are not present here.
D. Give atropine per agency dysrhythmia protocol – Atropine is used for symptomatic bradycardia, which this client does not exhibit.

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Correct Answer is D

Explanation

A. Ventricular tachycardia is a run of three or more consecutive ventricular beats at a rapid rate, not every other beat.
B. Multifocal premature ventricular contractions (PVCs) arise from different ventricular foci and have different shapes, but this scenario describes uniform shape and consistent pattern.
C. Ventricular couplets are two consecutive PVCs, not a pattern where every other beat is abnormal.
D. Ventricular bigeminy is the correct term for a rhythm in which every other beat is a premature ventricular contraction (PVC). These PVCs typically have no visible P wave and a wide, bizarre QRS complex, matching the description given.

A. Hepatomegaly B. Dry, hacking cough C. Crackles in the lungs D. Dizziness

Correct Answer is A

Explanation

A. Hepatomegaly (enlarged liver) is a classic sign of right ventricular failure due to systemic venous congestion.
B. A dry, hacking cough is more commonly associated with left-sided heart failure and pulmonary congestion.
C. Crackles in the lungs result from fluid backing up into the lungs, a hallmark of left-sided heart failure, not right-sided.
D. Dizziness may occur in left-sided failure due to decreased cardiac output and poor cerebral perfusion, but it is not a key feature of right-sided failure.

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A client has a normal cardiac rhythm and a heart rate of 72 beats/minute. The nurse determines the P-R interval is 0.20 seconds. The most appropriate intervention by the nurse would be to

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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