A client has undergone diagnostic testing and received a diagnosis of sinus bradycardia. Which interventions are most appropriate and should be included in the client's plan of care? (SELECT ALL THAT APPLY)
Prevention of vagal stimulation
Assess for acute pain
Prevention of falls
Assess for neurologic changes
Monitor fluid volume excess
Correct Answer : A,C,D
Rationale:
A. Preventing vagal stimulation can help prevent bradycardia.
B. Acute pain is not typically associated with sinus bradycardia.
C. Preventing falls is important because bradycardia can lead to dizziness and falls.
D. Assessing for neurologic changes is important because bradycardia can affect cerebral perfusion.
E. Monitoring fluid volume excess is not directly related to sinus bradycardia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Looking for P waves is important for assessing atrial activity, but it does not directly calculate heart rate.
B. Counting how many QRS complexes occur in a 6-second strip and multiplying by 10 is a quick and accurate way to calculate heart rate.
C. Reading the monitor or ECG interpretation provides information about the rhythm and morphology of the heart, but it does not directly calculate heart rate.
D. Measuring T waves is important for assessing cardiac repolarization, but it does not directly calculate heart rate.
Correct Answer is B
Explanation
A. A sinus tachycardia is characterized by a sinus P wave at a rate of more than 100 per minute followed by a narrow QRS complex unlike in the strip depicted above.
B. The above ECG strip shows a ventricular tachycardia based on the wide QRS with a rate more than 120 bpm, AV dissociation and the fusion beats.
C. A complete heart block is characterized by QRS complexes being conducted at their own rates and totally independent of the P wave.
D. An idioventricular rhythm is characterized by a slow regular ventricular rhythm with a rate less than 50 bpm unlike in the above strip. It also has a prolonged QRS interval with no P wave.
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