A nurse analyzes a rhythm strip for a patient who has had a myocardial infarction and observes the following: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, QRS complex wide and distorted, and QRS duration of 0.18 second.

How should the nurse interpret this cardiac rhythm?

Sinus tachycardia.

Ventricular tachycardia.

Ventricular fibrillation.

Atrial flutter.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Sinus tachycardia is a regular, rapid heart rate caused by rapid firing of the sinoatrial node. It is characterized by a heart rate of greater than 100 beats per minute, and P waves are present before each QRS complex. This does not match the description given.
Choice B rationale
Ventricular tachycardia is a fast, regular beating of the ventricles that may last for only a few seconds or for much longer. In this condition, the ventricular rate is often between 120 and 200 beats per minute, and P waves are not associated with the QRS complexes. This matches the description given.
Choice C rationale
Ventricular fibrillation is a severe condition in which the heart beats with rapid, erratic electrical impulses. This causes the ventricles to quiver uselessly instead of pumping blood. The description does not match this condition.
Choice D rationale
Atrial flutter is a condition that shares similarities with atrial fibrillation, both involve an irregular heartbeat. However, atrial flutter is more organized and less chaotic than atrial fibrillation, which can make it more manageable. The description does not match this condition.

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Correct Answer is C

Explanation

Choice A rationale
Stable angina is characterized by chest pain that occurs with exertion and is relieved by rest. If a patient with angina pectoris is experiencing chest pain at rest and needs to take three nitroglycerin pills to relieve the pain, this is not typical of stable angina.
Choice B rationale
A full-blown acute myocardial infarction (MI), or heart attack, typically presents with severe chest pain, shortness of breath, and other symptoms. While chest pain at rest could be a symptom of an MI, other symptoms would likely be present.
Choice C rationale
Unstable angina is characterized by chest pain that occurs at rest, is severe and prolonged, and is not relieved by nitroglycerin. Therefore, a patient with angina pectoris who is experiencing chest pain at rest and needs to take three nitroglycerin pills to relieve the pain could be experiencing unstable angina.
Choice D rationale
Pulmonary embolus, a blockage in one of the pulmonary arteries in the lungs, typically presents with sudden-onset shortness of breath, chest pain that may become worse upon deep breathing or coughing, and other symptoms. Chest pain at rest could be a symptom of a pulmonary embolus, but other symptoms would likely be present.

A. The patient smokes cigarettes. B. The patient eats bananas twice a day. C. The patient wears mittens outside. D. The patient takes calcium channel blockers.

Correct Answer is A

Explanation

Choice A rationale
Smoking cigarettes can exacerbate the symptoms of Raynaud’s disease by causing further constriction of the blood vessels. Therefore, a patient who continues to smoke cigarettes may need further education about the management of Raynaud’s disease.
Choice B rationale
Eating bananas twice a day is not typically a concern for patients with Raynaud’s disease.
Choice C rationale
Wearing mittens outside, especially in cold weather, is a recommended strategy for managing Raynaud’s disease. It can help to prevent episodes of Raynaud’s by keeping the hands warm and reducing exposure to cold temperatures.
Choice D rationale
Taking calcium channel blockers is a common treatment for Raynaud’s disease. These medications help to relax and open up the small blood vessels in the hands and feet, reducing the severity and frequency of Raynaud’s episodes.

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Naxlex Comprehensive Predictor Exams

A patient with angina pectoris is experiencing chest pain at rest and needs to take three nitroglycerin (NTG) pills to relieve the pain. What should the nurse consider this as a major symptom of?

Correct Answer is C

Explanation

Which of the following findings in a patient with Raynaud’s disease would indicate a need for further teaching?

Correct Answer is A

Explanation

A patient with dilated cardiomyopathy has recently developed atrial fibrillation that has been unresponsive to drug therapy for several days. What topic should the nurse plan to include in patient teaching?

An obese post-surgical patient reports sudden discomfort in her leg. Upon assessment, the nurse finds the leg to be cold and pale, with no pedal or popliteal pulse. What should the nurse suspect?

A nurse is caring for a client who has developed cardiac tamponade. Which of the following symptoms should the nurse expect to observe?

For a patient recovering from an acute myocardial infarction (AMI) who inquires about safely resuming sexual intercourse, what would be the best response from the nurse?

A 52-year-old male is diagnosed with chronic venous insufficiency, presenting with pooling of blood in the veins of the lower extremities and edema. Which of the following is an expected assessment finding of this disorder?

A 35-year-old patient presents with pulmonary hypertension and is diagnosed with right heart failure. What is the most likely cause of this condition?

A patient has been admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI). The patient is restless, anxious, has a blood pressure of 86/40 mm Hg, and a heart rate of 132 beats/min. What is the priority problem for this patient?