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 A

Explanation

Choice A rationale
Clubbed fingers can be a symptom of conditions such as endocarditis, a heart condition that involves inflammation of the inner lining of the heart.
Choice B rationale
While myocardial infarction (heart attack) is a serious condition, it is not typically associated with clubbing of the fingers.
Choice C rationale
Acute kidney injury does not typically cause clubbing of the fingers.
Choice D rationale
Chronic thrombophlebitis, a condition characterized by inflammation and blood clots in the veins, is not typically associated with clubbing of the fingers.

A. A 39-year-old patient experiencing tenderness and swelling in the right calf following a flight. B. A 58-year-old patient on anticoagulants for atrial fibrillation presenting with black stools. C. A 67-year-old patient with a gangrenous foot ulcer and a weak pedal pulse. D. A 50-year-old patient reporting sudden, severe upper back pain.

Correct Answer is B

Explanation

Choice A rationale
A 39-year-old patient experiencing tenderness and swelling in the right calf following a flight may be experiencing deep vein thrombosis (DVT), a condition that can lead to serious complications such as pulmonary embolism if not treated. However, DVT is not immediately life-threatening in most cases.
Choice B rationale
A 58-year-old patient on anticoagulants for atrial fibrillation presenting with black stools is likely experiencing gastrointestinal bleeding, a common side effect of anticoagulant therapy. This can lead to severe blood loss, anemia, and hypovolemic shock, which can be life-threatening if not promptly addressed. Therefore, this patient should be prioritized for assessment.
Choice C rationale
A 67-year-old patient with a gangrenous foot ulcer and a weak pedal pulse likely has peripheral artery disease and an infection that could lead to sepsis if not treated. However, while this condition needs medical attention, it is not as immediately life-threatening as gastrointestinal bleeding.
Choice D rationale
A 50-year-old patient reporting sudden, severe upper back pain could be experiencing a number of conditions, ranging from musculoskeletal strain to aortic dissection. While an aortic dissection is a medical emergency, without additional symptoms such as chest pain, shortness of breath, or loss of consciousness, this patient is not the highest priority.

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Naxlex Comprehensive Predictor Exams

While conducting an admission assessment, the nurse observes clubbing of the patient’s fingers. Based on this finding, the nurse should he patient about which disease process?

Correct Answer is A

Explanation

After the shift change, which patient in the emergency department should the nurse prioritize for assessment?

Correct Answer is B

Explanation

Given the electrocardiogram tracing below for a client who is unresponsive and without a pulse, what should be the nurse’s priority action?

While admitting a patient with pericarditis, what manifestations of this disorder should the nurse assess for?

The standard policy on the cardiac unit states, “Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg.”. Which patient should the nurse call the health care provider about?

A nurse performs Homans maneuver by flexing the knee and sharply dorsiflexing the foot. What response indicates a positive Homans sign?

A client is admitted to the telemetry unit with an episode of substernal chest pain. His diagnostic studies reveal an elevated ST segment on the electrocardiogram (ECG) and an elevated cardiac troponin level. What would be an appropriate initial nursing goal?

The nurse is caring for a client with weak pedal pulses, absent hair on bilateral legs, and a full-thickness wound on the right lateral malleolus with defined margins, including a minimal amount of serous exudate. Which of the following interventions is contraindicated?

What patient data would indicate to the nurse that the infusion of a thrombolytic agent should be stopped in a patient with an acute myocardial infarction?