A nurse is analyzing a client’s electrocardiogram (ECG) strip and identifies the following information: Heart rate: 92/min.
Rhythm: Irregular.
P wave: Unable to identify.
PR interval: Unable to measure. QRS duration: 0.10 seconds.
Based upon this information, the nurse should interpret the client’s rhythm as indicating which of the following?
Supraventricular tachycardia.
Atrial fibrillation.
Sinus bradycardia.
First-degree heart block.
The Correct Answer is B
Choice A rationale
Supraventricular tachycardia (SVT) is characterized by a rapid heart rate originating above the ventricles, typically with a regular rhythm and identifiable P waves. The described ECG strip shows an irregular rhythm and an inability to identify P waves, which is not consistent with SVT5.
Choice B rationale
Atrial fibrillation (AF) is characterized by an irregularly irregular rhythm, absence of identifiable P waves, and variable PR intervals. The ECG findings of an irregular rhythm, inability to identify P waves, and a QRS duration of 0.10 seconds are consistent with AF6.
Choice C rationale
Sinus bradycardia is characterized by a regular rhythm with a heart rate less than 60 beats per minute and identifiable P waves preceding each QRS complex. The described ECG strip shows an irregular rhythm and an inability to identify P waves, which is not consistent with sinus bradycardia.
Choice D rationale
First-degree heart block is characterized by a prolonged PR interval with a regular rhythm. The described ECG strip shows an irregular rhythm and an inability to measure the PR interval, which is not consistent with first-degree heart block.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Maintaining a semi-Fowler’s position can help improve lung expansion and ease breathing in clients with chronic obstructive pulmonary disease (COPD). However, it does not directly address the issue of mucus congestion and difficulty in expectorating (bringing up) mucus.
While positioning can aid in overall respiratory comfort, it is not the most effective intervention for managing mucus congestion in COPD clients.
Choice B rationale
A low-salt diet is beneficial for overall health and can help manage conditions such as hypertension and heart disease. However, it does not have a direct impact on mucus congestion in clients with COPD. Dietary modifications are important for managing comorbidities, but they do not address the primary concern of mucus clearance in this scenario.
Choice C rationale
Encouraging the client to drink 2 to 3 liters of water daily is an effective intervention for managing mucus congestion in clients with COPD. Adequate hydration helps thin the mucus, making it easier to cough up and clear from the airways. This intervention directly addresses the client’s complaint of difficulty in expectorating mucus and can improve respiratory function and comfort.
Choice D rationale
Administering oxygen via nasal cannula at 2 L/min can help improve oxygenation in clients with COPD. However, it does not address the issue of mucus congestion and difficulty in expectorating mucus. While supplemental oxygen is important for managing hypoxemia, it is not the primary intervention for mucus clearance. The focus should be on interventions that help thin and mobilize mucus to alleviate the client’s symptoms.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale
A heart rate of 110/min and regular is not an immediate concern in this context. Tachycardia can occur due to various reasons, including anxiety or pain, and does not require immediate follow-up.
Choice B rationale
Oxygen saturation of 95-96% is within the normal range and does not require immediate follow-up.
Choice C rationale
Subcutaneous emphysema requires immediate follow-up because it indicates air leakage into the subcutaneous tissue, which can be a sign of pneumothorax or other complications.
Choice D rationale
A trachea that is midline does not require immediate follow-up as it indicates there is no mediastinal shift.
Choice E rationale
A dry puncture site does not require immediate follow-up as it indicates there is no ongoing issue at the insertion site.
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