A nurse is analyzing a client's electrocardiogram 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?

First-degree heart block.

Supraventricular tachycardia.

Sinus bradycardia.

Atrial fibrillation.

Answer and Explanation

The Correct Answer is D

Choice A rationale

First-degree heart block is characterized by a prolonged PR interval (greater than 0.20 seconds) due to a delay in the conduction of the electrical impulse from the atria to the ventricles. The ECG strip described lacks identifiable P waves and a measurable PR interval, thus ruling out first-degree heart block. The QRS duration is within the normal range (0.06-0.10 seconds), which is also inconsistent with higher-degree AV blocks that might show a widened QRS complex if a ventricular escape rhythm is present.

Choice B rationale

Supraventricular tachycardia (SVT) is characterized by a rapid heart rate (typically greater than 150 beats per minute) originating above the ventricles. While the rhythm might be regular or slightly irregular depending on the specific type of SVT, P waves are usually present, although they may be abnormal in morphology or hidden within the T wave. The ECG description indicates an irregular rhythm and the absence of identifiable P waves, making SVT an unlikely diagnosis.

Choice C rationale

Sinus bradycardia is defined by a slow heart rate (less than 60 beats per minute) originating from the sinoatrial (SA) node. The rhythm is regular, and P waves are present, preceding each QRS complex with a normal PR interval (0.12-0.20 seconds). The client's heart rate is 92 beats per minute, which is within the normal range (60-100 beats per minute), and the rhythm is irregular with no discernible P waves, thus excluding sinus bradycardia.

Choice D rationale

Atrial fibrillation (A-fib) is a common arrhythmia characterized by rapid, disorganized electrical activity in the atria, leading to an irregularly irregular ventricular response. The ECG findings of an irregular rhythm, the absence of identifiable P waves (replaced by fibrillatory waves, which are not explicitly mentioned but implied by the lack of P waves), and a normal QRS duration (indicating normal ventricular depolarization) are classic characteristics of atrial fibrillation. The heart rate can vary in A-fib; a rate of 92 beats per minute falls within a controlled ventricular response in the context of this arrhythmia.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

Headache is a common and expected adverse effect of nitroglycerin. Nitroglycerin causes vasodilation, including dilation of the cerebral blood vessels. This increased blood flow to the head is the primary physiological mechanism responsible for nitroglycerin-induced headaches.

A. The client's urine output is cloudy and odorous. B. The client has an aPTT of 80 seconds. C. The client experiences sudden weakness of one arm and leg. D. The client's ECG tracing shows an irregular heart rate without P waves.

Correct Answer is C

Explanation

Choice A rationale

Cloudy and odorous urine suggests a urinary tract infection. While important to address, it is not the priority in a client receiving heparin for atrial fibrillation, as it does not directly indicate an immediate, life-threatening complication related to anticoagulation. Normal urine is typically clear and has a mild odor.

Choice B rationale

An aPTT of 80 seconds indicates that the client's blood is anticoagulated. The therapeutic range for aPTT in a client receiving heparin is typically 1.5 to 2.5 times the control value (usually 25-35 seconds), so 80 seconds is within a therapeutic to slightly elevated range. While it requires monitoring, it is not the immediate priority compared to signs of bleeding or thromboembolism.

Choice C rationale

Sudden weakness of one arm and leg is a classic sign of a stroke, which could be an embolic event related to atrial fibrillation despite heparin therapy. This requires immediate attention as it indicates a potentially life-threatening complication. Rapid intervention is crucial to minimize neurological damage.

Choice D rationale

An irregular heart rate without P waves on the ECG is characteristic of atrial fibrillation, the underlying condition for which the client is receiving heparin. While this confirms the diagnosis, it is not a new or acute finding requiring immediate action in the same way as a potential stroke.

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Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain.The client reports relief from the chest pain but now he is experiencing a headache.Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who has atrial fibrillation and is receiving heparin.Which of the following findings is the nurse's priority?

Correct Answer is C

Explanation

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Which of the following are the most common manifestations of COPD?

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A nurse is caring for a 60-year-old male client who reports chest pain in the emergency department. Exhibits The nurse is preparing the client for the cardiac catheterization. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is reviewing laboratory results for a client who has atrial fibrillation.Which of the following blood test results should the nurse understand can be a possible cause of atrial fibrillation?

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