A nurse is assisting with collecting data on a client who is on a continuous ECG monitor. The client's ECG tracing shows no identifiable P waves and an irregular ventricular rate. The nurseshould recognize the client is experiencing which of the following cardiac dysrhythmias?

Complete heart block

Atrial fibrillation

Sinus tachycardia

First-degree AV block.

Answer and Explanation

The Correct Answer is B

a. Complete heart block: Complete heart block would typically present with a regular ventricular rate, but with no association between P waves and QRS complexes.

b. Atrial fibrillation: Atrial fibrillation is characterized by the absence of identifiable P waves and an irregular ventricular rate. The atria fibrillate, leading to chaotic electrical activity and an irregular ventricular response.

c. Sinus tachycardia: Sinus tachycardia is characterized by a regular ventricular rate and identifiable P waves. It is not associated with the absence of P waves.

d. First-degree AV block: First-degree AV block is characterized by a prolonged PR interval, but it does not result in the absence of P waves. The relationship between P waves and QRS

complexes is maintained.

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Correct Answer is B

Explanation

a. C-reactive protein: This is a marker of inflammation and is not specific to renal function. It is more commonly used to assess inflammation in various conditions.

b. Serum creatinine: Elevated levels of serum creatinine are indicative of impaired renal

function. Creatinine is a waste product that is normally filtered by the kidneys. Increased levels suggest decreased renal filtration.

c. Antinuclear antibody: This test is used to diagnose autoimmune diseases like SLE but does not directly measure renal function.

d. Erythrocyte sedimentation rate: This is a nonspecific marker of inflammation and is not directly related to renal function.

A. Maintain the client on bed rest. B. Strain the client's urine through a mesh filter. C. Encourage fluid intake of 1500 mL/day. D. Clamp the urinary catheter every 2 hr.

Correct Answer is B

Explanation

a. Maintain the client on bed rest: While rest may be indicated in some cases, it is not a specific intervention for managing renal stones with a urinary catheter.

b. Strain the client's urine through a mesh filter: Straining urine is essential to collect any stones that may have passed, allowing for analysis and identification.

c. Encourage fluid intake of 1500 mL/day: Adequate fluid intake is crucial to prevent stone formation, but the amount may vary depending on the client's specific needs and condition.

d. Clamp the urinary catheter every 2 hr: Clamping the urinary catheter is not a standard

intervention for managing renal stones. Straining the urine for stone collection is a more relevant intervention.

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A nurse is assisting with collecting data on a client who is on a continuous ECG monitor. The client's ECG tracing shows no identifiable P waves and an irregular ventricular rate. The nurseshould recognize the client is experiencing which of the following cardiac dysrhythmias?

Nursing Test Bank

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