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 C

Explanation

a. Slow: Atrial fibrillation is characterized by an irregular heart rate, but it may not necessarily be slow. The rate can vary, and it is irregularly irregular.

b. Not palpable: While atrial fibrillation can result in an irregularly irregular pulse, it is not necessarily indicative of a pulse that is not palpable.

c. Irregular: Atrial fibrillation is associated with an irregularly irregular pulse due to the chaotic and disorganized atrial activity.

d. Bounding: Bounding pulses are characterized by a forceful and strong pulse, which is not typically associated with atrial fibrillation.

A. Request an order for an antiemetic. B. Request a dietary consult. C. Check the client’s vital signs. D. Suggest that the client rests before eating the meal.

Correct Answer is C

Explanation

A. Request an order for an antiemetic - Checking vital signs is the priority before administering any medication. Antiemetics may be considered later, but the nurse needs to assess the client's overall condition first.

B. Request a dietary consult - Assessing vital signs comes before consulting for dietary issues.

The priority is to determine the client's immediate physiological status.

C. Check the client’s vital signs - This is the correct first action as it helps to evaluate the client's cardiovascular status, especially considering the potential toxicity of digoxin in the setting of

nausea and refusal of breakfast.

D. Suggest that the client rests before eating the meal - While rest may be beneficial, assessing vital signs takes precedence to rule out any acute cardiovascular compromise.

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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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Explanation

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