A nurse is providing care for a 70-year-old male client in the intensive care unit.

Exhibits

For each assessment finding, click to specify if the finding is expected or unexpected for a client post-tricuspid valve replacement surgery.

Choice A rationale

Calling emergency services without a thorough assessment may be premature. While the client reports difficulty breathing, the severity and underlying cause need to be determined first to guide appropriate intervention. Immediate escalation might not be necessary if the issue is easily resolvable.

Choice B rationale

Assessing the client's respiratory status, including respiratory rate, depth, oxygen saturation, and lung sounds, is the priority action. This assessment will provide crucial information about the severity of the client's breathing difficulty and help determine the appropriate next steps. Objective data is essential for effective intervention.

Choice C rationale

Encouraging coughing and expectoration might be helpful if the difficulty breathing is due to retained secretions. However, without first assessing the respiratory status, it's unclear if this is the primary issue. This intervention might delay necessary actions if another problem exists.

Choice D rationale

Increasing the oxygen flow rate without a physician's order and without assessing the client's oxygen saturation can be dangerous for COPD clients. COPD patients can be sensitive to high oxygen concentrations, potentially leading to decreased respiratory drive. Assessment is needed before any oxygen adjustments.

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.