A nurse is reviewing a client's cardiac rhythm strips and notes a constant P-R interval of
0.35 seconds. Which of the following dysrhythmias is the client displaying?
Premature atrial complexes
Complete heart block
Atrial fibrillation
First-degree atrioventricular block
The Correct Answer is D
A. Incorrect. Premature atrial complexes do not typically affect the P-R interval. They are characterized by an early P-wave followed by a QRS complex.
B. Incorrect. Complete heart block is characterized by a dissociation between the P-waves and QRS complexes, resulting in no relationship between atrial and ventricular activity.
C. Incorrect. Atrial fibrillation is characterized by chaotic and irregular atrial activity without distinct P-waves, making the P-R interval irrelevant.
D. Correct. In first-degree atrioventricular block, the P-R interval is prolonged beyond the normal range of 0.12-0.20 seconds. A constant P-R interval of 0.35 seconds indicates a first- degree atrioventricular block.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Waiting for 2 minutes between suctions is a standard practice to prevent damage to the trachea and to allow the client to recover from the suctioning process. This action is also appropriate and does not require intervention.
B. Suction is typically applied for 10-15 seconds while withdrawing the catheter to prevent hypoxia and trauma to the airway.
C. Encouraging a client to cough during suctioning is generally acceptable because coughing helps expel secretions from the airway.However, the nurse should ensure that the client does not cough too forcefully, as this could lead to trauma or discomfort.
D. The catheter should be attached to suction while being inserted and withdrawn to effectively clear secretions from the airway.
Correct Answer is D
Explanation
A. Incorrect. Releasing the tourniquet is a step that can be taken after advancing the catheter into the vein.
B. Incorrect. Retracting the stylet at this point could disrupt the position of the catheter and cause leakage or damage.
C. Incorrect. Flushing the catheter with saline is an appropriate step after ensuring the catheter is correctly placed in the vein.
D. Correct. After noting a blood return in the flashback chamber, the next step is to advance the catheter into the vein to ensure proper placement for intravenous access.
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