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?
Atrial fibrillation.
Complete heart block.
First-degree atrioventricular block.
Premature atrial complexes.
The Correct Answer is C
This is because the PR interval is longer than normal, which indicates a delay in the conduction of electrical impulses from the atria to the ventricles through the AV node. A normal PR interval is 0.12 to 0.2 seconds, or 3 to 5 small squares on the EKG strip. In this case, the PR interval is 0.35 seconds, which is more than 5 small squares.
Choice A is wrong because atrial fibrillation is a type of arrhythmia where the atria beat irregularly and rapidly, producing chaotic and variable P waves and an irregular ventricular response.
There is no constant PR interval in atrial fibrillation.
Choice B is wrong because complete heart block is a type of arrhythmia where there is no conduction of electrical impulses from the atria to the ventricles, resulting in independent and dissociated atrial and ventricular rhythms.
There are no consistent P waves or PR intervals in complete heart block.
Choice D is wrong because premature atrial complexes are extra beats that originate from the atria and interrupt the normal sinus rhythm.
They produce abnormal P waves that are different from the sinus P waves, and may have a shorter or longer PR interval depending on the timing of the impulse.
However, they do not cause a constant prolongation of the PR interval.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Dizziness is a manifestation of hypovolemia, which is a decrease in blood volume due to fluid loss. Hypovolemia can cause orthostatic hypotension, which is a drop in blood pressure when changing positions. This can lead to dizziness, lightheadedness, or fainting.
Choice A is wrong because it is not a sign of hypovolemia, but rather a possible cause of it. Epistaxis is a nosebleed that can result from trauma, infection, dryness, or coagulation disorders.
Choice B is wrong because it is not a specific sign of hypovolemia, but rather a nonspecific symptom that can have many causes. Headache can be associated with dehydration, but it can also be caused by stress, infection, inflammation, or other factors.
Choice D is wrong because it is not a sign of hypovolemia, but rather a sign of fluid volume excess.
Fluid volume excess is an increase in blood volume due to fluid retention or overload. Fluid volume excess can cause dyspnea, which is difficulty breathing or shortness of breath.
Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg for adults. Normal ranges for heart rate are 60 to 100 beats per minute for adults.
Correct Answer is A
Explanation
This is because continuous enteral feedings through an NG tube can increase the risk of aspiration, which is the inhalation of food or fluids into the lungs. Measuring gastric residual volumes (GRV) can help monitor the tolerance and absorption of the feedings and prevent overfeeding. GRV is the amount of fluid aspirated from the stomach via an enteral tube to check for gastric emptying. The normal range of GRV is less than 200 ml.
Choice B is wrong because advancing the rate of the feeding every 2 hr can lead to overfeeding, abdominal distension, nausea, vomiting and diarrhea.
The rate of the feeding should be adjusted according to the client’s nutritional needs and tolerance.
Choice C is wrong because maintaining the head of the bed at a 20° angle is not enough to prevent aspiration. The head of the bed should be elevated at least 30° to 45° during and for at least one hour after feeding.
Choice D is wrong because flushing the NG tube with 30 mL 0.9% sodium chloride before and after medication is not related to continuous enteral feedings. This is a practice to prevent clogging of the tube and ensure proper delivery of medication. Flushing the tube with water before and after feeding is also recommended to maintain patency and hydration.
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