A nurse leaves a coffee shop and sees a man lying on the ground. He is unresponsive and has no pulse and the nurse begins chest compressions. EMS arrives and connects the cardiac monitor displaying this rhythm. Identify the rhythm.
Sinus Rhythm
Ventricular Tachycardia
Ventricular Fibrillation
Sinus Tachycardia
The Correct Answer is C
A. Sinus rhythm is the normal rhythm of the heart with regular P waves, QRS complexes, and T waves. The presence of a sinus rhythm would mean the heart is pumping blood effectively, so the client would not be pulseless. This is inconsistent with the clinical scenario.
B. Ventricular tachycardia (VT) is a fast, regular rhythm originating in the ventricles. VT can lead to pulselessness if not treated, but it has distinct QRS complexes that are wide and regular, unlike the chaotic waveform seen in VF.
C. Ventricular Fibrillation appears as rapid, chaotic electrical activity without identifiable P waves, QRS complexes, or T waves. This rhythm prevents the heart from pumping blood, causing the client to be pulseless and unresponsive. VF is the most common arrhythmia associated with sudden cardiac arrest and requires immediate defibrillation.
D. Sinus tachycardia is a fast heart rate (>100 bpm) with regular rhythm, identifiable P waves, and QRS complexes. This rhythm typically occurs in response to stress, fever, or hypovolemia, and the client would have a pulse, which contradicts the scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Neurologic status is important to monitor but is not directly related to evaluating calcium gluconate's effect on hyperkalemia.
B. Urine volume would not directly reflect the immediate effects of calcium gluconate in managing hyperkalemia.
C. Calcium gluconate is given to protect the heart from the effects of hyperkalemia by stabilizing the cardiac membrane. Monitoring the cardiac rhythm is essential to assess the effectiveness of the treatment.
D. The calcium level is relevant for monitoring the calcium treatment, but cardiac rhythm is a more immediate indicator of its effectiveness.
Correct Answer is B
Explanation
A. P wave touching the T wave can indicate an issue but is less urgent than chest pain.
B. Midsternal chest pain could indicate myocardial ischemia or infarction, requiring immediate intervention.
C. Increased urine output is not an urgent concern in this context.
D. Mild orthostatic hypotension is not as urgent as chest pain.
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