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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Orthopnea: Orthopnea is difficulty breathing when lying flat, but the client's description of waking up suddenly points to paroxysmal nocturnal dyspnea.

B. Paroxysmal nocturnal dyspnea: This is the correct answer. Paroxysmal nocturnal dyspnea occurs when a client with heart failure wakes up at night feeling suffocated due to fluid redistribution and pulmonary congestion.

C. Pulsus alternans: Pulsus alternans refers to alternating strong and weak heartbeats and is not related to the client's description of nocturnal dyspnea.

D. Acute bilateral pleural effusion: While pleural effusion can cause respiratory symptoms, paroxysmal nocturnal dyspnea is more specific to heart failure.

A. Amiodarone 300mg IV bolus, Amiodarone 150mg bolus if needed B. CPR C. Cardioversion D. Defibrillation

Correct Answer is D

Explanation

A. Amiodarone is an antiarrhythmic used to treat ventricular arrhythmias like monomorphic VT, but it is not the first-line treatment for a pulseless patient. Defibrillation should be performed immediately, and amiodarone can be administered after defibrillation if the rhythm persists.

B. CPR is essential for maintaining circulation in a pulseless patient, but defibrillation should be the first priority for monomorphic VT. CPR should be continued if defibrillation is not immediately available, but the most effective intervention is defibrillation to attempt to restore normal rhythm.

C. Cardioversion is used for stable, regular arrhythmias, but for a pulseless client in monomorphic VT, defibrillation is the appropriate first intervention. Cardioversion is typically used when the patient is conscious or stable and is not a priority for pulseless VT.

D. For a pulseless client with monomorphic ventricular tachycardia, defibrillation is the priority intervention. Defibrillation delivers an electric shock to the heart, which may terminate the abnormal rhythm and allow the heart to return to normal sinus rhythm. This is the most effective and immediate treatment for a pulseless client in ventricular tachycardia.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse will document this assessment finding as

Correct Answer is B

Explanation

What would be the priority intervention for the care of the client who is pulseless and has the following rhythm on the monitor?

Correct Answer is D

Explanation

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