Exhibits

The client's electrocardiogram (ECG) strip reveals sinus tachycardia. Select the 4 characteristics that the nurse is likely to see in the ECG.

Atrial and ventricular rates are 115 beats/minute

There is a wide QRS complexes.

The PP interval is regular.

There is absence of P waves.

The PR interval measures 0.12 seconds.

The QRS complex measures 0.08 seconds.

Answer and Explanation

Correct Answer : A,C,E,F

A. Atrial and ventricular rates are 115 beats/minute: Sinus tachycardia is defined by a heart rate greater than 100 beats/minute with normal sinus rhythm. The atrial and ventricular rates remain equal and typically range between 100–150 beats/minute in sinus tachycardia.

B. There is a wide QRS complex: Wide QRS complexes (>0.12 seconds) are not typical of sinus tachycardia and suggest an abnormal ventricular conduction, such as bundle branch block or ventricular rhythm, which is not supported by the sinus origin in this case.

C. The PP interval is regular: Regular PP intervals indicate consistent atrial depolarization, which is a hallmark of sinus rhythms, including sinus tachycardia. This reflects a stable and predictable SA node discharge.

D. The PR interval measures 0.12 seconds: A normal PR interval ranges from 0.12 to 0.20 seconds, and in sinus tachycardia, the PR interval remains within this normal range despite the faster rate.

E. There is absence of P waves: P waves are present and upright in leads II, III, and aVF during sinus tachycardia. Absence of P waves would suggest an atrial arrhythmia such as atrial fibrillation, not sinus tachycardia.

F. The QRS complex measures 0.08 seconds: A narrow QRS complex (<0.12 seconds) confirms that ventricular depolarization is occurring through the normal conduction pathways, which is typical in sinus tachycardia.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Obtain hemoglobin and hematocrit levels: A PTT of 152 seconds is significantly elevated, indicating a high risk of spontaneous bleeding. Monitoring hemoglobin and hematocrit helps detect internal or occult bleeding early.

B. Measure and record the client's IV fluid intake: While maintaining hydration is important, fluid intake does not directly address the risk associated with excessive anticoagulation. It is a routine measure, not a priority in this context.

C. Compare pedal pulse volume bilaterally: Assessing pedal pulses is important for evaluating perfusion, but it does not directly relate to the current risk of bleeding from excessive anticoagulation. It would be more relevant in the initial PE assessment.

D. Perform guaiac tests on the client’s next stools: Testing for occult blood is helpful in identifying gastrointestinal bleeding. However, waiting for the next bowel movement could delay detection. Hemoglobin and hematocrit offer more immediate insight into bleeding risk.

A. Agitated B. chest pain described as pressure and tightness that is unrelieved with rest C. Normal heart tones D. Rapid and shallow breaths E. Pain: Reported 7 on a 0 to 10 scale F. Clear breath sounds throughout bilateral lungs

Correct Answer is ["A","B","E"]

Explanation

Agitation: Agitation may indicate hypoxia or reduced cerebral perfusion due to cardiac compromise. In a patient with chest pain and borderline hypoxia, it can be an early warning sign of clinical deterioration that requires follow-up.
Chest pain described as pressure tightness unrelieved by rest: Unrelieved chest pain lasting longer than 20 minutes is strongly suggestive of myocardial infarction rather than stable angina. Immediate cardiac workup and intervention are needed to prevent myocardial damage.
Pain rated 7/10: A moderate to severe pain rating in the chest warrants urgent evaluation, especially when consistent with cardiac characteristics like tightness and pressure. High pain intensity is often correlated with worsening ischemia.

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Exhibits The client's electrocardiogram (ECG) strip reveals sinus tachycardia. Select the 4 characteristics that the nurse is likely to see in the ECG.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is ["A","B","E"]

Explanation

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Exhibits

The client's electrocardiogram (ECG) strip reveals sinus tachycardia. Select the 4 characteristics that the nurse is likely to see in the ECG.