How should the nurse interpret the rhythm shown on the electrocardiogram strip shown in the diagram?

asystole

ventricular fibrillation

sinus tachycardia

sinus bradycardia

Answer and Explanation

The Correct Answer is B

A. Asystole: Asystole would show a flat line with no electrical activity, which is not seen here.

B. Ventricular fibrillation: Ventricular fibrillation is characterized by chaotic, irregular waveforms without distinct P waves, QRS complexes, or T waves. The ECG strip shows this disorganized, erratic electrical activity consistent with ventricular fibrillation.

C. Sinus tachycardia: Sinus tachycardia would display a regular rhythm with identifiable P waves, QRS complexes, and T waves at a faster rate. This is not present in the ECG strip.

D. Sinus bradycardia: Sinus bradycardia would show a slower rate but with an organized rhythm and distinct P, QRS, and T waves. This is not indicated in the strip.

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Correct Answer is C

Explanation

A. The patient's chart may provide historical information but does not reflect the current pain intensity the client is experiencing.

B. Visual observation for nonverbal signs of pain can be useful, especially for nonverbal patients, but self-reporting is the most accurate measure of pain intensity.

C. The client's self-report of pain severity is the gold standard for assessing pain intensity, as it reflects the individual’s personal experience of pain.

D. While the nature and invasiveness of the surgical procedure can provide context for expected pain levels, they do not replace the importance of the client's self-report in managing pain effectively.

A. Pigeon B. Barrel C. Kyphotic D. Funnel

Correct Answer is B

Explanation

A. Pigeon chest (pectus carinatum) is a structural deformity of the chest and is not associated with COPD.

B. A barrel chest is commonly seen in clients with COPD due to hyperinflation of the lungs, causing the chest to appear rounded and expanded.

C. Kyphotic refers to an abnormal curvature of the spine (kyphosis) and is not a characteristic of COPD.

D. Funnel chest (pectus excavatum) is another structural deformity and is not typically associated with COPD.

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How should the nurse interpret the rhythm shown on the electrocardiogram strip shown in the diagram?

Nursing Test Bank

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