Rhythm Strip

A client comes to the emergency department (ED) complaining of a "racing heart and nervousness." The client's blood pressure is 106/60. The cardiac monitor displays the rhythm below. Which nursing action should be performed first?

Prepare the client for electrical cardioversion

Perform a carotid massage on the client.

Administer lidocaine 1mg/hour.

Ask the client if they drank a caffeinated beverage

Answer and Explanation

The Correct Answer is B

A. Prepare the client for electrical cardioversion: Electrical cardioversion is reserved for unstable patients (e.g., hypotension, altered mental status, chest pain, or signs of shock). This client, while tachycardic, has a blood pressure of 106/60, which indicates relative stability. Cardioversion is not the first-line intervention in stable supraventricular tachycardia (SVT).

B. Perform a carotid massage on the client: Carotid sinus massage is a vagal maneuver used to slow conduction through the AV node and can terminate paroxysmal supraventricular tachycardia (PSVT). It is a non-invasive, first-line intervention for a stable patient with narrow-complex tachycardia, as shown on the ECG strip.

C. Administer lidocaine 1 mg/hour: Lidocaine is an antiarrhythmic used primarily to treat ventricular arrhythmias, such as ventricular tachycardia or fibrillation. It is not indicated for atrial or supraventricular tachycardias and would not address the underlying rhythm.

D. Ask the client if they drank a caffeinated beverage: While excessive caffeine intake can contribute to tachycardia, asking about caffeine use does not address the acute arrhythmia or guide immediate treatment. It may be part of history-taking but is not a priority intervention in this situation.

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Correct Answer is C

Explanation

A. Atria is taking longer to depolarize and contract: This would be indicated by a prolonged or abnormal P wave, not a normal PR interval. The rhythm strip shows clearly visible, normal-appearing P waves followed by QRS complexes, ruling this out as the correct interpretation.

B. Conduction time is slowed from the SA node to the ventricles: A slowed conduction time would result in a PR interval longer than 0.20 seconds, characteristic of first-degree AV block. The PR interval on this strip measures within the standard range (0.12–0.20 seconds), so this is not accurate.

C. The PR interval is within the normal time limits: The PR interval on the ECG strip spans about 3 to 4 small boxes (0.12–0.16 seconds), which is within the normal range of 0.12 to 0.20 seconds. This indicates normal conduction from the atria through the AV node to the ventricles.

D. Ventricular repolarization is delayed: Delayed ventricular repolarization refers to a prolonged QT interval, not an abnormality in the PR interval. The PR interval evaluates atrial conduction, not ventricular repolarization, so this is an incorrect association.

A. Teach the client how to change the pacemaker dressing B. Immobilize the affected arm using a sling C. Arrange for ancillary personnel to feed the client D. Monitor urine output every two hours

Correct Answer is B

Explanation

A. Teach the client how to change the pacemaker dressing: Client education is important but not a priority in the immediate post-procedure phase. Dressing changes should initially be performed using sterile technique by clinical staff to prevent infection at the insertion site.

B. Immobilize the affected arm using a sling: After pacemaker insertion, the affected arm (usually on the side of the implantation) should be immobilized or limited in movement to prevent lead dislodgment. Elevating the arm above the shoulder or excessive motion can compromise pacemaker lead placement during the early healing period.

C. Arrange for ancillary personnel to feed the client: Assistance with feeding is only necessary if the client has physical or cognitive limitations. This is not a routine or priority intervention following pacemaker insertion unless clinically indicated by other assessments.

D. Monitor urine output every two hours: Frequent monitoring of urine output is not directly related to pacemaker insertion unless there are other concerns such as fluid imbalance or renal dysfunction. It's not a standard intervention in the immediate care plan for this procedure.

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Rhythm Strip A client comes to the emergency department (ED) complaining of a "racing heart and nervousness." The client's blood pressure is 106/60. The cardiac monitor displays the rhythm below. Which nursing action should be performed first?

Nursing Test Bank

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Correct Answer is C

Explanation

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Rhythm Strip

A client comes to the emergency department (ED) complaining of a "racing heart and nervousness." The client's blood pressure is 106/60. The cardiac monitor displays the rhythm below. Which nursing action should be performed first?