The client arrives to the emergency department with syncope. After placing the telemetry monitor on the client, the nurse sees this rhythm. How should the nurse interpret this rhythm?

Complete (third-degree) heart block

Pacemaker rhythm

Sinus bradycardia

First-degree heart block

Answer and Explanation

The Correct Answer is B

A. Complete (third-degree) heart block: This rhythm is characterized by a lack of relationship between P waves and QRS complexes, indicating a complete dissociation between atrial and ventricular activity.

B. A pacemaker rhythm on an ECG is characterized by the presence of pacing spikes followed by P waves or QRS complexes, depending on whether the pacemaker is pacing the atrium or the ventricle. If the pacemaker is pacing the ventricle, the pacing spike will be followed by a QRS complex. The QRS complexes in a paced rhythm are often wider than normal.

C. Sinus bradycardia: Sinus bradycardia is a slow but regular rhythm originating from the sinus node, with normal P waves and QRS complexes.

D. First-degree heart block: First-degree heart block is characterized by a prolonged PR interval (greater than 0.20 seconds) but with all P waves followed by QRS complexes, differing from third-degree heart block.

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Correct Answer is A

Explanation

A. Document the finding and continue to monitor the client: A PR interval of 0.24 seconds indicates first-degree AV block, which is often asymptomatic and benign if vital signs are stable. No immediate intervention is required other than continued monitoring.

B. Prepare the client for temporary pacemaker insertion: Pacemakers are not indicated for asymptomatic first-degree AV block.

C. Notify the health care provider immediately and then administer epinephrine IV: This is unnecessary as the client is stable and shows no signs of hemodynamic compromise.

D. Administer atropine per agency bradycardia protocol and then notify the health care provider: Atropine is not required for a stable heart rate of 72 bpm.

A. Maintain hyperventilation to a PaCO2 of 15 to 20mm Hg. B. Routinely suction to prevent accumulation of respiratory secretions C. Encourage visitation to prevent feelings of isolation. D. Avoid positioning the client with neck and hip flexion.

Correct Answer is D

Explanation

A. Maintain hyperventilation to a PaCO2 of 15 to 20 mm Hg. Hyperventilation can reduce ICP by causing vasoconstriction of cerebral blood vessels; however, a PaCO2 as low as 15–20 mmHg may lead to excessive vasoconstriction, reducing cerebral blood flow and causing cerebral ischemia. A PaCO2 target closer to 30–35 mmHg is typically recommended, and even this is used cautiously.

B. Routinely suction to prevent accumulation of respiratory secretions. Suctioning can increase ICP due to stimulation of the cough reflex. It should be performed only as needed and in a way that minimizes stimulation, such as preoxygenation and limiting suction duration.

C. Encourage visitation to prevent feelings of isolation. While social support is important, minimizing environmental stimuli (including limiting visitation) is crucial for clients with increased ICP to prevent overstimulation and further increases in ICP.

D. Avoid positioning the client with neck and hip flexion. Maintaining proper alignment of the head and neck is essential to promote venous drainage and reduce intracranial pressure (ICP). Flexion of the neck or hips can impede venous outflow, exacerbate ICP, and compromise cerebral perfusion.

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The client arrives to the emergency department with syncope. After placing the telemetry monitor on the client, the nurse sees this rhythm. How should the nurse interpret this rhythm?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is evaluating a cardiac monitor strip for their client that displays a sinus rhythm with a heart rate of 72 bpm. The PR interval is 0.24 seconds. The vital signs are stable and the client reports no symptoms. What is the most appropriate nursing intervention?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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