The nurse is caring for a client on a telemetry unit. The client's cardiac monitor exhibits the rhythm below. How should the nurse document this rhythm?
Sinus rhythm with first-degree heart block
ST-segment elevation myocardial infarction (STEMI)
Atrial fibrillation
Ventricular tachycardia
The Correct Answer is B
A. Sinus rhythm with first-degree heart block: This rhythm is characterized by a regular sinus rhythm with a prolonged PR interval (greater than 0.20 seconds), indicating a first-degree heart block.
B. ST-segment elevation myocardial infarction (STEMI): STEMI is indicated by significant ST-segment elevation in specific leads, showing acute myocardial infarction.
C. Atrial fibrillation: Atrial fibrillation shows an irregularly irregular rhythm without distinct P waves.
D. Ventricular tachycardia: Ventricular tachycardia is a rapid heart rhythm originating from the ventricles, with wide QRS complexes and no preceding P waves.
Nursing Test Bank
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Related Questions
Correct Answer is D
Explanation
A. Pacemaker: Pacemakers are used for bradyarrhythmias or heart block, not typically for atrial flutter.
B. Cardiac catheterization: This is used for diagnostic or interventional procedures, not for rhythm correction.
C. Pulmonary artery pressure monitoring: This is a monitoring tool for critically ill clients with heart failure or pulmonary hypertension, not a treatment for atrial flutter.
D. Cardioversion: Cardioversion is often used for atrial flutter when drug therapy fails. It delivers synchronized electrical energy to restore normal sinus rhythm.
Correct Answer is A
Explanation
A. BP 170/64, pulse 58: Cushing's triad includes increased systolic blood pressure with widened pulse pressure, bradycardia, and irregular respirations, indicating increased intracranial pressure.
B. BP 180/90, pulse 96: Hypertension is present, but the elevated pulse does not align with bradycardia seen in Cushing's triad.
C. BP 110/70, pulse 100: These values do not reflect the classic signs of Cushing's triad.
D. BP 100/60, pulse 54: While bradycardia is present, hypotension does not align with Cushing’s triad.
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