The nurse is caring for a patient whose cardiac monitor shows a total absence of electrical impulse as indicated by a flat line. The nurse does not detect a pulse or blood pressure. The nurse would document this as which of the following rhythms?
Atrial fibrillation
Asystole
Ventricular fibrillation
Atrial flutter
The Correct Answer is B
A. Atrial fibrillation is characterized by rapid, irregular electrical impulses originating from the atria, resulting in a quivering or fibrillating motion of the atria rather than a coordinated contraction.
B. Asystole is the absence of any electrical activity on the cardiac monitor, resulting in a flat line. It indicates the absence of ventricular contraction and is considered a medical emergency requiring immediate intervention (CPR and advanced cardiac life support).
C. Ventricular fibrillation is characterized by chaotic, disorganized electrical activity in the ventricles, resulting in ineffective quivering of the ventricles and loss of cardiac output.
D. Atrial flutter is characterized by rapid but regular electrical impulses originating from the atria, resulting in a sawtooth pattern on the ECG tracing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While a splenectomy can lead to increased workload on the liver, it does not directly predispose the patient to liver disease.
B. A history of splenectomy does not specifically increase the risk of lupus.
C. Patients who have undergone splenectomy are at increased risk of certain infections, particularly encapsulated bacteria such as Streptococcus pneumoniae, which can cause pneumonia.
D. A history of splenectomy does not directly increase the risk of renal disease.
Correct Answer is B
Explanation
A. In the oliguric phase of acute kidney injury, fluid intake may need to be restricted rather than encouraged to prevent fluid overload.
B. Hourly intake and output monitoring is crucial for managing fluid balance and assessing the progression of kidney injury. Close monitoring can help prevent fluid overload, which is a risk due to the reduced urine output. It also aids in the timely adjustment of fluid administration and the detection of any changes in the client's condition that may necessitate intervention.
C. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are contraindicated in acute kidney injury as they can further impair renal function.
D. In the oliguric phase, protein intake may need to be restricted to reduce the workload on the kidneys and minimize azotemia. A high-protein diet can increase the burden on already compromised kidneys due to the increased production of urea, a byproduct of protein metabolism that requires excretion by the kidneys.
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