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 D
Explanation
A. While draping is essential for maintaining sterility, it's typically done right before the physician performs the biopsy, not as a primary pre-procedure step for the nurse.
B. Monitoring for bleeding is important after the procedure, not necessarily beforehand.
C. Although informing the family can be helpful, the patient's understanding and consent are the top priority. Pain management is crucial for patient comfort and cooperation during the procedure.
D. Administering an analgesic helps reduce the patient's anxiety and discomfort during the bone marrow biopsy, which can be a painful procedure. This improves patient tolerance and allows the physician to perform the procedure more efficiently.
Correct Answer is B
Explanation
A. While bone involvement can occur in Hodgkin lymphoma, it is not typically associated with a high risk of spontaneous pathological fractures compared to multiple myeloma.
B. Multiple myeloma is characterized by the destruction of bone tissue, leading to an increased risk of spontaneous pathological fractures.
C. Leukemia primarily affects the bone marrow and may cause bone pain but does not typically lead to spontaneous pathological fractures.
D. Hemophilia is a bleeding disorder characterized by a deficiency in clotting factors and is not directly associated with an increased risk of spontaneous pathological fractures.
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