The nurse is documenting a client’s assessment. The rhythm below was obtained from the client’s cardiac monitor. How should the nurse document this strip?
Atrial tachycardia
Ventricular fibrillation
Atrial flutter
Sinus bradycardia
The Correct Answer is C
A. Atrial tachycardia: Atrial tachycardia is a rapid heart rhythm originating from the atria, but it does not have the characteristic "sawtooth" pattern seen in atrial flutter.
B. Ventricular fibrillation: Ventricular fibrillation is a chaotic rhythm originating from the ventricles, characterized by irregular, rapid waves with no discernible P waves or QRS complexes.
C. Atrial flutter: Atrial flutter is recognized by a "sawtooth" pattern of P waves, indicating rapid atrial depolarizations.
D. Sinus bradycardia: Sinus bradycardia is a slow but regular rhythm originating from the sinus node, with normal P waves and QRS complexes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Decerebrate posturing: This involves extension and outward rotation of the arms, which is not observed here.
B. Decorticate posturing: Internal rotation, adduction, and flexion of the arms are characteristic of decorticate posturing, indicating damage to the corticospinal tract.
C. Flexion withdrawal: This refers to pulling away from a painful stimulus and does not involve the described pattern of movement.
D. Localization of pain: This is an intentional movement toward the source of pain, which is not demonstrated in this scenario.
Correct Answer is C
Explanation
A. Call the physician: While notifying the physician is important, it is not the immediate priority in a life-threatening situation like ventricular fibrillation.
B. Administer oxygen: Administering oxygen is helpful, but the immediate priority in ventricular fibrillation is to initiate life-saving measures.
C. Initiate cardiopulmonary resuscitation (CPR): Ventricular fibrillation is a life-threatening emergency, and initiating CPR immediately is crucial to restore circulation and improve chances of survival.
D. Give a dose of epinephrine: Epinephrine is part of the advanced cardiac life support (ACLS) protocol, but it should be administered after initiating CPR and defibrillation.
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