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

Answer and Explanation

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.

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Correct Answer is B

Explanation

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.

A. The new graduate nurse elevates the client's head of the bed to 30 degrees. B. The new graduate nurse administers an analgesic before turning the client. C. The new graduate nurse is frequently suctioning the client without breaks. D. The new graduate nurse assesses the client's neurologic status every hour.

Correct Answer is C

Explanation

A. The new graduate nurse elevates the client's head of the bed to 30 degrees. Elevating the head of the bed to 30 degrees helps reduce ICP by promoting venous drainage from the brain.

B. The new graduate nurse administers an analgesic before turning the client. Analgesics are often necessary before turning a client with a head injury to minimize discomfort and prevent additional stress.

C. The new graduate nurse is frequently suctioning the client without breaks: Frequent suctioning without breaks can increase intracranial pressure (ICP) and compromise the patient's condition. Suctioning should be done with caution and only as needed, allowing for breaks in between to prevent ICP elevation.

D. The new graduate nurse assesses the client's neurologic status every hour. Regular neuro assessments are necessary for patients with head injuries to monitor changes in condition.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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