The nurse is evaluating a cardiac monitor strip for their client that displays a sinus rhythm with a heart rate of 72 bpm. The PR interval is 0.24 seconds. The vital signs are stable and the client reports no symptoms. What is the most appropriate nursing intervention?
Document the finding and continue to monitor the client.
Prepare the client for temporary pacemaker insertion.
Notify the client's health care provider immediately and then administer epinephrine IV.
Administer atropine per agency bradycardia protocol and then notify the health care provider
The Correct Answer is A
A. Document the finding and continue to monitor the client: A PR interval of 0.24 seconds indicates first-degree AV block, which is often asymptomatic and benign if vital signs are stable. No immediate intervention is required other than continued monitoring.
B. Prepare the client for temporary pacemaker insertion: Pacemakers are not indicated for asymptomatic first-degree AV block.
C. Notify the health care provider immediately and then administer epinephrine IV: This is unnecessary as the client is stable and shows no signs of hemodynamic compromise.
D. Administer atropine per agency bradycardia protocol and then notify the health care provider: Atropine is not required for a stable heart rate of 72 bpm.
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Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
A. Facilitates the insertion of a pacemaker: This is not the purpose of an electrophysiology study (EPS). A pacemaker may be considered based on the results, but EPS itself does not insert the device.
B. Assesses the function of the SA node: EPS is used to assess the electrical activity of the heart, including the function of the SA node.
C. Evaluates the effectiveness of prescribed antiarrhythmic medication: EPS can help evaluate how well antiarrhythmic medications are controlling arrhythmias.
D. Identifies the location of abnormal sites within cardiac muscle: EPS is often used to locate areas of the heart responsible for abnormal electrical conduction and arrhythmias.
E. Treats certain arrhythmias through the process of ablation: One of the therapeutic purposes of EPS is to perform ablation, which can treat certain arrhythmias by destroying abnormal tissue.
Correct Answer is A
Explanation
A. Troponin: Troponin is the most specific and reliable biomarker for myocardial injury. Levels rise within 3-6 hours and remain elevated for days, providing diagnostic and prognostic information.
B. Alkaline phosphatase: This is related to liver and bone disorders, not cardiac events.
C. Creatine kinase (CK): While CK-MB is specific to cardiac tissue, it is less specific and remains elevated for a shorter period compared to troponin.
D. Myoglobin: Myoglobin is an early but nonspecific marker of muscle damage and is not as reliable for diagnosing myocardial injury.
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