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

Answer and Explanation

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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Correct Answer is D

Explanation

A. Ventricular aneurysm. Ventricular aneurysms are a complication that typically develops weeks or months after an MI.

B. Heart failure. While heart failure is a risk following an MI, it is more of a concern in the longer term after the acute phase.

C. Pulmonary embolism. Pulmonary embolism is not a direct complication of MI and is less common in the immediate post-MI period.

D. Dysrhythmia: Within the first 24 hours following a myocardial infarction, dysrhythmias, particularly ventricular arrhythmias, are common and can be life-threatening. This is the highest risk during the early period after MI.

A. Atrial tachycardia B. Ventricular fibrillation C. Atrial flutter D. Sinus bradycardia

Correct Answer is C

Explanation

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 55-year-old client who is diagnosed with an evolving myocardial infarction (MI) insists on going home. The nurse encourages the client to be admitted because he knows that within the first 24 hours of a MI, there is a high risk for which of the following?

Correct Answer is D

Explanation

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?

Correct Answer is C

Explanation

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