The nurse is reading the cardiac monitor and notes that the patient's heart rhythm is extremely irregular and there are no discernible P waves. The ventricular rate is 90 beats per minute, and the patient is hemodynamically stable. The nurse realizes that the patient's rhythm is:
atrial flutter.
atrial flutter with rapid ventricular response
atrial tachycardia
atrial fibrillation
The Correct Answer is D
A. Atrial flutter typically presents with regular atrial activity, often at a rate of 250–350 beats per minute, producing sawtooth “flutter” waves on the ECG. The ventricular response can be regular or irregular, but the defining feature is the visible flutter waves, which are not present in this patient.
B. Rapid ventricular response occurs when the ventricular rate exceeds 100–150 beats per minute. In this patient, the ventricular rate is 90 bpm, which is within normal limits, making rapid response unlikely. Additionally, flutter waves are absent.
C. Atrial tachycardia is a regular rhythm originating from an ectopic atrial focus, usually with distinct P waves preceding each QRS. This patient’s rhythm is extremely irregular and lacks discernible P waves, so atrial tachycardia is not consistent with the findings.
D. Atrial fibrillation is characterized by completely irregular rhythm, absent P waves, and fibrillatory waves that are too fine to discern. The ventricular rate is variable and can be slow, normal, or rapid. This patient is hemodynamically stable, and the ventricular rate of 90 bpm is consistent with controlled atrial fibrillation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
True is correct because in patient care, pain management is a priority over sedation. Unrelieved pain can lead to physiological stress responses such as increased heart rate, blood pressure, and oxygen demand, which may worsen underlying conditions, especially in cardiac, surgical, or critically ill patients. Pain also impacts recovery, mobility, and overall patient comfort. Sedation, while sometimes necessary for patient comfort or procedural purposes, does not treat the underlying pain. Providing sedation without addressing pain can mask symptoms, delay diagnosis, or lead to unnecessary complications. Prioritizing pain management is consistent with patient-centered care principles and guidelines from organizations such as the American Nurses Association (ANA) and the World Health Organization (WHO).
Correct Answer is B
Explanation
A. While repeat blood gases may eventually be required, the priority is correcting the patient’s hypoxemia and acid-base imbalance. Waiting for another blood draw without immediate intervention could worsen hypoxia and tissue perfusion.
B. The ABG values indicate acidemia (pH 7.28), mild hypercapnia (PaCO₂ 46), and significant hypoxemia (PaO₂ 58, O₂ sat 88%). This patient is hypoxic and acidotic, likely requiring immediate ventilator adjustment or oxygen therapy. The respiratory therapist has the expertise to optimize ventilator settings or oxygen delivery, which is crucial for stabilizing the patient before further interventions.
C. While family notification is important, it is not the immediate priority in the context of acute hypoxemia and acid-base imbalance. Patient stabilization takes precedence over social interventions.
D. Repositioning may improve ventilation-perfusion matching, but it is insufficient to correct severe hypoxemia. Respiratory therapy intervention is required to ensure adequate oxygenation and ventilation.
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