This picture shows a 6 second rhythm strip of your client's cardiac telemetry. You would document this finding as:
Ventricular Tachycardia
Normal Sinus Rhythm
Ventricular Fibrillation
Atrial Fibrillation
The Correct Answer is B
A. Ventricular Tachycardia: This rhythm would be characterized by a rapid rate and wide, bizarre QRS complexes without visible P waves. The provided strip shows narrow QRS complexes and a regular rhythm, which is inconsistent with ventricular tachycardia. This patient is not demonstrating a life-threatening ventricular arrhythmia.
B. Normal Sinus Rhythm: The strip displays a regular rhythm with a P wave preceding every QRS complex, followed by a T wave. The rate is approximately 60 to 70 beats per minute, and the complexes are narrow and uniform. This represents the standard, healthy electrical conduction of the heart starting from the sinoatrial node.
C. Ventricular Fibrillation: Ventricular fibrillation would appear as a chaotic, wavy baseline with no identifiable QRS complexes or P waves. The strip clearly shows organized electrical activity and distinct mechanical contractions. This rhythm is incompatible with the stable, organized complexes seen in the client's telemetry.
D. Atrial Fibrillation: Atrial fibrillation is marked by an irregularly irregular rhythm and the absence of distinct P waves. The telemetry strip provided shows a very regular R-R interval and clear, consistent P waves before each contraction. Therefore, it does not meet the criteria for a diagnosis of atrial fibrillation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Assessing the legs and feet for peripheral edema: While edema is an important indicator of heart failure, it does not provide real-time information about the electrical activity of the heart. Edema is a chronic sign of volume overload rather than an acute indicator of dysrhythmia severity. It is not the most critical assessment prior to antiarrhythmic administration.
B. Checking the results of the most recent ECG: An ECG provides a snapshot of previous electrical activity but may not reflect the patient's current hemodynamic status. The nurse must assess the patient's actual physiological presentation at the moment the medication is being given. Bedside assessment is superior to relying solely on historical diagnostic data.
C. Listening to the apical pulse for a full minute: Antiarrhythmic medications can significantly alter heart rate and rhythm, potentially causing profound bradycardia or new conduction blocks. Assessing the apical pulse for 60 seconds provides the most accurate baseline of the heart's current rate and regularity. This is a mandatory safety step to ensure the patient can tolerate the drug.
D. Taking the blood pressure in both arms: While blood pressure is a vital sign, it is a secondary manifestation of the heart's pumping efficiency rather than a direct measure of the rhythm. A single arm reading is usually sufficient unless a specific vascular discrepancy is suspected. The primary concern with dysrhythmia medications is the heart rate itself.
Correct Answer is ["B","D","E"]
Explanation
A. Limiting physical activity: Sedentary behavior is a risk factor for hypertension and cardiovascular disease. Regular aerobic exercise helps lower blood pressure by improving vascular compliance and reducing systemic resistance. Clients should be encouraged to increase, rather than limit, their level of moderate physical activity.
B. Giving up smoking cigarettes: Nicotine causes immediate vasoconstriction and increases heart rate, leading to acute elevations in blood pressure. Long-term smoking damages the arterial walls and accelerates the development of atherosclerosis. Cessation is one of the most effective lifestyle changes for improving overall vascular health and reducing pressure.
C. Eating canned vegetables daily: Canned foods are typically very high in sodium, which is used as a preservative. High sodium intake leads to water retention and increased blood volume, which raises blood pressure. Clients should be advised to choose fresh or frozen vegetables to minimize their sodium consumption.
D. Pursuing measures for losing weight: Excess body weight increases the workload on the heart and is closely linked to metabolic changes that raise blood pressure. Even a modest reduction in weight can lead to a significant decrease in systolic and diastolic readings. Weight management is a cornerstone of non-pharmacological hypertension treatment.
E. Reducing sodium in the diet: High dietary salt intake triggers the body to retain fluid, increasing the total volume within the vascular system. Reducing sodium intake to less than 2,300 mg per day helps lower blood pressure and reduces the risk of stroke. This change directly addresses the fluid-volume component of hypertension.
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