To properly identify a cardiac rhythm, the nurse will determine if the client's rhythm contains the following factors: (Select All that Apply.)

the P-P and R-R distances are equal and regular

the rhythm rate using a 3-second strip

the duration of the U waves

there is a QRS complex after each P wave

P waves are present, upright and rounded

Answer and Explanation

Correct Answer : A,B,D,E

A. The P-P and R-R distances are equal and regular: Equal and regular spacing between P-P and R-R intervals indicates that both atrial and ventricular rhythms are regular. This is a fundamental aspect of rhythm interpretation, helping to distinguish between regular and irregular rhythms such as atrial fibrillation or sinus arrhythmia.

B. The rhythm rate using a 3-second strip: Assessing the heart rate using a 3-second or 6-second ECG strip helps determine whether the rhythm is bradycardic, tachycardic, or within normal limits, which is crucial for accurate rhythm classification.

C. The duration of the U waves: U waves are typically small and follow the T wave. Although their presence can suggest conditions like hypokalemia, they are not routinely assessed in basic rhythm identification. Evaluating U wave duration is more relevant in electrolyte imbalance analysis than in identifying rhythm type.

D. There is a QRS complex after each P wave: A consistent QRS following every P wave indicates effective conduction from the atria to the ventricles. Each atrial depolarization (P wave) should be followed by a ventricular depolarization (QRS complex) if the signal is being conducted properly through the AV node. This finding supports a diagnosis of sinus rhythm and helps rule out AV blocks, where conduction may be delayed or blocked entirely.

E. P waves are present, upright and rounded: P waves that are upright and rounded in lead II suggest the electrical impulse is originating from the SA node. Their presence and morphology are essential criteria for identifying sinus rhythm and differentiating it from atrial arrhythmias like flutter or fibrillation.

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Correct Answer is C

Explanation

A. Complete the remainder of the assessment: While ongoing assessment is important, the rhythm strip shows atrial flutter, a potentially unstable arrhythmia, and the client is experiencing symptoms (nausea after breakfast) which could suggest compromised cardiac output. Completing the remainder assessment delays the necessary intervention.

B. Obtain an order for adenosine IV: Adenosine is typically used for stable supraventricular tachycardia (SVT), not for atrial flutter, as it may not terminate the rhythm. It may slow conduction enough to better visualize flutter waves, but initiating it without a provider's order or further evaluation is inappropriate.

C. Notify the physician of the symptoms: The client’s rhythm strip shows atrial flutter with a rapid ventricular response and the patient is experiencing nausea, which could indicate decreased perfusion or early decompensation. Immediately notifying the provider is the safest and most appropriate action for further evaluation and treatment planning.

D. Administer the prescribed ACE inhibitor: ACE inhibitors are used for blood pressure control or heart failure management, not for acute rhythm disturbances. Administering it would not address the current rhythm or symptoms and could worsen hypotension if cardiac output is compromised.

A. Administer the dose later in the day when their nausea subsides B. Assess the client's apical rate C. Contact the physician for STAT serum potassium level D. Administer the client's prescribed dose intravenously

Correct Answer is B

Explanation

A. Administer the dose later in the day when their nausea subsides: Delaying the dose does not address the underlying concern of potential digoxin toxicity. Symptoms like nausea and visual disturbances suggest toxicity and require immediate assessment rather than postponement.

B. Assess the client's apical rate: The first and most appropriate nursing action is to assess the apical heart rate for one full minute, as bradycardia is a key indicator of digoxin toxicity. If the rate is below 60 bpm, the dose should be held, and the provider should be notified.

C. Contact the physician for STAT serum potassium level: Hypokalemia increases the risk of digoxin toxicity, but while checking potassium is important, it is not the first step. Assessment of heart rate is more immediately critical in evaluating the need to hold the medication.

D. Administer the client's prescribed dose intravenously: Administering the dose especially IV when the client has symptoms of toxicity could worsen the situation. Digoxin should be held, not given, until further evaluation and provider notification.

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To properly identify a cardiac rhythm, the nurse will determine if the client's rhythm contains the following factors: (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Rhythm Strip The nurse is evaluating the following rhythm strip on a client in the telemetry unit. The client is alert and oriented but is complaining of slight nausea after eating breakfast. What is the nurse's best action?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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