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 D

Explanation

A. Blood pressure reading of 120/80: While a normal blood pressure is desirable, this value alone does not indicate improvement in fluid overload or pulmonary symptoms. It may remain normal even if respiratory status worsens or fails to improve.

B. Urine output 30 mL for one hour: Although urine output is an important measure of diuretic effectiveness, 30 mL/hr is the minimum acceptable rate, not necessarily a strong indicator of clinical improvement. More robust diuresis may be expected following IV furosemide.

C. Serum sodium level is 135 mEq/L (135–145): A normal sodium level reflects stable electrolyte status but does not directly indicate improvement in pulmonary congestion or dyspnea. Sodium may be affected by many factors unrelated to heart failure symptom relief.

D. Respiratory rate 16 per minute: A decrease in respiratory rate from 26 to 16 suggests improved oxygenation, reduced pulmonary congestion, and decreased work of breathing. It is the most direct and clinically relevant indicator of symptomatic improvement in this context.

A. Dilated B. Restrictive C. Hypertrophic D. Myocarditis

Correct Answer is A

Explanation

A. Dilated: Peripartum cardiomyopathy is a form of dilated cardiomyopathy that can occur during the last month of pregnancy or within five months after delivery. It is characterized by ventricular dilation and impaired systolic function, leading to signs of heart failure in previously healthy women.

B. Restrictive: Restrictive cardiomyopathy is a rare form that involves impaired ventricular filling due to stiffened myocardial walls. It is typically associated with infiltrative diseases like amyloidosis or sarcoidosis, not with pregnancy or the postpartum period.

C. Hypertrophic: Hypertrophic cardiomyopathy is usually genetic and involves thickened ventricular walls, especially the interventricular septum. It is not linked to childbirth and tends to present earlier in life with symptoms like syncope or sudden cardiac death in young athletes.

D. Myocarditis: Myocarditis involves inflammation of the heart muscle due to infection or autoimmune causes. Although it can occur postpartum, it is not specifically associated with childbirth like peripartum cardiomyopathy, which is a distinct clinical entity.

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Potassium 2.8 mEq/L
Sodium 133 mEq/L
Chloride 90 mEq/L
Glucose 200 mg/dl
Magnesium 2.5 mg/dL
Calcium 8.0 mg/dL

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

The client with heart failure exhibits bibasilar crackles, dyspnea and a respiratory rate of 26/min. The physician prescribes furosemide 40 mg IV and enalapril 5 mg PO. Which parameter would the nurse use to best evaluate if the client is responding to these medications?

Correct Answer is D

Explanation

The nurse is caring for a 24 year old post-partum client with a diagnosis of cardiomyopathy. The nurse understands that which of the following types of cardiomyopathy can be associated with childbirth?

Correct Answer is A

Explanation

The nurse is assessing a client with a diagnosis of mitral valve stenosis. Which element of assessment data indicates that the disease is worsening?

The patient with restrictive cardiomyopathy asks the nurse what could have caused this disorder. Which response by the nurse is most accurate?

A client is to receive an intravenous dose of adenosine. What immediate response to this medication should the nurse expect?

Rhythm Strip A client comes to the emergency department (ED) complaining of a "racing heart and nervousness." The client's blood pressure is 106/60. The cardiac monitor displays the rhythm below. Which nursing action should be performed first?

The nurse who is working in the telemetry unit measures the PR interval of the client's rhythm strip depicted below. What is the nurse's analysis of the PR interval?

The nurse is assessing a new admission and hears a murmur at the second left intercostal space along the left sternal border. The nurse anticipates the client has a murmur of which valve?

The nurse understands that sinus tachycardia differs from normal sinus rhythm because: