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 A

Explanation

A. Pulmonic: The pulmonic valve is best auscultated at the second left intercostal space along the left sternal border. A murmur heard in this location is most likely associated with pulmonic valve abnormalities such as pulmonary stenosis or pulmonary regurgitation.

B. Aortic: The aortic valve is auscultated at the second right intercostal space at the right sternal border. A murmur at this site may indicate aortic stenosis or regurgitation, but not when heard on the left side as in this scenario.

C. Tricuspid: Tricuspid valve murmurs are typically heard best at the lower left sternal border, around the fourth or fifth intercostal space. This location is more inferior than where the nurse auscultated the murmur in the current assessment.

D. Mitral: The mitral valve is best heard at the fifth intercostal space at the midclavicular line (the cardiac apex). Murmurs related to mitral stenosis or regurgitation would not typically be heard at the second intercostal space near the sternum.

A. surgery has caused an episode of supraventricular tachycardia. B. is febrile which is causing the heart rate to be elevated. C. is in heart failure and the heart rate is elevated to compensate. D. probably has a low oxygen saturation causing an increased respiratory rate.

Correct Answer is B

Explanation

A. surgery has caused an episode of supraventricular tachycardia: While stress or surgery can trigger arrhythmias, the ECG shown demonstrates a sinus tachycardia pattern (narrow QRS complexes with identifiable P waves before each QRS), not supraventricular tachycardia (SVT), which typically has a very rapid, regular rhythm often without visible P waves.

B. is febrile which is causing the heart rate to be elevated: The client has a temperature of 102°F (38.8°C), which can increase metabolic demand and lead to sinus tachycardia. Fever is a common and expected cause of elevated heart rate, especially when accompanied by infection, such as the client’s post-op wound infection.

C. is in heart failure and the heart rate is elevated to compensate: There is no evidence from the scenario (no dyspnea, crackles, edema, or reduced BP) that supports heart failure. The elevated HR is more directly related to the fever and infection, not cardiac decompensation.

D. probably has a low oxygen saturation causing an increased respiratory rate: The respiratory rate is slightly elevated (22/min), but there is no mention of hypoxia or oxygen saturation levels. Tachycardia secondary to hypoxia would require clinical indicators of respiratory distress or desaturation, which are not demonstrated.

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WBC	8.5
Hemoglobin	17g/dL
Hematocrit	54%
BUN	28mg/dL
Creatinine	1.1 mg/dL
Potassium	4.9 mEq/L

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 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?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

The nurse observes the following rhythm of a client on the telemetry unit. Which action should be completed first?

The nurse is caring for a client with heart failure who is being discharged on lisinopril 10 mg PO bid. Which teaching about this medication should be included in the discharge instructions?

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 nurse assesses a client who is prescribed digoxin. The client reports nausea and seeing green halos. Which action should the nurse perform?

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

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?

The nurse is administering tamsulosin to a client. Which disease process should the nurse expect to find in the client's past medical history?