To properly identify a cardiac rhythm, the nurse will obtain the following factors. (SELECT ALL THAT APPLY)

if there is a QRS complex after each p wave

the rate using only a 3- second strip

the duration of the u waves

if the p waves are present

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

Answer and Explanation

Correct Answer : A,D,E

A) If there is a QRS complex after each P wave:
This is an important consideration when identifying a cardiac rhythm. The P wave represents atrial depolarization, and the QRS complex represents ventricular depolarization. In a normal sinus rhythm, every P wave is followed by a QRS complex, which confirms that the impulse originating in the SA node is being conducted properly through the atrioventricular (AV) node and into the ventricles. The presence of a QRS after every P wave helps confirm normal conduction and rhythm.

B) The rate using only a 3-second strip:
While the heart rate is an essential part of the rhythm assessment, using only a 3-second strip is not the most accurate method for determining the rate. Typically, a 6-second strip is used to estimate the rate, multiplying the number of R-R intervals by 10 to obtain the heart rate. A 3-second strip can be used for quick estimates but may lead to inaccurate calculations of the heart rate.

C) The duration of the U waves:
The U wave is often a normal variant seen in the ECG and is not always present. If it is visible, its duration is typically not a primary focus in rhythm interpretation unless there are concerns about electrolyte imbalances, such as hypokalemia. The U wave is not a core factor to consider when identifying the overall rhythm.

D) If the P waves are present:
The presence of P waves is important for identifying the rhythm, particularly when differentiating between sinus rhythms (normal) and non-sinus rhythms (such as atrial arrhythmias). In normal sinus rhythm, P waves should be present, reflecting atrial depolarization initiated by the SA node. The absence of P waves can indicate atrial fibrillation, atrial flutter, or other arrhythmias.

E) If the P-P and R-R distances are equal:
This is crucial in identifying a regular rhythm. The P-P interval refers to the distance between successive P waves (atrial depolarization), and the R-R interval refers to the distance between successive R waves (ventricular depolarization). In normal sinus rhythm or regular rhythms, both the P-P and R-R intervals should be equal, indicating that the atrial and ventricular rhythms are consistent. If they are unequal, it suggests an irregular rhythm (e.g., atrial fibrillation).

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Correct Answer is B

Explanation

A) Determine when the patient last ate and call for spiritual advisor:
While it is important to gather a comprehensive history, including when the patient last ate, and to provide emotional support such as calling a spiritual advisor, these actions are not the priority in this situation. The immediate concern is the patient's physical condition and addressing the potential trauma to the chest and abdominal organs. Bowel sounds in the chest suggest a serious injury, such as a diaphragmatic rupture, which requires immediate surgical intervention.

B) Assess vital signs and immediately notify the trauma surgeon:
Hearing bowel sounds in the chest is a strong indication of a diaphragmatic injury, possibly a rupture, which can lead to the bowel being displaced into the chest cavity. This is a life-threatening emergency that can result in respiratory distress, impaired organ function, and infection. The nurse should assess vital signs to determine if the patient is stable or in shock and then immediately notify the trauma surgeon to facilitate urgent surgical intervention. Immediate surgical repair is necessary to prevent further complications such as respiratory compromise or sepsis.

C) Request an order for a chest x-ray and stop IV fluids:
A chest x-ray may be ordered later to confirm the presence of diaphragmatic injury or other chest trauma, but the priority action is to notify the trauma surgeon immediately. Stopping IV fluids is not appropriate in this situation; the patient likely needs continued fluid resuscitation, especially if they are in shock or have significant blood loss from their traumatic injuries.

D) Medicate the patient's pain and obtain consent for surgery:
Pain management is important for the patient’s comfort, but surgical intervention should not be delayed while obtaining consent. The trauma surgeon should be notified immediately, and surgery should be expedited without waiting for consent. In trauma cases, consent for life-saving procedures may be implied if the patient is unconscious or unable to provide consent due to the urgency of the situation.

A. begins training to prepare to run a marathon next year B. refuses to attend church and states that ‘’his faith has failed him’’ C. promises God to give up smoking if allowed to live until their children are married D. gathers the family together in order to discuss what their last wishes are

Correct Answer is B

Explanation

A) Begins training to prepare to run a marathon next year:
This response is not characteristic of the stage of anger. Instead, this behavior suggests denial or possibly bargaining, as the client may be attempting to maintain a sense of normalcy or even hope in the face of a terminal illness like Amyotrophic Lateral Sclerosis (ALS).

B) Refuses to attend church and states that "his faith has failed him":
This statement reflects the anger stage of Kubler-Ross’s five stages of grief. During the anger stage, individuals often experience intense feelings of frustration, helplessness, and resentment about their situation. They may direct these emotions towards others, including higher powers or themselves. In this case, the client is expressing anger by blaming his circumstances and feeling abandoned by his faith, a common reaction when facing an irreversible condition like ALS.

C) Promises God to give up smoking if allowed to live until their children are married:
This behavior represents the bargaining stage of grief, not anger. In the bargaining phase, individuals may attempt to negotiate with a higher power or themselves, making promises or deals in exchange for a prolongation of life or a desired outcome. The client is trying to strike a "deal" by making promises for future behavior in exchange for a specific wish, reflecting bargaining rather than anger.

D) Gathers the family together in order to discuss what their last wishes are:
This scenario aligns more with the acceptance stage of grief. In the acceptance stage, individuals come to terms with their diagnosis and begin to make plans for the end of their life. The act of discussing last wishes indicates that the client is accepting the reality of their condition and preparing for what is to come.

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To properly identify a cardiac rhythm, the nurse will obtain the following factors. (SELECT ALL THAT APPLY)

Nursing Test Bank

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Correct Answer is B

Explanation

A client is diagnosed with Amyotrophic Lateral Sclerosis (ALS). Which situation represents Kubler-Ross grief stage of anger? The client:

Correct Answer is B

Explanation

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