A client has a normal cardiac rhythm and a heart rate of 72 beats/minute. The nurse determines the P-R interval is 0.20 seconds. The most appropriate intervention by the nurse would be to
Notify the health care provider immediately.
Document the finding and continue to monitor the patient.
Prepare the patient for temporary pacemaker insertion.
Give atropine per agency dysrhythmia protocol.
The Correct Answer is B
A. Notifying the health care provider immediately is not necessary, as the PR interval is at the upper limit of normal (0.20 seconds) and the client is stable.
B. Document the finding and continue to monitor the patient – A PR interval of 0.20 seconds with a normal heart rate and rhythm does not require intervention; just ongoing observation.
C. Prepare the patient for temporary pacemaker insertion – This is used for serious conduction blocks or symptomatic bradycardia, which are not present here.
D. Give atropine per agency dysrhythmia protocol – Atropine is used for symptomatic bradycardia, which this client does not exhibit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Diuretics should be taken early in the morning to avoid nocturia, but not at bedtime.
B. A weight gain of 1 kg (2.2 lb) or more in a day or 1.4–2.3 kg (3–5 lb) in a week should be reported; 0.5 kg (1 lb) in a week is not typically concerning.
C. Regular exercise (e.g., at least three times per week) is encouraged in Class I heart failure to promote cardiovascular health and endurance. This is an appropriate and recommended instruction.
D. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) and should be avoided in clients with heart failure as it may cause fluid retention and worsen heart function.
Correct Answer is C
Explanation
A. A blood pressure of 84/50 mm Hg is more consistent with the progressive stage of shock, where compensation is failing.
B. Petechiae may be seen in disseminated intravascular coagulation (DIC), a complication of severe shock, typically not in the compensatory stage.
C. Confusion is an early sign of impaired cerebral perfusion, which can occur in the compensatory stage of shock. It reflects the body’s efforts to maintain perfusion to vital organs despite declining cardiac output.
D. Anuria (no urine output) is a late finding, typically seen in the irreversible stage of shock, indicating complete renal failure.
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