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 []
Explanation
Potential Condition: Atrial Fibrillation
The client presents with an irregular, tachycardic rhythm with unclear P waves, which are classic signs of atrial fibrillation (AF). Symptoms such as palpitations, dizziness, and shortness of breath are common with AF, particularly with a rapid ventricular response.
Actions to Take
• Administer an anticoagulant: AF increases the risk of thrombus formation in the atria, which can lead to embolic stroke. Anticoagulation reduces this risk, especially in symptomatic or persistent cases.
• Obtain a 12-lead ECG: This helps confirm the diagnosis, assess the rhythm in detail, and rule out other arrhythmias or ischemic changes that may be present.
Parameters to Monitor
• Manifestations of stroke: Clients with AF are at increased risk for embolic stroke. Neurological status should be closely monitored for signs of confusion, facial droop, weakness, or speech changes.
• PTT/INR: These lab values help assess coagulation status, particularly when anticoagulants such as warfarin or heparin are initiated, to ensure therapeutic levels and avoid bleeding complications.
Correct Answer is B
Explanation
A. Blood flowing back from the left atrium to the left ventricle describes mitral regurgitation, not aortic regurgitation.
B. Aortic regurgitation involves the backflow of blood from the aorta into the left ventricle during diastole due to an incompetent aortic valve. This leads to volume overload in the left ventricle.
C. Obstruction of blood from the left atrium to the left ventricle occurs in mitral stenosis, not aortic regurgitation.
D. Obstruction of blood flow from the left ventricle is characteristic of aortic stenosis, not aortic regurgitation.
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