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 D
Explanation
A. Warfarin does not convert atrial fibrillation to sinus rhythm; it is an anticoagulant, not a rhythm control medication.
B. Slowing ventricular response is achieved with rate-control medications like beta blockers or calcium channel blockers, not warfarin.
C. Warfarin prevents clot formation but does not dissolve existing clots.
D. Warfarin reduces the risk of stroke by preventing thrombus formation in clients with atrial fibrillation
Correct Answer is D
Explanation
A. Platelets are administered to treat or prevent bleeding due to thrombocytopenia or platelet dysfunction, not primarily for volume loss.
B. Albumin is a plasma volume expander and may be used in hypovolemia, but it does not replace oxygen-carrying capacity like RBCs do.
C. Cryoprecipitates are rich in clotting factors (e.g., fibrinogen, factor VIII) and are used for coagulopathies, not as a primary treatment for hypovolemic shock.
D. Packed RBCs are the appropriate choice in hypovolemic shock, especially when blood loss has occurred, as they restore oxygen-carrying capacity and circulating blood volume.
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