A nurse analyzes a rhythm strip for a patient who has had a myocardial infarction and observes the following: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, QRS complex wide and distorted, and QRS duration of 0.18 second.

How should the nurse interpret this cardiac rhythm?

Choice A rationale
While calf tenderness and swelling after a plane ride could potentially indicate a deep vein thrombosis, this condition is not immediately life-threatening in most cases. The patient would need evaluation and treatment, but other patients might have more urgent needs14.
Choice B rationale
A patient taking anticoagulants for atrial fibrillation who has black stools could potentially have gastrointestinal bleeding, which would need evaluation. However, this condition might not be immediately life-threatening, and other patients might have more urgent needs14.
Choice C rationale
A patient with a gangrenous foot ulcer and a weak pedal pulse would need evaluation and treatment. However, this condition might not be immediately life-threatening, and other patients might have more urgent needs14.
Choice D rationale
A patient reporting sudden sharp and severe upper back pain could potentially have an aortic dissection, which is a life-threatening condition that requires immediate evaluation and treatment. Therefore, this patient should be assessed first14.

Choice A rationale
Serum hemoglobin of 14.7 g/dL is within the normal range for adults, which is typically 12.0 to
16.0 g/dL for women and 13.5 to 17.5 g/dL for men. Hemoglobin is a protein in red blood cells that carries oxygen throughout the body. While it’s important to monitor hemoglobin levels, a value of 14.7 g/dL does not raise immediate concerns related to hypertension.
Choice B rationale
A blood glucose level of 96 mg/dL is considered normal. The normal range for fasting blood glucose is between 70 and 100 mg/dL1. Blood glucose levels are important to monitor, especially in patients with diabetes, but a value of 96 mg/dL is not immediately concerning in the context of hypertension.
Choice C rationale
A serum potassium level of 4.5 mEq/L is within the normal range, which is typically 3.6 to 5.2 mEq/L1. Potassium is an essential electrolyte that helps regulate heart and muscle contractions and maintain fluid balance in the body. While it’s important to monitor potassium levels, a value of 4.5 mEq/L does not raise immediate concerns related to hypertension.
Choice D rationale
A serum creatinine level of 2.8 mg/dL is high. Creatinine is a waste product that’s produced by your muscles and filtered out of your blood by your kidneys. High levels of creatinine can indicate that the kidneys aren’t working properly, which can be a complication of hypertension. Therefore, this result is the most important to communicate to the healthcare provider.