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?

Sinus tachycardia.

Ventricular tachycardia.

Ventricular fibrillation.

Atrial flutter.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Sinus tachycardia is a regular, rapid heart rate caused by rapid firing of the sinoatrial node. It is characterized by a heart rate of greater than 100 beats per minute, and P waves are present before each QRS complex. This does not match the description given.
Choice B rationale
Ventricular tachycardia is a fast, regular beating of the ventricles that may last for only a few seconds or for much longer. In this condition, the ventricular rate is often between 120 and 200 beats per minute, and P waves are not associated with the QRS complexes. This matches the description given.
Choice C rationale
Ventricular fibrillation is a severe condition in which the heart beats with rapid, erratic electrical impulses. This causes the ventricles to quiver uselessly instead of pumping blood. The description does not match this condition.
Choice D rationale
Atrial flutter is a condition that shares similarities with atrial fibrillation, both involve an irregular heartbeat. However, atrial flutter is more organized and less chaotic than atrial fibrillation, which can make it more manageable. The description does not match this condition.

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Correct Answer is D

Explanation

Choice A rationale
Atrial Flutter is a type of arrhythmia where the atria beat regularly, but much faster than usual. The treatment for Atrial Flutter is typically medication, not cardioversion.
Choice B rationale
Ventricular Tachycardia is a fast, abnormal heart rate. It starts in your heart’s lower chambers, or ventricles. Ventricular Tachycardia is a serious condition and can be life-threatening. While cardioversion can be used in some cases, it is not the primary treatment.
Choice C rationale
Atrial Fibrillation is when the upper chambers of the heart (atria) beat irregularly. This causes the atria to twitch, leading to an abnormal heart rhythm. The treatment for Atrial Fibrillation is typically medication, not cardioversion.
Choice D rationale
Ventricular Fibrillation is a life-threatening heart rhythm that results in a rapid, erratic heartbeat. During Ventricular Fibrillation, the heart quivers and can’t pump any blood, causing cardiac arrest. The treatment for Ventricular Fibrillation is Defibrillation.

A. Reduce anxiety and relieve pain. B. Improve myocardial oxygenation and reduce cardiac workload. C. Eliminate family stressors and provide a calm environment. D. Start the client on a low-sodium diet and decrease fluid intake.

Correct Answer is B

Explanation

Choice A rationale
While reducing anxiety and relieving pain are important aspects of care, they are not the primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level. These findings indicate myocardial injury, which requires interventions to improve myocardial oxygenation and reduce cardiac workload.
Choice B rationale
The primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level is to improve myocardial oxygenation and reduce cardiac workload. This can be achieved through medications, oxygen therapy, and bed rest.
Choice C rationale
Eliminating family stressors and providing a calm environment can contribute to reducing anxiety and promoting relaxation, but it is not the primary goal in this situation.
Choice D rationale
Starting the client on a low-sodium diet and decreasing fluid intake are interventions for managing heart failure, not for an acute myocardial injury.

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Naxlex Comprehensive Predictor Exams

A nurse in the Emergency Department is evaluating a patient’s cardiac rhythm. What is the correct interpretation of the rhythm and the appropriate treatment?

Correct Answer is D

Explanation

A client is admitted to the telemetry unit with an episode of substernal chest pain. His diagnostic studies reveal an elevated ST segment on the electrocardiogram (ECG) and an elevated cardiac troponin level. What would be an appropriate initial nursing goal?

Correct Answer is B

Explanation

When assessing a male patient in the telemetry unit who is experiencing persistent, crushing chest pain, which symptoms would lead the nurse to suspect a myocardial infarction?

In the context of Interprofessional Care of the Client and Family Across the Lifespan, a nurse is planning discharge teaching for a patient with chronic heart failure who has been prescribed digoxin (Lanoxin) and hydrochlorothiazide. What instruction should the nurse include in the teaching?

A patient with dilated cardiomyopathy has recently developed atrial fibrillation that has been unresponsive to drug therapy for several days. What topic should the nurse plan to include in patient teaching?

What positive outcome should a nurse anticipate in a patient taking Vasotec, an Angiotensin-Converting Enzyme (ACE) inhibitor?

Coarctation of the aorta refers to the local narrowing of the aorta near which location?

Which patient statement would help the nurse confirm a previous diagnosis of chronic stable angina?

A patient who has been experiencing chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test is most specific for the nurse to monitor in determining whether the patient has had an AMI?

A newborn child has been diagnosed with tetralogy of Fallot. What symptoms would the nurse expect to observe in this child?