A nurse is analyzing a client’s electrocardiogram (ECG) strip and identifies the following information: Heart rate: 92/min.
Rhythm: Irregular.
P wave: Unable to identify.
PR interval: Unable to measure. QRS duration: 0.10 seconds.
Based upon this information, the nurse should interpret the client’s rhythm as indicating which of the following?
Supraventricular tachycardia.
Atrial fibrillation.
Sinus bradycardia.
First-degree heart block.
The Correct Answer is B
Choice A rationale
Supraventricular tachycardia (SVT) is characterized by a rapid heart rate originating above the ventricles, typically with a regular rhythm and identifiable P waves. The described ECG strip shows an irregular rhythm and an inability to identify P waves, which is not consistent with SVT5.
Choice B rationale
Atrial fibrillation (AF) is characterized by an irregularly irregular rhythm, absence of identifiable P waves, and variable PR intervals. The ECG findings of an irregular rhythm, inability to identify P waves, and a QRS duration of 0.10 seconds are consistent with AF6.
Choice C rationale
Sinus bradycardia is characterized by a regular rhythm with a heart rate less than 60 beats per minute and identifiable P waves preceding each QRS complex. The described ECG strip shows an irregular rhythm and an inability to identify P waves, which is not consistent with sinus bradycardia.
Choice D rationale
First-degree heart block is characterized by a prolonged PR interval with a regular rhythm. The described ECG strip shows an irregular rhythm and an inability to measure the PR interval, which is not consistent with first-degree heart block.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Take temperature weekly. This statement is incorrect. Clients with neutropenia should monitor their temperature daily, not weekly, because they are at high risk for infections. A fever can be an early sign of infection, and prompt detection is crucial for timely treatment.
Choice B rationale
Perform mild exercise, such as gardening. This statement is incorrect. While mild exercise can be beneficial, activities like gardening can expose neutropenic clients to soil and plants that may harbor bacteria and fungi, increasing the risk of infection.
Choice C rationale
Avoid crowds. This statement is correct. Neutropenic clients are highly susceptible to infections due to their weakened immune systems. Avoiding crowded places reduces the risk of exposure to pathogens that can cause infections.
Choice D rationale
Eat plenty of fresh fruits and vegetables. This statement is incorrect. While fresh fruits and vegetables are generally healthy, they can harbor bacteria and other pathogens that pose a risk for neutropenic individuals. It is often recommended that neutropenic clients eat cooked or canned fruits and vegetables instead.
Correct Answer is D
Explanation
Choice A rationale
Including fluoridated water in the toddler’s diet does not prevent iron deficiency anemia.
Choice B rationale
Administering fat-soluble vitamins daily is not a method of preventing iron deficiency anemia.
Choice C rationale
Limiting intake of high-protein foods is not related to preventing iron deficiency anemia.
Choice D rationale
Avoiding a diet that consists primarily of milk is recommended because excessive milk intake can interfere with iron absorption and lead to iron deficiency anemia.
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