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?

Choice A rationale
Maintaining a semi-Fowler’s position can help improve lung expansion and ease breathing in clients with chronic obstructive pulmonary disease (COPD). However, it does not directly address the issue of mucus congestion and difficulty in expectorating (bringing up) mucus.
While positioning can aid in overall respiratory comfort, it is not the most effective intervention for managing mucus congestion in COPD clients.
Choice B rationale
A low-salt diet is beneficial for overall health and can help manage conditions such as hypertension and heart disease. However, it does not have a direct impact on mucus congestion in clients with COPD. Dietary modifications are important for managing comorbidities, but they do not address the primary concern of mucus clearance in this scenario.
Choice C rationale
Encouraging the client to drink 2 to 3 liters of water daily is an effective intervention for managing mucus congestion in clients with COPD. Adequate hydration helps thin the mucus, making it easier to cough up and clear from the airways. This intervention directly addresses the client’s complaint of difficulty in expectorating mucus and can improve respiratory function and comfort.
Choice D rationale
Administering oxygen via nasal cannula at 2 L/min can help improve oxygenation in clients with COPD. However, it does not address the issue of mucus congestion and difficulty in expectorating mucus. While supplemental oxygen is important for managing hypoxemia, it is not the primary intervention for mucus clearance. The focus should be on interventions that help thin and mobilize mucus to alleviate the client’s symptoms.

Choice A rationale
A room that is within view of the nurses’ station is not suitable for a client with active tuberculosis. This placement does not provide the necessary isolation to prevent the spread of the infection to other patients and staff. Tuberculosis is an airborne disease, and the client needs to be in a room that minimizes the risk of airborne transmission.
Choice B rationale
A room with another nonsurgical client is also inappropriate for a client with active tuberculosis. Placing the client with another patient increases the risk of transmission of the infection. Tuberculosis requires strict airborne precautions, and the client should be in a private room with appropriate ventilation.
Choice C rationale
A room in the ICU is not necessary unless the client requires intensive care for other reasons. The primary concern for a client with active tuberculosis is to prevent the spread of the infection, which can be effectively managed in a regular medical-surgical unit with proper isolation measures.
Choice D rationale
A room with air exhaust directly to the outdoor environment is the correct choice. This type of room, often referred to as a negative pressure room, ensures that air from the room does not flow to other parts of the facility, thereby preventing the spread of infectious airborne particles. This setup is essential for managing clients with active tuberculosis.