A nurse is assessing an ECG rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second. The overall heart rate is 60 beats/min. The nurse assesses the cardiac rhythm as:
Sick sinus syndrome
Normal sinus rhythm
Sinus bradycardia
First degree heart block
The Correct Answer is B
A. Sick sinus syndrome – This involves an abnormal SA node function, often with varying rhythm disturbances (e.g., sinus pauses, bradycardia-tachycardia). The strip described is regular and does not reflect these changes.
B. Normal sinus rhythm – The rhythm is regular, the PR interval is within normal limits (0.12–0.20 seconds), the heart rate is 60 beats/min (within the normal range of 60–100), and P waves precede each QRS complex consistently.
C. Sinus bradycardia – Although the rate is 60, which is at the low end of normal, it is not below 60. Bradycardia is defined as <60 bpm.
D. First-degree heart block – First-degree AV block is characterized by a prolonged PR interval >0.20 seconds. The PR interval here is 0.16 seconds, which is normal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Spinal cord perfusion is not monitored with a pulmonary artery catheter; it typically requires different neuromonitoring techniques.
B. Hemodynamic status is accurately monitored using a pulmonary artery catheter (also called a Swan-Ganz catheter), which provides information on cardiac output, pulmonary artery pressures, and other cardiovascular parameters.
C. Intracranial pressure is monitored using devices like an intraventricular catheter or subarachnoid bolt, not a pulmonary artery catheter.
D. Renal function is assessed through laboratory tests (e.g., BUN, creatinine) and urine output, not via a pulmonary artery catheter
Correct Answer is C
Explanation
A. Diuretics should be taken early in the morning to avoid nocturia, but not at bedtime.
B. A weight gain of 1 kg (2.2 lb) or more in a day or 1.4–2.3 kg (3–5 lb) in a week should be reported; 0.5 kg (1 lb) in a week is not typically concerning.
C. Regular exercise (e.g., at least three times per week) is encouraged in Class I heart failure to promote cardiovascular health and endurance. This is an appropriate and recommended instruction.
D. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) and should be avoided in clients with heart failure as it may cause fluid retention and worsen heart function.
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