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. Airway: Ensure the airway is open.
B. Breathing: Provide rescue breaths if the person is not breathing.
C. Circulation: Begin chest compressions to maintain blood flow.
D. Defibrillation: Use an automated external defibrillator (AED) as soon as it's available, especially in cases of shockable rhythms like ventricular fibrillation.
Correct Answer is D
Explanation
A. Sepsis is a general systemic infection that can arise from many sources but is not the specific concern addressed by prophylactic antibiotics in valve replacement patients.
B. Otitis media (middle ear infection) is unrelated to dental or surgical procedures and not a concern in valve replacement clients.
C. Deep vein thrombosis (DVT) is prevented with anticoagulants and mobility, not antibiotics.
D. Bacterial endocarditis is a serious infection of the heart's inner lining or valves. Clients with valve replacements are at increased risk, especially during procedures like dental work that may introduce bacteria into the bloodstream. Antibiotic prophylaxis is essential to prevent this potentially life-threatening condition.
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