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 D
Explanation
A. Jugular distention is typically associated with right-sided heart failure.
B. Dependent edema is more common in right-sided heart failure due to systemic venous congestion.
C. Hepatomegaly occurs with right-sided heart failure from liver congestion.
D. Frothy sputum is a classic finding in left-sided heart failure due to pulmonary congestion and edema.
Correct Answer is B
Explanation
A. Circulating blood volume is decreased – This is true specifically in hypovolemic shock, but it does not apply to all types of shock (e.g., septic or cardiogenic shock).
B. Cells lack an adequate blood supply and are deprived of oxygen and nutrients – This is the most accurate and comprehensive description of the pathophysiology of shock. Shock is defined as a state of cellular and tissue hypoperfusion, regardless of the underlying cause.
C. Hemorrhage occurs as a result of trauma – While hemorrhage can cause hypovolemic shock, it is not the universal cause of all types of shock.
D. Blood is shunted from vital organs to peripheral areas of the body – The opposite is true in shock: blood is typically shunted away from peripheral tissues to preserve perfusion to vital organs like the brain and heart.
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