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 C
Explanation
A. Strict bed rest is not the priority; early mobility may be encouraged once the patient is stable.
B. Pain management is important but not the first priority in septic shock.
C. Monitoring vital signs frequently is the priority because it allows the nurse to detect changes in perfusion, blood pressure, heart rate, and oxygenation status, which are critical for timely intervention in septic shock.
D. Assisting with hygiene is part of routine care but is not a priority during the acute management of septic shock.
Correct Answer is B
Explanation
A. A heart rate of 160/min is more indicative of the progressive stage of shock, where compensation begins to fail.
B. Blood pressure 115/68 mmHg is within normal limits and reflects the compensatory stage, where the body maintains perfusion through mechanisms like increased heart rate and vasoconstriction.
C. Hypokalemia is not a typical finding in the compensatory stage; electrolyte shifts are more pronounced in later stages.
D. Mottled skin is a sign of poor perfusion, typically seen in the progressive or irreversible stages of shock.
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