A nurse is assisting with collecting data on a client who is on a continuous ECG monitor. The client's ECG tracing shows no identifiable P waves and an irregular ventricular rate. The nurseshould recognize the client is experiencing which of the following cardiac dysrhythmias?
Complete heart block
Atrial fibrillation
Sinus tachycardia
First-degree AV block.
The Correct Answer is B
a. Complete heart block: Complete heart block would typically present with a regular ventricular rate, but with no association between P waves and QRS complexes.
b. Atrial fibrillation: Atrial fibrillation is characterized by the absence of identifiable P waves and an irregular ventricular rate. The atria fibrillate, leading to chaotic electrical activity and an irregular ventricular response.
c. Sinus tachycardia: Sinus tachycardia is characterized by a regular ventricular rate and identifiable P waves. It is not associated with the absence of P waves.
d. First-degree AV block: First-degree AV block is characterized by a prolonged PR interval, but it does not result in the absence of P waves. The relationship between P waves and QRS
complexes is maintained.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. Allow the client to take her morning vitamins: This is generally acceptable unless there are specific preoperative instructions regarding medication.
b. Allow the client to keep her tongue stud in: Metallic objects, including tongue studs, are
usually removed before surgery to prevent interference with equipment and to ensure patient safety.
c. Allow the client to keep her hearing aids in: It is important for the client with a hearing
impairment to keep hearing aids in place to facilitate communication and maintain awareness of the environment.
d. Allow the client to consume clear liquids up to the time of surgery: Clear liquids are typically restricted before surgery to prevent aspiration. This action may not align with standard
preoperative fasting guidelines.
Correct Answer is B
Explanation
a. Maintain the client on bed rest: While rest may be indicated in some cases, it is not a specific intervention for managing renal stones with a urinary catheter.
b. Strain the client's urine through a mesh filter: Straining urine is essential to collect any stones that may have passed, allowing for analysis and identification.
c. Encourage fluid intake of 1500 mL/day: Adequate fluid intake is crucial to prevent stone formation, but the amount may vary depending on the client's specific needs and condition.
d. Clamp the urinary catheter every 2 hr: Clamping the urinary catheter is not a standard
intervention for managing renal stones. Straining the urine for stone collection is a more relevant intervention.
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