A nurse is caring for a client on a cardiac monitor and whose rhythm suddenly changes. There are no P waves; instead she observes wavy lines. The QRS complexes measure 0.08 second and are irregular. The client's heart rate is 120 beats/minute. The nurse interprets that this rhythm is:

Ventricular tachycardia

Sinus tachycardia

Ventricular fibrillation

Atrial fibrillation

Answer and Explanation

The Correct Answer is D

A. Ventricular tachycardia presents with wide QRS complexes (usually >0.12 second), and the rhythm is typically regular—not irregular as seen here.
B. Sinus tachycardia has identifiable P waves before each QRS complex and a regular rhythm, which is not the case here.
C. Ventricular fibrillation presents as a chaotic, irregular waveform with no identifiable QRS complexes, resulting in no effective cardiac output—this is more severe than the rhythm described.
D. Atrial fibrillation is characterized by the absence of P waves, irregularly irregular rhythm, wavy baseline (fibrillatory waves), and often a rapid ventricular response, such as the heart rate of 120 bpm observed in this client.

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Correct Answer is D

Explanation

A. Ventricular tachycardia is less commonly triggered by suctioning.
B. Sinus tachycardia may occur but is not the most common arrhythmia during suctioning.
C. Supraventricular tachycardia is not typically associated with suctioning.
D. Sinus bradycardia is the most common arrhythmia caused by vagal stimulation during endotracheal suctioning.

A. Heart rate 160/min B. Blood pressure 115/68 mmHg C. Hypokalemia D. Mottled skin

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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A nurse is caring for a client on a cardiac monitor and whose rhythm suddenly changes. There are no P waves; instead she observes wavy lines. The QRS complexes measure 0.08 second and are irregular. The client's heart rate is 120 beats/minute. The nurse interprets that this rhythm is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse who is caring for a client in ICU on a ventilator assesses a need for suctioning and is aware that the most common cardiac arrhythmia occurring during endotracheal suctioning is:

Correct Answer is D

Explanation

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

The nurse notes that a client's cardiac monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm?

A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions?

The nurse is caring for a client who suddenly develops bradycardia. The client is breathing but with a decreased level of consciousness and decreased blood pressure. Which of the following treatments would be done by the nurse first?

A nurse is providing discharge instructions for a client who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective?

A client being admitted to the cardiac care unit complains of dyspnea on exertion and fatigue. His ECG demonstrates dysrhythmias associated with left ventricular hypertrophy. Which of the following diagnostic tools would be the most helpful in diagnosing cardiomyopathy?

A nurse is caring for a client on a cardiac monitor and whose rhythm suddenly changes. There are no P waves; instead she observes wavy lines. The QRS complexes measure 0.08 second and are irregular. The client's heart rate is 120 beats/minute. The nurse interprets that this rhythm is:

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?

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