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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Warfarin does not convert atrial fibrillation to sinus rhythm; it is an anticoagulant, not a rhythm control medication.
B. Slowing ventricular response is achieved with rate-control medications like beta blockers or calcium channel blockers, not warfarin.
C. Warfarin prevents clot formation but does not dissolve existing clots.
D. Warfarin reduces the risk of stroke by preventing thrombus formation in clients with atrial fibrillation
Correct Answer is A
Explanation
A. A friction rub is the characteristic auscultatory finding in pericarditis. It is a high-pitched, scratchy sound heard best at the left lower sternal border and is caused by the inflamed pericardial layers rubbing against each other.
B. Wheezes are continuous, musical sounds usually associated with airway narrowing, such as in asthma or COPD.
C. Rales (crackles) are heard in conditions like pulmonary edema or pneumonia, not pericarditis.
D. Rhonchi are low-pitched, snoring sounds associated with mucus or obstruction in the larger airways.
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