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. Scarring of the mitral valve is typically associated with rheumatic heart disease, not pericarditis.
B. Deformity of the valve leaflets is seen in valvular heart diseases, not pericarditis.
C. Inflammation of the endocardium refers to endocarditis, a different condition from pericarditis.
D. Pericardial effusion, the accumulation of fluid in the pericardial sac, is a common complication of pericarditis and can lead to cardiac tamponade if not managed.

A. Restrict the client's fluid intake. B. Perform neurovascular checks with vital signs. C. Instruct the client to perform range-of-motion exercises to his lower extremities. D. Ambulate the client 1 hr following the procedure.

Correct Answer is B

Explanation

A. Fluids are usually encouraged to help flush out contrast dye, so restricting fluid intake is not appropriate.
B. Performing neurovascular checks along with vital signs is essential to monitor for complications such as bleeding, hematoma, or impaired circulation after femoral artery access.
C. Range-of-motion exercises on the affected leg may increase the risk of bleeding or hematoma and are generally avoided initially.
D. Early ambulation (such as within 1 hour) is usually contraindicated; clients are typically kept on bed rest for several hours to prevent bleeding at the catheter site.

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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:

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Naxlex Comprehensive Predictor Exams

The nurse providing discharge teaching to a client admitted with pericarditis. The nurse informs the client that pericarditis can lead to:

Correct Answer is D

Explanation

A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

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