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 C
Explanation
A. Fluid overload is associated with elevated CVP, not low CVP.
B. Left ventricular failure may eventually cause elevated pulmonary pressures and increased CVP, but a low CVP does not indicate left-sided failure.
C. Hypovolemia (low circulating blood volume) leads to a decreased central venous pressure (CVP) because there is less venous return to the heart. This is the most accurate interpretation of a low CVP reading.
D. An intracardiac shunt may affect circulation dynamics but is not a typical cause of isolated low CVP.
Correct Answer is B
Explanation
A. Ventricular tachycardia presents with wide QRS complexes and a fast ventricular rate, but not sawtooth P waves.
B. Atrial flutter is characterized by a rapid atrial rate (typically around 250–350 beats/min) and "sawtooth" flutter waves on the ECG. The ventricular response is often regular, as seen in this client with a ventricular rate of 82 beats/min.
C. Atrial fibrillation presents with an irregularly irregular rhythm and absent P waves, replaced by fibrillatory waves — not the sawtooth pattern described here.
D. Ventricular fibrillation shows chaotic, irregular, and disorganized electrical activity with no identifiable P waves, QRS complexes, or T waves, and would not present as a stable rhythm with a ventricular rate of 82 bpm.
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