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. Splinter hemorrhages are a common sign of infective endocarditis but are not immediately life-threatening.
B. Fever is a typical manifestation of infection and expected in infective endocarditis, not a priority unless unresponsive to treatment.
C. Clusters of petechiae in the mouth indicate microemboli or vascular involvement, but they are not an acute threat.
D. Dyspnea is the priority finding because it may indicate heart failure or pulmonary embolism, both of which are serious complications of infective endocarditis and require immediate intervention.
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.
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