A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring.
The cardiac rhythm strip shows a wavy baseline, no distinguishable P waves, and an increased heart rate.
The nurse should identify the cardiac rhythm as which of the following?
Atrial fibrillation.
Ventricular asystole.
Second-degree heart block.
Sinus tachycardia.
The Correct Answer is A
Choice A rationale:
The described cardiac rhythm with a wavy baseline, no distinguishable P waves, and an increased heart rate is consistent with atrial fibrillation. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to an irregular and often rapid heart rate. This rhythm is characterized by the absence of distinct P waves on the ECG.
Choice B rationale:
Ventricular asystole is a flatline on the ECG, indicating the absence of electrical activity in the heart. It is a life-threatening arrhythmia and requires immediate intervention with cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) protocols.
Choice C rationale:
Second-degree heart block is characterized by intermittent failure of atrial electrical impulses to conduct to the ventricles. This results in occasional dropped beats and a varying heart rate. It is not consistent with the described ECG findings in the question.
Choice D rationale:
Sinus tachycardia is a regular, fast heart rate originating from the sinoatrial (SA) node. In sinus tachycardia, P waves are present, indicating that the electrical impulses originate in the SA node. The described ECG findings do not match the characteristics of sinus tachycardia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Consuming foods high in bran fiber can help regulate bowel movements and alleviate symptoms of irritable bowel syndrome (IBS). Fiber adds bulk to the stool and can prevent constipation, a common symptom in IBS patients. Adequate dietary fiber intake is generally recommended for individuals with IBS.
Choice B rationale:
Increasing intake of foods high in gluten might worsen symptoms in individuals with gluten sensitivity or celiac disease. Gluten-containing foods can trigger gastrointestinal distress in susceptible individuals and should be avoided if gluten intolerance is present.
Choice C rationale:
Some individuals with IBS are lactose intolerant, which means they have difficulty digesting milk products. Increasing intake of milk products can exacerbate symptoms such as bloating, gas, and diarrhea in these individuals. It is important to assess the client's tolerance to lactose-containing foods before recommending their consumption.
Choice D rationale:
Sweetening foods with fructose corn syrup may worsen symptoms in individuals with IBS. Fructose is a type of sugar that can cause gastrointestinal distress in some people, especially those with fructose malabsorption. Recommending sweeteners with low fructose content would be more appropriate for individuals with IBS.
Correct Answer is B
Explanation
The correct answer is Choice B: Speak in a normal voice at a natural pace.
Choice A rationale: Directing statements to the interpreter is inappropriate because it can make the client feel excluded from the conversation. The focus of communication should be on the client, and the interpreter is present only to facilitate understanding between the nurse and the client. Direct eye contact and addressing the client directly is important for establishing rapport and trust.
Choice B rationale: Speaking in a normal voice at a natural pace is crucial when working with an interpreter to ensure accurate translation and comprehension. It provides the interpreter with enough time to accurately convey the message while maintaining a conversational flow. Speaking too fast or in an unnatural tone can create confusion and lead to misinterpretation, ultimately affecting the quality of care provided to the client.
Choice C rationale: Using gestures while speaking with the client may not be helpful when working with an interpreter. Gestures may be culturally specific and can lead to misunderstandings or misinterpretations. Furthermore, the interpreter may not be able to accurately convey the intended message through gestures, leading to communication errors.
Choice D rationale: Pausing in the middle of sentences is not recommended when working with an interpreter. This practice can disrupt the flow of the conversation, confuse the interpreter, and lead to incomplete translations. It is essential to speak in complete sentences and provide pauses between sentences to enable the interpreter to accurately translate the information to the client.
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