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 B
Explanation
In the context of an emergency response plan following an external disaster and the need to create bed space for potential admissions, the nurse should consider early discharge for clients who are stable and whose discharge will not compromise their safety or health. Based on the given options, the most appropriate candidate for early discharge would be:
B) A client who is 1 day postoperative following a vertebroplasty.
Clients who are one day postoperative after a vertebroplasty are typically recovering from a relatively minor procedure and may be stable for discharge if their condition remains uncomplicated.
The other options:
A) A client receiving heparin for deep-vein thrombosis may require ongoing monitoring and treatment, and early discharge might not be appropriate.
C) A client with cancer and a sealed implant for radiation therapy likely has specific treatment needs and should not be discharged early.
D) A client with COPD and a respiratory rate of 44/min likely has respiratory distress and should not be discharged early. Their condition requires close monitoring and intervention.
Correct Answer is C
Explanation
Choice A rationale: Hypoglycemia refers to low blood sugar levels. This condition can occur in newborns, especially those born to mothers with diabetes, preterm babies, babies who are small for gestational age, or those who have experienced a difficult delivery. However, the provided information does not indicate any signs of hypoglycemia such as jitteriness, poor feeding, or lethargy.
Choice B rationale: Bronchopulmonary dysplasia (BPD) is a chronic lung disease that affects newborns and infants. It’s more common in premature infants who have received oxygen therapy or mechanical ventilation. The newborn’s information does not suggest any risk factors for BPD.
Choice C rationale: Transient tachypnea of the newborn (TTN) is a respiratory problem that can be seen shortly after delivery in babies who have no other health issues. It’s caused by fluid in the lungs. The newborn’s increased respiratory rate and grunting are signs of TTN. This condition is more common in babies delivered via cesarean birth, as in this case.
Choice D rationale: Tachycardia refers to a heart rate that’s too fast. While the newborn’s heart rate is on the higher side of normal (normal range: 120-160 beats per minute), it’s not high enough to be considered tachycardia. Therefore, based on the provided information, the newborn is at risk for developing Transient tachypnea of the newborn (Choice C). The other conditions mentioned do not align with the symptoms and risk factors presented in the scenario.
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