A nurse is reviewing a client's cardiac rhythm strips and notes a constant P-R interval of
0.35 seconds. Which of the following dysrhythmias is the client displaying?
Premature atrial complexes
Complete heart block
Atrial fibrillation
First-degree atrioventricular block
The Correct Answer is D
A. Incorrect. Premature atrial complexes do not typically affect the P-R interval. They are characterized by an early P-wave followed by a QRS complex.
B. Incorrect. Complete heart block is characterized by a dissociation between the P-waves and QRS complexes, resulting in no relationship between atrial and ventricular activity.
C. Incorrect. Atrial fibrillation is characterized by chaotic and irregular atrial activity without distinct P-waves, making the P-R interval irrelevant.
D. Correct. In first-degree atrioventricular block, the P-R interval is prolonged beyond the normal range of 0.12-0.20 seconds. A constant P-R interval of 0.35 seconds indicates a first- degree atrioventricular block.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. The International Normalized Ratio (INR) is used to monitor the effectiveness of warfarin therapy, which is commonly prescribed to prevent blood clotting. The INR provides information about the client's prothrombin time (PT) in relation to a standardized value.
B. Fibrinogen level measures clotting potential but is not directly related to warfarin therapy monitoring.
C. Activated Partial Thromboplastin Time (aPTT) is used to monitor other anticoagulants like heparin, not warfarin.
D. Platelet count measures the number of platelets in the blood and is not specifically related to warfarin therapy monitoring.
Correct Answer is ["A","D","E","F","G"]
Explanation
Based on the information provided, the nurse should consider the following client findings for further evaluation:
A. Weight: The client's weight loss of 5 pounds (2.26 kg) over the last week needs further evaluation as it could be indicative of an underlying health issue.
D. Travel history: The client's recent travel to South Africa and the presence of respiratory symptoms raises concerns about possible exposure to infectious diseases, including tuberculosis, which is more prevalent in certain regions. Further evaluation of the travel history is essential.
E. Sputum characteristics: The client's report of "blood-tinged sputum" is concerning and should be evaluated further to rule out potential serious respiratory conditions.
F. Temperature: The presence of a "low-grade fever" should be further evaluated to assess the possible infectious etiology of the client's symptoms.
G. Heart Rate: The heart rate should be assessed further as an elevated heart rate could indicate an underlying systemic infection or other health issues.
The following client findings do not necessarily indicate the need for further evaluation in this context:
B. Report of cough: The client's report of a cough is the primary reason for their presentation to the emergency department and will, of course, be further evaluated as part of the assessment.
C. Blood pressure: Though monitoring blood pressure is essential, the information provided does not indicate any specific concerns regarding the client's blood pressure at this point.
A comprehensive assessment and further evaluation are necessary to determine the underlying cause of the client's symptoms. The nurse should collaborate with other healthcare professionals to conduct appropriate diagnostic tests and investigations to establish a diagnosis and provide appropriate care.
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