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
Atrial fibrillation.
Complete heart block
First-degree atrioventricular block
Premature atrial complexes
The Correct Answer is C
- . Answer and explanation.
The correct answer is choice C, first-degree atrioventricular block.
This is because the PR interval is longer than normal, which indicates a delay in the conduction of electrical impulses from the atria to the ventricles through the AV node. A normal PR interval is 0.12 to 0.2 seconds, or 3 to 5 small squares on the EKG strip.
In this case, the PR interval is 0.35 seconds, which is more than 5 small squares.
Choice A is wrong because atrial fibrillation is a type of arrhythmia where the atria beat irregularly and rapidly, producing chaotic and variable P waves and an irregular ventricular response.
There is no constant PR interval in atrial fibrillation.
Choice B is wrong because complete heart block is a type of arrhythmia where there is no conduction of electrical impulses from the atria to the ventricles, resulting in independent and dissociated atrial and ventricular rhythms.
There are no consistent P waves or PR intervals in complete heart block.
Choice D is wrong because premature atrial complexes are extra beats that originate from the atria and interrupt the normal sinus rhythm.
They produce abnormal P waves that are different from the sinus P waves, and may have a shorter or longer PR interval depending on the timing of the impulse.
However, they do not cause a constant prolongation of the PR interval.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is **choice D. Remind the client to use the incentive spirometer**.
Choice D rationale:
Reminding the client to use the incentive spirometer is an appropriate intervention for the nurse to delegate to assistive personnel. Using an incentive spirometer is a simple breathing exercise that helps prevent respiratory complications after surgery. Assistive personnel can provide reminders and encouragement to the client to use the incentive spirometer as directed, while the nurse focuses on more complex nursing interventions.
Choice A rationale:
Observing the position of the suspended weight is a critical aspect of Buck's traction management. The nurse should monitor this closely to ensure proper alignment and prevent complications. This intervention should not be delegated to assistive personnel.
Choice B rationale:
Checking the client's pedal pulse on the right leg is essential for monitoring circulation in the affected limb. Any changes in pulse quality or absence of a pulse could indicate a serious complication, such as compartment syndrome. This assessment should be performed by the nurse to ensure accurate findings and timely intervention if needed.
Choice C rationale:
Asking the client to describe her pain is part of the nursing assessment and should be done by the nurse. The nurse needs to assess the client's pain level, location, and characteristics to develop an appropriate pain management plan. Delegating this to assistive personnel could lead to inaccurate or incomplete information.
In summary, reminding the client to use the incentive spirometer is the only intervention that can be safely delegated to assistive personnel in this scenario, as it is a simple task that does not require nursing judgment or assessment. The other interventions are critical nursing responsibilities that should be performed by the nurse to ensure client safety and optimal outcomes.
Correct Answer is D
Explanation
The correct answer is choice D, spotting.
Placenta previa is a condition where the placenta implants in the lower part of the uterus, partly or completely covering the cervical opening.
This can cause painless, bright red vaginal bleeding, usually in the third trimester.
Spotting is a sign of placenta previa and should be reported to the provider immediately.
Choice A is wrong because nausea is not a specific finding of placenta previa.
Nausea can occur in normal pregnancy or in other conditions such as hyperemesis gravidarum or preeclampsia.
Choice B is wrong because polyhydramnios is not a finding of placenta previa.
Polyhydramnios is a condition where there is too much amniotic fluid in the uterus, which can cause complications such as preterm labor, cord prolapse, or fetal malformations.
Choice C is wrong because uterine tenderness is not a finding of placenta previa.
Uterine tenderness is a sign of abruptio placentae, which is a condition where the placenta separates from the uterine wall before delivery.
This can cause severe abdominal pain, dark red vaginal bleeding, and fetal distress.
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