After exercising, a client is hooked up to a cardiac monitor. The rhythm below is noted. How should the nurse document this rhythm?

Junctional tachycardia

Sinus tachycardia

Atrial flutter

Ventricular fibrillation

Answer and Explanation

The Correct Answer is B

A. Junctional tachycardia: Junctional tachycardia originates from the atrioventricular (AV) node, with a faster rate and usually no visible P waves preceding the QRS complexes.

B. Sinus tachycardia: Sinus tachycardia is characterized by a regular, rapid heart rhythm originating from the sinus node, typically seen after exercise, with identifiable P waves before each QRS complex.

C. Atrial flutter: Atrial flutter presents with a “sawtooth” pattern of P waves, indicating rapid atrial contractions, which is different from sinus tachycardia.

D. Ventricular fibrillation: Ventricular fibrillation is a chaotic and irregular rhythm originating from the ventricles, which is a life-threatening condition.

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Correct Answer is C

Explanation

A. The client is able to sit erect without assistance: This suggests a lower level injury, likely below C-2, as higher injuries often result in paralysis of respiratory muscles.

B. The client is able to move fingers slightly: This would be indicative of a higher level injury, but C-1 to C-2 injuries typically result in complete paralysis below the neck.

C. The client is displaying shallow respirations: Injuries at the C-1 or C-2 level can affect the diaphragm and the ability to breathe deeply, leading to shallow respirations.

D. The client is able to speak in full sentences: A C-1 to C-2 injury would likely affect the ability to speak, as it could impair the phrenic nerve and respiratory muscles needed for adequate breathing and speech.

A. Document the finding and continue to monitor the client. B. Prepare the client for temporary pacemaker insertion. C. Notify the client's health care provider immediately and then administer epinephrine IV. D. Administer atropine per agency bradycardia protocol and then notify the health care provider

Correct Answer is A

Explanation

A. Document the finding and continue to monitor the client: A PR interval of 0.24 seconds indicates first-degree AV block, which is often asymptomatic and benign if vital signs are stable. No immediate intervention is required other than continued monitoring.

B. Prepare the client for temporary pacemaker insertion: Pacemakers are not indicated for asymptomatic first-degree AV block.

C. Notify the health care provider immediately and then administer epinephrine IV: This is unnecessary as the client is stable and shows no signs of hemodynamic compromise.

D. Administer atropine per agency bradycardia protocol and then notify the health care provider: Atropine is not required for a stable heart rate of 72 bpm.

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After exercising, a client is hooked up to a cardiac monitor. The rhythm below is noted. How should the nurse document this rhythm?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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