The nurse is caring for a client on a telemetry unit. The client's cardiac monitor exhibits the rhythm below. How should the nurse document this rhythm?

Sinus rhythm with first-degree heart block

ST-segment elevation myocardial infarction (STEMI)

Atrial fibrillation

Ventricular tachycardia

Answer and Explanation

The Correct Answer is B

A. Sinus rhythm with first-degree heart block: This rhythm is characterized by a regular sinus rhythm with a prolonged PR interval (greater than 0.20 seconds), indicating a first-degree heart block.

B. ST-segment elevation myocardial infarction (STEMI): STEMI is indicated by significant ST-segment elevation in specific leads, showing acute myocardial infarction.

C. Atrial fibrillation: Atrial fibrillation shows an irregularly irregular rhythm without distinct P waves.

D. Ventricular tachycardia: Ventricular tachycardia is a rapid heart rhythm originating from the ventricles, with wide QRS complexes and no preceding P waves.

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Correct Answer is A

Explanation

A. Intracranial pressure (ICP) is now 15: Mannitol is an osmotic diuretic used to reduce intracranial pressure (ICP). The intended effect of the medication is to lower ICP. A decrease in ICP to 15 mmHg is within the normal range and indicates the medication has worked effectively.

B. The patient voids 250 mL over 2 hours is incorrect. While mannitol promotes diuresis, the amount of urine output alone does not directly indicate a reduction in ICP. The goal is to lower ICP, which is best assessed by measuring the ICP itself.

C. The patient's pupils are dilated and sluggish is incorrect. Dilated and sluggish pupils can be a sign of increased ICP, not a response to effective treatment.

D. Seizure behavior is absent is incorrect. While mannitol can help reduce ICP and potentially prevent seizures, the absence of seizure behavior is not a direct indicator of the medication's effect on ICP.

A. A client with left-sided heart failure on oxygen via nasal cannula B. A client with syncope who is being discharged today C. A client scheduled for a cardiac ultrasound this morning D. A client with controlled atrial fibrillation with a heart rate of 82

Correct Answer is A

Explanation

A. A client with left-sided heart failure on oxygen via nasal cannula: This client is at risk for respiratory distress due to pulmonary congestion. Immediate assessment is needed to ensure oxygenation and manage potential deterioration.

B. A client with syncope who is being discharged today: This client is stable if being discharged, so assessment can be delayed.

C. A client scheduled for a cardiac ultrasound this morning: This is a non-urgent diagnostic procedure and does not take priority.

D. A client with controlled atrial fibrillation with a heart rate of 82: Controlled atrial fibrillation indicates stability, so this client can be assessed later.

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The nurse is caring for a client on a telemetry unit. The client's cardiac monitor exhibits the rhythm below. How should the nurse document this rhythm?

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Naxlex Comprehensive Predictor Exams

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