The nurse is documenting a client’s assessment. The rhythm below was obtained from the client’s cardiac monitor. How should the nurse document this strip?

Atrial tachycardia

Ventricular fibrillation

Atrial flutter

Sinus bradycardia

Answer and Explanation

The Correct Answer is C

A. Atrial tachycardia: Atrial tachycardia is a rapid heart rhythm originating from the atria, but it does not have the characteristic "sawtooth" pattern seen in atrial flutter.

B. Ventricular fibrillation: Ventricular fibrillation is a chaotic rhythm originating from the ventricles, characterized by irregular, rapid waves with no discernible P waves or QRS complexes.

C. Atrial flutter: Atrial flutter is recognized by a "sawtooth" pattern of P waves, indicating rapid atrial depolarizations.

D. Sinus bradycardia: Sinus bradycardia is a slow but regular rhythm originating from the sinus node, with normal P waves and QRS complexes.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. 0.9% normal saline IV at 100 mL/hr continuous: This order requires clarification. In acute heart failure, fluid management is crucial. A continuous IV infusion of normal saline could exacerbate fluid overload and worsen heart failure. Typically, IV fluids are given cautiously or restricted in heart failure cases.

B. Bumetanide (Bumex) 1 mg IV bolus every 12 hr: This is a loop diuretic, which is appropriate for managing fluid overload in heart failure.

C. Laboratory testing of serum potassium upon admission: This is appropriate, as diuretics like Bumex can lower potassium levels, so it is important to monitor electrolyte levels.

D. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain: This is appropriate for pain management and to help with anxiety and breathing difficulties in acute heart failure.

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is documenting a client’s assessment. The rhythm below was obtained from the client’s cardiac monitor. How should the nurse document this strip?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI) Which order by the provider requires clarification by the nurse?

Correct Answer is A

Explanation

The nurse is evaluating a cardiac monitor strip for their client that displays a sinus rhythm with a heart rate of 72 bpm. The PR interval is 0.24 seconds. The vital signs are stable and the client reports no symptoms. What is the most appropriate nursing intervention?

Correct Answer is A

Explanation

A nurse is preparing to administer warfarin to a client with a mechanical valve replacement. The client's INR is 2.7. Which action should the nurse implement?

A patient recovering from a myocardial infarction (MI) develops cheat pain on day 3 that increases when taking a deep breath, lying flat, and is relieved by leaning forward. Which additional assessment data should the nurse collect next?

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor the client for which finding?

The nurse is caring for a client who has just had a pacemaker inserted. Which action should the nurse include in the initial plan of care?

The nurse is monitoring a 53-year-old client who is undergoing a cardiac exercise stress test after experiencing an episode of angina. Which client finding will require the test to be discontinued?

The nurse is caring for a client with an ischemic stroke who has apraxia. Which of the following deficits would the nurse expect the client to have?