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?

Document the finding and continue to monitor the client.

Prepare the client for temporary pacemaker insertion.

Notify the client's health care provider immediately and then administer epinephrine IV.

Administer atropine per agency bradycardia protocol and then notify the health care provider

Answer and Explanation

The Correct Answer is A

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.

Nursing Test Bank

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Correct Answer is A

Explanation

A. Auscultate for a pericardial friction rub: These symptoms are classic for pericarditis, a complication of MI. A pericardial friction rub is a key diagnostic finding.

B. Inspect the skin for petechiae: Petechiae are associated with conditions like infective endocarditis or thrombocytopenia, not pericarditis.

C. Palpate the radial pulses bilaterally: Assessing radial pulses is essential for circulation but does not directly relate to pericarditis symptoms.

D. Assess for abdominal pain: Abdominal pain is not typical of pericarditis and would not be the priority assessment.

A. "It is an amino acid which reflects damage to the endothelial lining of arteries. B. "It is a substance composed of free fatty acids reflective of atherosclerosis C. "It is a reliable indicator of the presence of heart failure." D. “It is a protein produced by the liver in response to systemic inflammation."

Correct Answer is C

Explanation

A. "It is an amino acid which reflects damage to the endothelial lining of arteries." BNP is not related to endothelial damage.

B. "It is a substance composed of free fatty acids reflective of atherosclerosis." BNP is not composed of free fatty acids, and it does not reflect atherosclerosis.

C. "It is a reliable indicator of the presence of heart failure." BNP is a hormone released by the heart in response to increased pressure and volume. Elevated levels of BNP are commonly used as a diagnostic marker for heart failure, especially during exacerbations or decompensation.

D. "It is a protein produced by the liver in response to systemic inflammation." BNP is produced by the heart, not the liver.

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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?

Nursing Test Bank

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