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.

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Correct Answer is A

Explanation

A. “Brain death has occurred if there is no spontaneous breathing or brainstem reflexes.” Brain death is defined as the irreversible cessation of all functions of the entire brain, including the brainstem. The absence of spontaneous breathing and brainstem reflexes (such as pupillary response, gag reflex, and eye movements) are critical criteria used to confirm brain death.

B. “If respiratory efforts cease and no apical pulse is audible, brain death is present.” While the cessation of respiratory efforts is a key component of brain death, the presence or absence of an apical pulse alone is not sufficient for determining brain death. Brain death is determined based on the complete absence of brain function, including brainstem reflexes.

C. “Brain death has occurred if a person has flaccid muscles and does not awaken.” Muscle flaccidity and lack of consciousness may be signs of severe brain injury, but they do not necessarily confirm brain death. Brain death is diagnosed based on the absence of brainstem reflexes and spontaneous breathing.

D. “CPR does not restore a heartbeat, the brain cannot function.” While it is true that CPR may not restore circulation in brain-dead patients, this statement is incomplete and not a precise definition of brain death. Brain death is determined by the irreversible cessation of all brain activity, not just by the failure of CPR to restore circulation.

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 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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?

Correct Answer is A

Explanation

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