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 D

Explanation

A. Restlessness: This may occur in the pre-active phase of dying but is not specific to the actively dying phase.

B. Decreased appetite: A reduced appetite is common earlier in the dying process, not specific to the actively dying phase.

C. Skin pallor: Skin changes, such as pallor, occur earlier; mottling is more indicative of the actively dying phase.

D. Anuria: Anuria (absence of urine output) is a hallmark sign of multisystem failure and the actively dying phase.

A. Hold the medication and notify the HCP B. Administer the medication as ordered. C. Prepare to administer vitamin K (AquaMephyton). D. Assess the client for abnormal bleeding. E. Fat embolism

Correct Answer is B

Explanation

A. Hold the medication and notify the HCP: This is unnecessary. An INR of 2.7 is within the therapeutic range for a client with a mechanical valve replacement (2.5 to 3.5). No intervention is required.

B. Administer the medication as ordered: The INR of 2.7 is within the desired therapeutic range for clients on warfarin with mechanical valve replacements, so the nurse should proceed with the prescribed dose.

C. Prepare to administer vitamin K (AquaMephyton): Vitamin K is used to reverse the effects of warfarin if the INR is too high (usually greater than 5).

D. Assess the client for abnormal bleeding: While important, this is not the first action. The INR is within the therapeutic range, so the priority is to administer the medication.

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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

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who is near death. Which of the following findings would indicate to the nurse that the client is in the actively dying phase?

Correct Answer is D

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?

Correct Answer is B

Explanation

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