The nurse is monitoring a client in the post-anesthesia care unit (PACU) following a coronary artery bypass graft, observing a regular ventricular rate of 82 beats/min and "sawtooth" P waves with an atrial rate of approximately 300 beat/min. How does the nurse interpret this rhythm?
Ventricular tachycardia
Atrial flutter
Atrial fibrillation
Ventricular fibrillation
The Correct Answer is B
A. Ventricular tachycardia presents with wide QRS complexes and a fast ventricular rate, but not sawtooth P waves.
B. Atrial flutter is characterized by a rapid atrial rate (typically around 250–350 beats/min) and "sawtooth" flutter waves on the ECG. The ventricular response is often regular, as seen in this client with a ventricular rate of 82 beats/min.
C. Atrial fibrillation presents with an irregularly irregular rhythm and absent P waves, replaced by fibrillatory waves — not the sawtooth pattern described here.
D. Ventricular fibrillation shows chaotic, irregular, and disorganized electrical activity with no identifiable P waves, QRS complexes, or T waves, and would not present as a stable rhythm with a ventricular rate of 82 bpm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hepatomegaly (enlarged liver) is a classic sign of right ventricular failure due to systemic venous congestion.
B. A dry, hacking cough is more commonly associated with left-sided heart failure and pulmonary congestion.
C. Crackles in the lungs result from fluid backing up into the lungs, a hallmark of left-sided heart failure, not right-sided.
D. Dizziness may occur in left-sided failure due to decreased cardiac output and poor cerebral perfusion, but it is not a key feature of right-sided failure.
Correct Answer is C
Explanation
A. A blood pressure of 84/50 mm Hg is more consistent with the progressive stage of shock, where compensation is failing.
B. Petechiae may be seen in disseminated intravascular coagulation (DIC), a complication of severe shock, typically not in the compensatory stage.
C. Confusion is an early sign of impaired cerebral perfusion, which can occur in the compensatory stage of shock. It reflects the body’s efforts to maintain perfusion to vital organs despite declining cardiac output.
D. Anuria (no urine output) is a late finding, typically seen in the irreversible stage of shock, indicating complete renal failure.
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