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.
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Related Questions
Correct Answer is D
Explanation
A. Sinus bradycardia is characterized by a heart rate below 60 beats/min, which is inconsistent with this client’s elevated heart rate of 128.
B. Ventricular tachycardia is a potentially life-threatening rhythm with wide QRS complexes, usually not the immediate expected rhythm without other signs such as hypotension or loss of consciousness.
C. Normal sinus rhythm has a heart rate between 60–100 beats/min; this client’s rate of 128 exceeds that range.
D. Sinus tachycardia is the most likely rhythm, especially in a client who has used cocaine, a stimulant known to increase sympathetic nervous system activity, leading to increased heart rate and elevated blood pressure.
Correct Answer is A
Explanation
A. A friction rub is the characteristic auscultatory finding in pericarditis. It is a high-pitched, scratchy sound heard best at the left lower sternal border and is caused by the inflamed pericardial layers rubbing against each other.
B. Wheezes are continuous, musical sounds usually associated with airway narrowing, such as in asthma or COPD.
C. Rales (crackles) are heard in conditions like pulmonary edema or pneumonia, not pericarditis.
D. Rhonchi are low-pitched, snoring sounds associated with mucus or obstruction in the larger airways.
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