The nurse notes that a client's cardiac monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm?

Ventricular tachycardia

Multifocal premature ventricular contractions

Ventricular couplets

Ventricular bigeminy

Answer and Explanation

The Correct Answer is D

A. Ventricular tachycardia is a run of three or more consecutive ventricular beats at a rapid rate, not every other beat.
B. Multifocal premature ventricular contractions (PVCs) arise from different ventricular foci and have different shapes, but this scenario describes uniform shape and consistent pattern.
C. Ventricular couplets are two consecutive PVCs, not a pattern where every other beat is abnormal.
D. Ventricular bigeminy is the correct term for a rhythm in which every other beat is a premature ventricular contraction (PVC). These PVCs typically have no visible P wave and a wide, bizarre QRS complex, matching the description given.

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Correct Answer is D

Explanation

A. Class I: No limitation of physical activity; ordinary activity does not cause symptoms. This client clearly experiences symptoms with ordinary activities.
B. Class II: Slight limitation of physical activity; comfortable at rest, but ordinary activity causes fatigue, dyspnea, or chest pain. This client is more limited than Class II.
C. Class IV: Unable to carry out any physical activity without discomfort; symptoms may be present even at rest. This client does not have symptoms at rest.
D. Class III: Marked limitation of physical activity; comfortable at rest, but less-than-ordinary activity (e.g., brushing teeth, walking to the bathroom) causes fatigue, dyspnea, or chest pain. This best fits the client's condition.

A. Restrict the client's fluid intake. B. Perform neurovascular checks with vital signs. C. Instruct the client to perform range-of-motion exercises to his lower extremities. D. Ambulate the client 1 hr following the procedure.

Correct Answer is B

Explanation

A. Fluids are usually encouraged to help flush out contrast dye, so restricting fluid intake is not appropriate.
B. Performing neurovascular checks along with vital signs is essential to monitor for complications such as bleeding, hematoma, or impaired circulation after femoral artery access.
C. Range-of-motion exercises on the affected leg may increase the risk of bleeding or hematoma and are generally avoided initially.
D. Early ambulation (such as within 1 hour) is usually contraindicated; clients are typically kept on bed rest for several hours to prevent bleeding at the catheter site.

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The nurse notes that a client's cardiac monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

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