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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Taking a diuretic before sleep can lead to nocturia (frequent urination at night), disrupting sleep. Also, fluid intake may need to be restricted, not encouraged.
B. Clients with heart failure are usually advised to limit sodium to 2 grams or less per day, not 4 grams, to help reduce fluid retention.
C. Naproxen (a NSAID) is not recommended for clients with heart failure as it can cause fluid retention and worsen the condition.
D. Slowing down when tired after exercise shows an understanding of energy conservation and pacing—appropriate for managing heart failure symptoms. This indicates that teaching was effective.
Correct Answer is C
Explanation
A. Strict bed rest is not the priority; early mobility may be encouraged once the patient is stable.
B. Pain management is important but not the first priority in septic shock.
C. Monitoring vital signs frequently is the priority because it allows the nurse to detect changes in perfusion, blood pressure, heart rate, and oxygenation status, which are critical for timely intervention in septic shock.
D. Assisting with hygiene is part of routine care but is not a priority during the acute management of septic shock.
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