The nurse obtains a monitor strip on a patient who has had a myocardial infarction and makes the following analysis: P wave not apparent, ventricular rate 196, R-R interval regular, P-R interval not measurable, QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as;
ventricular tachycardia.
atrial fibrillation.
atrial tachycardia.
ventricular fibrillation.
The Correct Answer is A
The characteristics described in the monitor strip analysis suggest ventricular tachycardia. The absence of a visible P wave and the wide and distorted QRS complex indicates that the electrical impulse is originating in the ventricles rather than the atria. The ventricular rate of 196 and regular R-R intervals further support the diagnosis of ventricular tachycardia.
B. Atrial fibrillation in (option B) is incorrect because it is characterized by irregularly irregular R-R intervals and the absence of discernible P waves. The QRS complex is typically narrow
C. Atrial tachycardia in (option C) is incorrect because it would have a rapid atrial rate with regular R-R intervals, and P waves may or may not be discernible. The QRS complex is typically narrow.
D. Ventricular fibrillation in (option D) is incorrect because it would present as a chaotic, rapid, and irregular electrical activity with no discernible P waves, QRS complexes, or regular R-R intervals. It is a life-threatening emergency that requires immediate defibrillation.
Therefore, based on the provided information, the nurse would interpret the patient's cardiac rhythm as ventricular tachycardia. However, it is important to note that an accurate interpretation should be made by a qualified healthcare professional, and the patient's clinical context should also be considered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Mean arterial pressure (MAP) is a measure of the average pressure within the arteries during one cardiac cycle. It represents the perfusion pressure that drives blood flow to organs and tissues. MAP is calculated using the formula:
MAP = Diastolic blood pressure + 1/3 (Systolic blood pressure - Diastolic blood pressure)
Blood loss, particularly in cases of significant hemorrhage, leads to a decrease in blood volume. When blood volume decreases, there is less circulating blood available to generate pressure within the arterial system. This reduction in blood volume results in decreased MAP.
Therefore, in the case of massive blood loss after trauma, the student can correlate it with a lower blood volume, which in turn leads to a lower MAP. The decrease in blood volume reduces the perfusion pressure, compromising organ and tissue perfusion
A. It causes vasoconstriction and increased MAP in (option A) is incorrect because: While vasoconstriction can occur as a compensatory mechanism to maintain blood pressure, it does not necessarily lead to an increased MAP in the context of significant blood loss.
C. It raises cardiac output and MAP in (option C) is incorrect because Blood loss typically leads to a reduction in cardiac output due to decreased blood volume. Therefore, it does not raise cardiac output and MAP.
D. There is no direct correlation to MAP in (option D) is incorrect because: There is indeed a direct correlation between blood loss and MAP. As blood volume decreases, MAP decreases as well.
Therefore, the correct correlation between blood loss and MAP is that lower blood volume lowers MAP.
Correct Answer is ["21"]
Explanation
flow rate for an infusion= (Volume in mL * Drop factor) / Time in minutes.
volume of the infusion bag is 250 mL, the drop factor is 10 gtts/mL, and the time is 2 hours, which is 120 minutes.
(250 mL * 10 gtts/mL) / 120 minutes = 2500 gtts / 120 minutes ≈ 20.83 gtts/minute. Therefore, the nurse should run the infusion at a rate of approximately 21 drops per minute to deliver 1 unit of packed red blood cells over the 2-hour period.
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