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 A
Explanation
In the early stage of septic shock, the body initiates compensatory mechanisms to combat the infection and restore adequate tissue perfusion. Tachypnoea (rapid breathing) and tachycardia (elevated heart rate) are common early signs of septic shock.
Tachypnoea occurs as a response to increased metabolic demand and to compensate for impaired oxygenation and tissue perfusion. Tachycardia is the body's attempt to maintain cardiac output and compensate for decreased blood pressure.
B. Pallor and cool skin in (option B) is incorrect because Pallor and cool skin can occur in later stages of septic shock when perfusion to the peripheral tissues is compromised. However, they are not specific to the early stage.
C. Blood pressure 84/50 mm Hg in (option C) is incorrect because A blood pressure reading of 84/50 mm Hg indicates hypotension, which is typically seen in later stages of septic shock. In the early stage, blood pressure may still be within normal or slightly decreased range.
D. Respiratory acidosis in (optionD) is incorrect because: Respiratory acidosis refers to an imbalance in acid-base status and is not specific to the early stage of septic shock. Acid-base disturbances may occur at any stage of shock but are not indicative of the early stage.

Correct Answer is D
Explanation
The absence of palpable pulses suggests a lack of effective cardiac output, and the patient is in cardiac arrest. In this situation, immediate initiation of cardiopulmonary resuscitation (CPR) is crucial to maintain circulation and provide oxygenation to vital organs.
CPR consists of chest compressions and rescue breaths to circulate oxygenated blood to the brain and other vital organs. It is the primary intervention in cardiac arrest to provide temporary life support until advanced cardiac life support (ACLS) measures, such as defibrillation or medication administration, can be initiated.
A. Administering the prescribed Beta-Blocker in (option A) is incorrect because Administering a beta-blocker is not the initial action in a patient who is in cardiac arrest and requires immediate resuscitation.
B. Prepare for Cardioversion per hospital protocol (option B) is incorrect because Cardioversion, which is the delivery of an electric shock to the heart, may be considered in certain situations like unstable ventricular tachycardia or certain supraventricular tachycardias. However, in the given scenario, the patient is unresponsive and has no pulses, indicating cardiac arrest where CPR takes precedence over cardioversion.
C. Give 100% oxygen per non-rebreather mask in (option C) is incorrect because: While oxygenation is important, it should not delay or replace the initiation of CPR, which is the immediate priority in a patient without palpable pulses.
Therefore, the first action that the nurse should take in this scenario is to start CPR.
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