The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, P-R interval not measurable, ventricular rate 162, R-R interval regular, QRS complex wide and QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as
ventricular tachycardia.
ventricular fibrillation.
sinus tachycardia.
atrial flutter.
The Correct Answer is A
A. Ventricular tachycardia is characterized by a ventricular rate >100 bpm, regular rhythm, no visible P waves, and wide QRS complexes (>0.12 seconds). The findings described—ventricular rate of 162, regular R-R intervals, no visible P waves, and a QRS duration of 0.18 seconds—are consistent with ventricular tachycardia.
B. Ventricular fibrillation shows a chaotic, irregular rhythm with no identifiable QRS complexes, which is not the case here.
C. Sinus tachycardia would have visible P waves and a normal QRS duration.
D. Atrial flutter typically has "sawtooth" flutter waves and a more organized atrial rhythm with a distinct P wave pattern, which is absent in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. PVCs during suctioning may indicate hypoxia or irritation; the priority is to stop suctioning and ventilate the patient with 100% oxygen to prevent worsening arrhythmias.
B. Medications may be needed later, but immediate action is oxygenation and stopping suctioning.
C. Adjusting suction pressure is important but secondary to ensuring patient oxygenation.
D. Documentation is necessary but not the priority when PVCs are noted.
Correct Answer is D
Explanation
A. Ventricular tachycardia presents with wide QRS complexes (usually >0.12 second), and the rhythm is typically regular—not irregular as seen here.
B. Sinus tachycardia has identifiable P waves before each QRS complex and a regular rhythm, which is not the case here.
C. Ventricular fibrillation presents as a chaotic, irregular waveform with no identifiable QRS complexes, resulting in no effective cardiac output—this is more severe than the rhythm described.
D. Atrial fibrillation is characterized by the absence of P waves, irregularly irregular rhythm, wavy baseline (fibrillatory waves), and often a rapid ventricular response, such as the heart rate of 120 bpm observed in this client.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.