To properly identify a cardiac rhythm, the nurse will determine if the client's rhythm contains the following factors: (Select All that Apply.)

the P-P and R-R distances are equal and regular

the rhythm rate using a 3-second strip

the duration of the U waves

there is a QRS complex after each P wave

P waves are present, upright and rounded

Answer and Explanation

Correct Answer : A,B,D,E

A. The P-P and R-R distances are equal and regular: Equal and regular spacing between P-P and R-R intervals indicates that both atrial and ventricular rhythms are regular. This is a fundamental aspect of rhythm interpretation, helping to distinguish between regular and irregular rhythms such as atrial fibrillation or sinus arrhythmia.

B. The rhythm rate using a 3-second strip: Assessing the heart rate using a 3-second or 6-second ECG strip helps determine whether the rhythm is bradycardic, tachycardic, or within normal limits, which is crucial for accurate rhythm classification.

C. The duration of the U waves: U waves are typically small and follow the T wave. Although their presence can suggest conditions like hypokalemia, they are not routinely assessed in basic rhythm identification. Evaluating U wave duration is more relevant in electrolyte imbalance analysis than in identifying rhythm type.

D. There is a QRS complex after each P wave: A consistent QRS following every P wave indicates effective conduction from the atria to the ventricles. Each atrial depolarization (P wave) should be followed by a ventricular depolarization (QRS complex) if the signal is being conducted properly through the AV node. This finding supports a diagnosis of sinus rhythm and helps rule out AV blocks, where conduction may be delayed or blocked entirely.

E. P waves are present, upright and rounded: P waves that are upright and rounded in lead II suggest the electrical impulse is originating from the SA node. Their presence and morphology are essential criteria for identifying sinus rhythm and differentiating it from atrial arrhythmias like flutter or fibrillation.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Review daily the necessity of the central venous catheter: One of the most effective strategies to reduce the risk of catheter-related bloodstream infections is to remove the central line as soon as it is no longer needed. Daily evaluation of necessity prevents prolonged catheter use, which significantly increases infection risk. Removing the source of potential infection is the ultimate preventative action.

B. Maintain a pressure of 300 mm Hg on the flush bag: While maintaining appropriate flush pressure is important for catheter patency and preventing blood clots, it does not play a direct role in preventing bloodstream infections. This action is more related to ensuring adequate line function rather than infection control.

C. Cleanse the insertion site daily with isopropyl alcohol: Current guidelines recommend using chlorhexidine-based solutions rather than isopropyl alcohol for skin antisepsis due to better antimicrobial efficacy. Daily site care is important, but the choice of antiseptic is critical in reducing infection risk.

D. Change the pressurized tubing system and flush bag daily: Tubing and flush systems should be changed typically every 72–96 hours unless contamination is suspected. Changing them daily is not recommended and does not provide added protection against infection it may even increase risk with unnecessary manipulation.

A. Administer the dose later in the day when their nausea subsides B. Assess the client's apical rate C. Contact the physician for STAT serum potassium level D. Administer the client's prescribed dose intravenously

Correct Answer is B

Explanation

A. Administer the dose later in the day when their nausea subsides: Delaying the dose does not address the underlying concern of potential digoxin toxicity. Symptoms like nausea and visual disturbances suggest toxicity and require immediate assessment rather than postponement.

B. Assess the client's apical rate: The first and most appropriate nursing action is to assess the apical heart rate for one full minute, as bradycardia is a key indicator of digoxin toxicity. If the rate is below 60 bpm, the dose should be held, and the provider should be notified.

C. Contact the physician for STAT serum potassium level: Hypokalemia increases the risk of digoxin toxicity, but while checking potassium is important, it is not the first step. Assessment of heart rate is more immediately critical in evaluating the need to hold the medication.

D. Administer the client's prescribed dose intravenously: Administering the dose especially IV when the client has symptoms of toxicity could worsen the situation. Digoxin should be held, not given, until further evaluation and provider notification.

View Question and Answer

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

To properly identify a cardiac rhythm, the nurse will determine if the client's rhythm contains the following factors: (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best reduces the risk of catheter-related bloodstream infection (CRBSI)?

Correct Answer is A

Explanation

The nurse assesses a client who is prescribed digoxin. The client reports nausea and seeing green halos. Which action should the nurse perform?

Correct Answer is B

Explanation

The nurse is caring for a client in the telemetry unit and notices the rhythm below. The client is unresponsive and pulseless. After calling for assistance, what should be the nurse's next action?

The nurse understands that chest pain related to pericarditis is classically relieved by

The client is to receive an oral suspension of Drug H 75 mg PO. The nurse has Drug H available in a suspension 0.15 Gm per 5 mL. What should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

The nurse is caring for a client diagnosed with acute decompensated heart failure. The client is increasingly anxious and restless. The nurse should plan to implement which prescribed orders to assist in relieving these symptoms?

The nurse is caring for a client during a cardiac arrest. The monitor displays the rhythm below. Which intervention should the nurse perform at this time?

The nurse identifies the following rhythm on the cardiac monitor. Which treatment modality will the nurse anticipate for this client?