To properly identify a cardiac rhythm, the nurse will obtain the following factors. (SELECT ALL THAT APPLY)

if there is a QRS complex after each p wave

the rate using only a 3- second strip

the duration of the u waves

if the p waves are present

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

Answer and Explanation

Correct Answer : A,D,E

A) If there is a QRS complex after each P wave:
This is an important consideration when identifying a cardiac rhythm. The P wave represents atrial depolarization, and the QRS complex represents ventricular depolarization. In a normal sinus rhythm, every P wave is followed by a QRS complex, which confirms that the impulse originating in the SA node is being conducted properly through the atrioventricular (AV) node and into the ventricles. The presence of a QRS after every P wave helps confirm normal conduction and rhythm.

B) The rate using only a 3-second strip:
While the heart rate is an essential part of the rhythm assessment, using only a 3-second strip is not the most accurate method for determining the rate. Typically, a 6-second strip is used to estimate the rate, multiplying the number of R-R intervals by 10 to obtain the heart rate. A 3-second strip can be used for quick estimates but may lead to inaccurate calculations of the heart rate.

C) The duration of the U waves:
The U wave is often a normal variant seen in the ECG and is not always present. If it is visible, its duration is typically not a primary focus in rhythm interpretation unless there are concerns about electrolyte imbalances, such as hypokalemia. The U wave is not a core factor to consider when identifying the overall rhythm.

D) If the P waves are present:
The presence of P waves is important for identifying the rhythm, particularly when differentiating between sinus rhythms (normal) and non-sinus rhythms (such as atrial arrhythmias). In normal sinus rhythm, P waves should be present, reflecting atrial depolarization initiated by the SA node. The absence of P waves can indicate atrial fibrillation, atrial flutter, or other arrhythmias.

E) If the P-P and R-R distances are equal:
This is crucial in identifying a regular rhythm. The P-P interval refers to the distance between successive P waves (atrial depolarization), and the R-R interval refers to the distance between successive R waves (ventricular depolarization). In normal sinus rhythm or regular rhythms, both the P-P and R-R intervals should be equal, indicating that the atrial and ventricular rhythms are consistent. If they are unequal, it suggests an irregular rhythm (e.g., atrial fibrillation).

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Correct Answer is D

Explanation

A) Ice packs may be applied to the site for 30 minutes every hour for comfort:
This is not an appropriate recommendation for skin care related to radiation therapy. Applying ice packs to the skin can cause vasoconstriction and might worsen skin irritation or damage from radiation. Instead, the patient should be advised to avoid extreme temperatures, including hot or cold compresses, which could exacerbate skin issues in the radiation field.

B) Incorporate rest periods throughout the day:
While rest is important for overall well-being during radiation therapy, this instruction does not directly address the skin care needs associated with radiation. The primary concern with radiation therapy is protecting the skin from further irritation and damage, so specific skin care measures are more crucial in this context than general rest periods.

C) Do not share bathrooms/toilets with others for 48 hours after treatment:
This instruction is not necessary for most patients undergoing radiation therapy, especially for lung cancer. The concern about not sharing bathrooms or toilets generally applies to patients receiving brachytherapy or radioactive implants, where radiation is placed inside the body. For external radiation, there is no risk of contamination through shared bathroom use.

D) Wear loose, soft clothing over the treated area:
This is the most appropriate instruction for skin care during radiation therapy. Radiation therapy can cause the skin to become tender, red, and irritated, so wearing loose, soft clothing will help minimize friction and pressure on the skin. Tight or rough clothing can irritate the radiation site, increasing the risk of skin breakdown. Loose, breathable fabrics like cotton can help keep the skin comfortable and allow it to heal while protecting it from further damage.

A. Intestines B. Liver C. Spleen D. Stomach

Correct Answer is C

Explanation

A) Intestines:
While abdominal trauma can affect the intestines, Kehr's sign, Cullen's sign, and Gray Turner's sign are more commonly associated with damage to the spleen rather than the intestines. Kehr's sign, in particular, is a hallmark of splenic injury, with pain referred to the left shoulder due to diaphragmatic irritation from blood in the peritoneum.

B) Liver:
Liver injuries often present with right upper quadrant pain, jaundice, and elevated liver enzymes. While liver injuries can cause internal bleeding, Cullen's and Gray Turner's signs are more closely associated with retroperitoneal bleeding from the spleen rather than liver injuries. Kehr's sign, which is left-sided shoulder pain, would not typically indicate a liver injury.

C) Spleen:
The spleen is the most likely abdominal organ affected in this case due to the left-sided rib fractures. When the spleen is injured (often as a result of blunt trauma), it can cause intraperitoneal hemorrhage. This bleeding can irritate the diaphragm, leading to Kehr's sign, which presents as left shoulder pain. Additionally, Cullen's sign (periumbilical bruising) and Gray Turner's sign (flank bruising) are indicative of retroperitoneal bleeding, which can occur with splenic rupture or laceration.

D) Stomach:
While stomach injuries can occur with blunt abdominal trauma, they are less likely to cause the signs and symptoms seen in this patient (Kehr's, Cullen's, and Gray Turner's signs). Stomach trauma typically leads to pain and potential perforation, but it doesn't often cause the peritoneal bleeding patterns seen with splenic injuries.

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To properly identify a cardiac rhythm, the nurse will obtain the following factors. (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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