When using an ECG rhythm strip to quickly estimate the ventricular rate for a client, the nurse should:
count the number of large squares in the R-R interval and divide by 30C
print a 1-minute ECG strip and count the number of ORS complexes,
count the number of QRS complexes in 6 seconds and multiply by 10.
calculate the number of small squares between one QRS complex and the next one and divide by 1500.
The Correct Answer is C
A. Counting the number of large squares between R-R intervals and dividing by 30 is not the correct method for estimating the ventricular rate on an ECG strip.
B. Printing a 1-minute ECG strip and counting the QRS complexes (option B) is accurate but unnecessary for a quick estimation.
C. The most common and efficient method for estimating the ventricular rate quickly is to count the number of QRS complexes in a 6-second strip (often marked by two dashed lines) and multiply by 10. This gives an estimate of the heart rate per minute.
D. Counting the number of small squares between QRS complexes and dividing by 1500 is the most accurate method but requires more time and precision than counting QRS complexes in 6 seconds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Mobitz II is a type of second-degree AV block characterized by constant PR intervals and sudden dropped QRS complexes (i.e., the PR interval does not lengthen progressively). This is a more serious block because the dropped beats are unpredictable and could lead to complete block.
B. Sinus bradycardia is a slower-than-normal heart rate (usually less than 60 beats per minute) that originates from the sinus node. First-degree AV block is characterized by a prolonged PR interval, but unlike second-degree block, there are no dropped QRS complexes.
C. Mobitz I (Wenckebach) is a second-degree AV block where the PR interval gradually lengthens with each successive beat until a QRS complex is dropped. After the dropped beat, the cycle repeats. This is a relatively benign block and often resolves without intervention, though it requires monitoring.
D. Third-degree heart block (also known as complete heart block) occurs when there is no communication between the atria and ventricles. The atria and ventricles beat independently of each other. There are no relationship between the P waves and QRS complexes, and the ventricular rate is typically slower than the atrial rate.
Correct Answer is C
Explanation
A. While family support is important, encouraging complete assistance with all activities of daily living (ADLs) is not an ideal intervention. The goal is to maintain as much independence as possible, even if that means modifying or pacing activities. Encouraging complete dependency can lead to deconditioning and further loss of function.
B. Clustering activities is not the best intervention for this problem. Clustering involves grouping multiple tasks together at once, which can overwhelm the patient and lead to fatigue. Instead, the nurse should encourage pacing and spreading out activities to avoid overexertion, even if the patient has energy.
C. Providing alternating periods of activity and rest is a fundamental strategy in managing activity intolerance due to chronic heart failure. This approach helps balance the energy demands of daily activities with rest to prevent fatigue and overexertion. By alternating activity and rest, the patient can perform necessary tasks while minimizing strain on the heart.
D. The goal in chronic heart failure is to help the patient maintain independence and function as much as possible. Limiting self-care could lead to increased dependency and reduced quality of life. Activity modifications and appropriate pacing are better strategies.
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