The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats/minute. Which would be a correct interpretation based on these characteristics?
1.Sinus bra...
The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular.
The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64
beats/minute. Which would be a correct interpretation based on these characteristics?
1.Sinus bradycardia
2.Sick sinus syndrome
3.Normal sinus rhythm
4.First-degree heart block - 3.
Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The
PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second,
respectively.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Adult Health: Cardiovascular
Strategy(s): Subject
Priority Concepts: Clinical Judgment, Perfusion
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no
electrocardiographic complexes on the screen. Which is the priority action of the nurse?
1.Call a code.
2.Call the health care provider.
3.Check the client's status and lead placement.
4.Press the recorder button on the electrocardiogram console. - 3.
Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode
displacement. Accurate assessment of the client and equipment is necessary to determine the cause
and identify the appropriate intervention. The remaining options are secondary to client assessment.
Strategy(s): Strategic Words, Steps of the Nursing Process
A client is having frequent premature ventricular contractions. The nurse should place priority on
assessment of which item?
1.Sensation of palpitations
2.Causative factors, such as caffeine
3.Precipitating factors, such as infection
4.Blood pressure and oxygen saturation - 4.
Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to
monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to
decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature
ventricular contractions can be caused by cardiac disorders, states of hypoxemia, or by any number of
physiological stressors, such as infection, illness, surgery, or trauma, and by intake of caffeine, nicotine,
or alcohol.
The nurse is evaluating a client's response to cardioversion. Which observation would be of highest
priority to the nurse?
1.Blood pressure
2.Status of airway
3.Oxygen flow rate
,4.Level of consciousness - 2.
Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then
oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection.
The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-
defibrillator. The nurse immediately would assess which item based on priority?
1.Anxiety level of the client and family
2.Presence of a Medic-Alert card for the client to carry
3.Knowledge of restrictions of postdischarge physical activity
4.Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver -
4.
The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator
needs to assess device settings, similar to after insertion of a permanent pacemaker. Specifically, the
nurse needs to know whether the device is activated, the heart rate cutoff above which it will fire, and
the number of shocks it is programmed to deliver. The remaining options are also nursing interventions
but are not the priority.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Adult Health: Cardiovascular
Strategy(s): Strategic Words, Maslow's Hierarchy of Needs Theory
Priority Concepts: Perfusion, Safety
, A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR
interval is 0.14 second, the QRS complex measures 0.08 second, and the PP and RR intervals are regular.
How should the nurse correctly interpret this rhythm?
1.Sinus dysrhythmia
2.Sinus tachycardia
3.Sinus bradycardia
4.Normal sinus rhythm - 2.
Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and
normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia,
the atrial and ventricular rates are greater than 100 beats/minute.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Adult Health: Cardiovascular
Strategy(s): Subject
Priority Concepts: Clinical Judgment, Perfusion
The nurse in the medical unit is reviewing the laboratory test results for a client who has been
transferred from the intensive care unit. The nurse notes that a cardiac troponin T level assay was
performed while the client was in the intensive care unit. The nurse determines that this test was
performed to assist in diagnosing which condition?
1.Heart failure
2.Atrial fibrillation
3.Myocardial infarction
4.Ventricular tachycardia - 3.
Cardiac troponin T or cardiac troponin I has been found to be a protein marker in the detection of
myocardial infarction, and assay for this protein is used in some institutions to aid in the diagnosis of a
myocardial infarction. The test is not used to diagnose heart failure, ventricular tachycardia, or atrial
fibrillation.
Cognitive Ability: Analyzing
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