A nurse is analyzing a client's electrocardiogram (ECG) strip and identifies the following information: Heart rate: 92/min Rhythm: Irregular P wave:
Unable to identify PR interval:
Unable to measure QRS duration:
0.10 seconds Based upon this information,
thenurse should interpret the client's rhythm as indicating which of the following?
Supraventricular tachycardia
Atrial fibrillation
Sinus bradycardia
First-degree heart block
The Correct Answer is B
A. Supraventricular tachycardia (SVT) typically has identifiable P waves; the absence of P waves suggests a different condition.
B. Atrial fibrillation is characterized by an irregular rhythm, inability to identify P waves, and varying intervals. This interpretation aligns with the client's ECG findings.
C. Sinus bradycardia would show identifiable P waves and a regular rhythm with a heart rate less than 60 bpm, which does not match the provided information.
D. First-degree heart block would also show identifiable P waves and regularity in the rhythm with a prolonged PR interval, which is not indicated here.
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Correct Answer is C
Explanation
A. Bradycardia is not typically expected in toddlers with heart failure; instead, tachycardia (increased heart rate) is more common as the body compensates for decreased cardiac output.
B. Weight loss is generally not a typical finding in toddlers with heart failure; rather, they often experience weight gain due to fluid retention.
C. Orthopnea, or difficulty breathing when lying flat, is a common symptom of heart failure and would be expected in a toddler due to fluid overload affecting respiratory function.
D. Increased urine output is usually not expected in heart failure; rather, fluid retention often leads to decreased urine output as the kidneys respond to the body's fluid balance needs.
Correct Answer is ["A","B","D","E"]
Explanation
A. It is important for the client to remain in bed for a specified time (typically 4 to 6 hours) to prevent complications such as bleeding at the catheter insertion site.
B. Checking peripheral pulses in the affected extremity is crucial for assessing circulation and identifying any potential complications, such as hematoma or occlusion.
C. High-Fowler's position is not typically appropriate immediately after cardiac catheterization; the client should remain flat or with limited elevation to reduce stress on the insertion site.
D. Keeping the hip and leg extended is important to prevent flexion at the site of catheter insertion, reducing the risk of bleeding or hematoma formation.
E. Measuring vital signs is essential after a procedure like cardiac catheterization to monitor for any changes that may indicate complications; however, the frequency is typically more frequent than every 4 hours initially.