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","D"]
Explanation
A. This reflects a lack of understanding of conservation, as cutting a sandwich does not increase the quantity of food.
B. This belief shows a misunderstanding of conservation, where children may not recognize that the volume remains constant regardless of the container's shape.
C. Understanding that the amount of a substance remains the same even if its appearance changes is a key characteristic of conservation.
D. Recognizing that a ball of clay can be flattened and rolled back into a ball without changing its amount also demonstrates an understanding of conservation.
E. This belief indicates a misunderstanding of conservation, as the amount of liquid does not change based on the height or width of the container.
Correct Answer is C
Explanation
A. Clients on digoxin should actually have an adequate intake of potassium, as low potassium levels can increase the risk of digoxin toxicity.
B. If a pediatric client spits out digoxin, the dose should not be repeated automatically; instead, the nurse should assess the situation and follow the facility's protocol regarding missed doses.
C. Measuring the apical pulse for one full minute before administering digoxin is critical; if the pulse is below the established threshold (usually <60 bpm for children), the medication should be held and the provider notified.
D. While evaluating for nausea, vomiting, and anorexia is important, it is not an appropriate immediate action before administering the medication. The priority action is to assess the apical pulse.