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 D
Explanation
A. Preparing for immediate surgery is necessary, but the priority intervention is to ensure adequate oxygenation and blood flow through the ductus arteriosus before surgery can be performed.
B. Initiating feeding through a nasogastric tube is not a priority for an infant with this condition, as their immediate need is to address the circulatory issue rather than feeding.
C. Administering oxygen via nasal cannula may provide some relief but is not sufficient as a standalone intervention for transposition of the great vessels, which requires maintaining ductal patency to allow mixing of oxygenated and deoxygenated blood.
D. Administering prostaglandin E1 (PGE1) is the priority intervention, as it helps maintain patency of the ductus arteriosus, allowing for temporary stabilization of the infant’s condition until surgical intervention can be performed.
Correct Answer is B
Explanation
A. Enforcing strict bed rest without any physical activity can lead to feelings of isolation and boredom, which may negatively affect the child's well-being and engagement.
B. Allowing the child to decorate their hospital room with personal items fosters a sense of ownership and comfort, helping to promote emotional well-being and engagement during hospitalization.
C. Limiting visits can increase feelings of loneliness and anxiety in the child, which is not conducive to their emotional health; maintaining social connections is important for well-being.
D. Using medical terms may confuse the child and does not support their understanding or engagement; explanations should be age-appropriate and easily understood.