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. Using a tongue depressor can provoke spasm of the epiglottis and lead to airway obstruction; therefore, this action is contraindicated in a child with epiglottitis.
B. Airborne precautions are not necessary for epiglottitis; droplet precautions are more appropriate due to the risk of transmission.
C. Monitoring oxygen saturation is critical in this situation to assess the child's respiratory status and ensure adequate oxygenation, making it the most appropriate action.
D. Obtaining a throat culture may not be safe or practical in this scenario, as it can provoke further distress and complications; immediate assessment and stabilization are prioritized.
Correct Answer is ["C","D","E"]
Explanation
A. Pertussis primarily affects the respiratory tract rather than just the nostrils.
B. Pertussis is caused by the bacterium Bordetella pertussis, making it a bacterial infection, not viral.
C. The bacteria release toxins that damage the cilia of the epithelial cells in the respiratory tract, disrupting their function.
D. Inflammation occurs in the lungs and airway due to the infection, contributing to symptoms such as cough.
E. The infection leads to excessive secretions that are difficult to expel, resulting in the characteristic whooping cough associated with pertussis.