Take full exam for free

A nurse is caring for a client in a cardiac unit. Using the five criteria for ECG analysis information, the nurse interprets the client's ECG as which of the following rhythm interpretations?Heart Rate: 59 bpmRhythm: RegularPresence of P waves: One P wave for every QRS complexPR interval: 0.20 secondsQRS complex duration: 0.10 seconds

Ventricular tachycardia

Sinus tachycardia

Sinus bradycardia

Normal sinus rhythm

Answer and Explanation

The Correct Answer is C

A) Ventricular tachycardia: Ventricular tachycardia is characterized by a rapid heart rate exceeding 100 bpm, typically arising from abnormal ventricular activity. In this case, the heart rate is 59 bpm, which does not support this interpretation. Additionally, ventricular tachycardia usually presents with wide QRS complexes and no discernible P waves, neither of which is true in this scenario.

B) Sinus tachycardia: Sinus tachycardia is defined by a heart rate exceeding 100 bpm originating from the sinoatrial (SA) node, with a regular rhythm and normal P waves. The heart rate of 59 bpm in this client is too low for a diagnosis of sinus tachycardia, making this option incorrect.

C) Sinus bradycardia: Sinus bradycardia occurs when the heart rate is less than 60 bpm, with a regular rhythm and a normal PR interval and QRS duration. The provided data shows a heart rate of 59 bpm, a regular rhythm, one P wave for every QRS complex, a PR interval of 0.20 seconds, and a QRS duration of 0.10 seconds, which aligns perfectly with the criteria for sinus bradycardia.

D) Normal sinus rhythm: Normal sinus rhythm typically presents with a heart rate of 60-100 bpm, a regular rhythm, and appropriate P waves for each QRS complex. Given the heart rate of 59 bpm, this does not meet the criteria for normal sinus rhythm, as it falls below the acceptable range.

Free Nursing Test Bank

Take full exam free

View Related questions

A. Ambulating soon after surgery B. Flexing her ankles C. Massaging her legs D. Elevating her feet

Correct Answer is C

Explanation

A) Ambulating soon after surgery: Early ambulation is encouraged for postoperative clients to promote circulation and reduce the risk of venous thromboembolism (VTE). Mobilizing helps prevent stasis of blood in the veins, making this an appropriate action rather than an unsafe one.

B) Flexing her ankles: Ankle flexion exercises can help improve venous return and circulation in the lower extremities. This action is generally recommended to prevent VTE, making it a safe and beneficial practice for postoperative clients.

C) Massaging her legs: Massaging the legs is considered unsafe for a client at risk for VTE. This action can dislodge a thrombus (blood clot) if one is present, leading to potential complications such as pulmonary embolism. Therefore, the nurse should instruct the client to avoid leg massages.

D) Elevating her feet: Elevating the feet is a recommended practice to promote venous return and reduce swelling in postoperative clients. This action can help prevent VTE and is generally considered safe and beneficial.

A. "I will apply my compression stockings. B. "I will limit long periods of standing." C. "I may develop a brownish discoloration to my lower extremities." D. "With this problem, I may have lower extremity hair loss." E. "I will only take my cholesterol lowering medication every other day in the afternoon

Correct Answer is ["A","B","C","D"]

Explanation

A) "I will apply my compression stockings." Compression stockings are a standard recommendation for clients with peripheral venous disease (PVD). They help improve venous return and reduce symptoms like swelling and discomfort, indicating that the client understands the importance of managing their condition.

B) "I will limit long periods of standing." This statement reflects an understanding of the need to avoid activities that can exacerbate venous stasis and contribute to worsening symptoms in PVD. Limiting long periods of standing helps promote better blood flow and reduces the risk of complications.

C) "I may develop a brownish discoloration to my lower extremities." This statement indicates an awareness of a potential complication of PVD, often caused by venous stasis and pooling of blood. Brownish discoloration, or stasis dermatitis, can occur in the lower extremities, showing the client’s understanding of the condition.

D) "With this problem, I may have lower extremity hair loss." This statement is accurate as well; hair loss on the lower extremities can occur with PVD due to reduced blood flow and oxygen supply to the tissues. This recognition indicates that the client understands the potential effects of their diagnosis.

E) "I will only take my cholesterol lowering medication every other day in the afternoon." This statement reflects a misunderstanding of medication management. Clients with PVD should take prescribed medications as directed to manage their condition effectively, and altering the dosing schedule without consulting a healthcare provider can lead to adverse outcomes.

Free Nursing Test Bank

Correct Answer is C

Explanation

Correct Answer is ["A","B","C","D"]

Explanation

Quick Links

Resources

Free Nursing Test Bank

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?

Correct Answer is C

Explanation

The nurse is providing a client with teaching regarding a new diagnosis of peripheral venous disease (PVD). Which client statement indicates the client understood the education provided? (Select all that apply)

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is planning to assign tasks for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? (Select all that apply.)

The nurse is planning to teach a client with peripheral arterial disease (PAD) about measures to limit disease progression. Which interventions would the nurse include for this client? (Select all that apply)

A nurse is completing the medical reconciliation on an elderly client taking several medications. Which of the following prescribed medications places this client at risk for orthostatic hypotension? (Select all that apply.)

The nurse is educating the patient about the diagnosis of hypertension. Which statement made by the nurse is most accurate?

A nurse is reviewing the medication list for a client who has a new prescription for warfarin. The nurse should recognize which is incompatible with warfarin?

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?

A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding?

The nurse is assessing a client diagnosed with peripheral arterial disease (PAD). The client reports leg pain and cramping after walking a few blocks, which is relieved when the client stops and rests. The nurse documents that the client is experiencing which clinical manifestation?

Quick Links

Resources