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. "These tests will enable the provider to determine the heart structure and mobility of the heart valves." B. "Cardiac enzymes assist in diagnosing the presence of congestive heart failure." C. "Cardiac enzymes like troponin shows there has been damage to the heart tissues and muscle." D. "Cardiac enzymes will identify the exact location of the MI."

Correct Answer is C

Explanation

A) "These tests will enable the provider to determine the heart structure and mobility of the heart valves." This statement is incorrect because cardiac enzyme tests, including troponin levels, do not assess heart structure or valve mobility. Imaging studies like echocardiograms are typically used for evaluating heart structure and function.

B) "Cardiac enzymes assist in diagnosing the presence of congestive heart failure." While cardiac enzymes can provide some information about heart function, they are not specifically used to diagnose congestive heart failure. The primary role of cardiac enzymes, particularly troponin, is in diagnosing myocardial injury, such as an acute myocardial infarction.

C) "Cardiac enzymes like troponin shows there has been damage to the heart tissues and muscle." This statement accurately reflects the purpose of measuring troponin levels. Troponin is a protein released into the bloodstream when heart muscle cells are damaged, making it a crucial biomarker for diagnosing an acute myocardial infarction.

D) "Cardiac enzymes will identify the exact location of the MI." This statement is misleading. While troponin levels can indicate that damage has occurred, they do not provide information about the specific location of the myocardial infarction. Other imaging techniques, such as an angiogram, are needed to determine the exact location of blockages or damage.

A. Apply cold therapy to the affected leg. B. Monitor Homan's sign. C. Obtain a venous duplex ultrasound. D. Obtain impedance plethysmography.

Correct Answer is C

Explanation

A) Apply cold therapy to the affected leg: Cold therapy may be used for certain conditions to reduce swelling and pain, but in the case of suspected deep vein thrombosis (DVT) indicated by redness, warmth, tenderness, and pain in the calf, cold therapy is not appropriate. Instead, the focus should be on confirming the diagnosis before applying any treatment.

B) Monitor Homan's sign: Homan's sign involves dorsiflexion of the foot to assess for pain in the calf, which can suggest DVT. However, it is no longer considered a reliable diagnostic tool. Instead, confirmation through imaging or other diagnostic measures is preferred, so simply monitoring this sign would not be sufficient in this situation.

C) Obtain a venous duplex ultrasound: A venous duplex ultrasound is the gold standard for

diagnosing DVT. Given the client’s symptoms—redness, warmth, tenderness, and pain in the calf—the appropriate order is to obtain this ultrasound to confirm the presence of a thrombus. This imaging study provides critical information for diagnosis and subsequent management.

D) Obtain impedance plethysmography: While impedance plethysmography can assess venous flow and help diagnose DVT, it is less commonly used than venous duplex ultrasound. The more direct and widely accepted method for diagnosing DVT in this scenario is the ultrasound, making this option less suitable as the initial order.

Free Nursing Test Bank

Correct Answer is C

Explanation

Correct Answer is C

Explanation

Quick Links

Resources

Free Nursing Test Bank

Correct Answer is C

Explanation

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?

Correct Answer is C

Explanation

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 caring for a client due for their dose of carvedilol (Coreg). The nurse completes vital signs prior to administration of the medication. Which vital sign would be an indication to hold the dose scheduled and notify the healthcare provider?

A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that his blood pressure of 130/82 mm Hg places him in which of the following categories?

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.)

A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply).

The nurse is caring for a client diagnosed with Buerger's Disease (thromboangiitis obliterans). The nurse will prioritize educating the client about implementing which intervention?

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 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)

Quick Links

Resources