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. "For confirmed diagnosis of hypertension, the BP readings should be higher than normal on 2 or more separate occasions." B. "For confirmed diagnosis of hypertension, BP readings should be lower than normal on only one occasion." C. "For confirmed diagnosis of hypertension, BP readings should be higher than normal on more than three separate occasions." D. "For confirmed diagnosis of hypertension, the BP readings should be higher than normal on only one occasion."

Correct Answer is A

Explanation

A. "For confirmed diagnosis of hypertension, the BP readings should be higher than normal on 2 or more separate occasions.": This statement accurately reflects the criteria for diagnosing hypertension. According to guidelines, a diagnosis is typically confirmed when blood pressure readings consistently exceed normal levels (usually defined as 130/80 mm Hg) on two or more separate visits.

B. "For confirmed diagnosis of hypertension, BP readings should be lower than normal on only one occasion.": This statement is incorrect. A single low reading does not confirm a diagnosis of hypertension. In fact, it contradicts the concept of hypertension, which involves consistently high readings.

C. "For confirmed diagnosis of hypertension, BP readings should be higher than normal on more than three separate occasions.": This statement is misleading. While multiple readings are often taken, the threshold for diagnosis is two or more elevated readings, not three.

D. "For confirmed diagnosis of hypertension, the BP readings should be higher than normal on only one occasion.": This statement is inaccurate, as a single elevated reading is not sufficient for diagnosis. Consistent elevations over multiple occasions are necessary for a confirmed diagnosis.

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 A

Explanation

Correct Answer is C

Explanation

Quick Links

Resources

Free Nursing Test Bank

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

Correct Answer is A

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 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 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 assessing client with advanced peripheral arterial disease (PAD). Which of the following findings would the nurse expect?

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 caring for a client who is being administered spironolactone (Aldactone). Which of the following laboratory values should be monitored due to taking this medication?

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

A nurse is teaching a client just diagnosed with mild hypertension. Which of the following information should the nurse include in the teaching?

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