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How should the nurse interpret the rhythm shown on the electrocardiogram strip shown in the diagram?

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A.

asystole

B.

ventricular fibrillation

C.

sinus tachycardia

D.

sinus bradycardia

Answer and Explanation

The Correct Answer is B

A. Asystole: Asystole would show a flat line with no electrical activity, which is not seen here.

 

B. Ventricular fibrillation: Ventricular fibrillation is characterized by chaotic, irregular waveforms without distinct P waves, QRS complexes, or T waves. The ECG strip shows this disorganized, erratic electrical activity consistent with ventricular fibrillation.

 

C. Sinus tachycardia: Sinus tachycardia would display a regular rhythm with identifiable P waves, QRS complexes, and T waves at a faster rate. This is not present in the ECG strip.

 

D. Sinus bradycardia: Sinus bradycardia would show a slower rate but with an organized rhythm and distinct P, QRS, and T waves. This is not indicated in the strip.


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View Related questions

Correct Answer is C

Explanation

A. The patient's chart may provide historical information but does not reflect the current pain intensity the client is experiencing.

B. Visual observation for nonverbal signs of pain can be useful, especially for nonverbal patients, but self-reporting is the most accurate measure of pain intensity.

C. The client's self-report of pain severity is the gold standard for assessing pain intensity, as it reflects the individual’s personal experience of pain.

D. While the nature and invasiveness of the surgical procedure can provide context for expected pain levels, they do not replace the importance of the client's self-report in managing pain effectively.

Correct Answer is D

Explanation

A. Petechiae are small, pinpoint hemorrhages and are considered objective data that can be observed and documented by the nurse.

B. Blood pressure is a vital sign and objective data that can be measured using a sphygmomanometer.

C. Cyanosis is a physical sign indicating low oxygenation in the blood and is objective data that can be observed.

D. Nausea is a subjective symptom reported by the client, reflecting their internal experience and cannot be measured or observed directly.

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