Nokea
The nurse is assessing a client's cardiac rhythm strip and notices that it is irregular without any P waves before the QRS complexes. The nurse should interpret this as
- A. sinus tachycardia.
- B. sinus bradycardia.
- C. normal sinus rhythm with premature ventricular contractions (PVC).
- D. atrial fibrillation
Correct Answer: D
Rationale: Atrial fibrillation is characterized by an irregular rhythm and absent P waves due to chaotic atrial activity.
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The nurse in the emergency department (ED) is assessing a client who may have an acute myocardial infarction. Which of the following findings would support this diagnosis?
- A. U-waves
- B. T-wave inversion
- C. ST-segment elevation
- D. Prolonged PR-interval
Correct Answer: C
Rationale: ST-segment elevation on ECG is a hallmark of acute myocardial infarction, indicating myocardial ischemia.
The nurse performs a physical assessment on a client with infective endocarditis (IE). The nurse observes flat, reddened non-tender maculae on the hands and feet. The nurse understands that these are
- A. Heberden's nodes
- B. Janeway lesions
- C. Tophi
- D. Bouchard's nodes
Correct Answer: B
Rationale: Janeway lesions are non-tender, erythematous maculae on the palms and soles, characteristic of infective endocarditis.
The nurse is assessing a client with systolic heart failure. Which of the following would be an expected finding of right-sided heart failure?
- A. ascites
- B. tachypnea
- C. cough
- D. orthopnea
Correct Answer: A
Rationale: Right-sided heart failure causes systemic congestion, leading to ascites due to fluid accumulation in the abdomen.
The nurse is caring for a client diagnosed with acute pericarditis. Which complication is the client at risk for developing?
- A. cardiac tamponade
- B. hemothorax
- C. pulmonary embolism
- D. tension pneumothorax
Correct Answer: A
Rationale: Acute pericarditis can lead to pericardial effusion, which may progress to cardiac tamponade, compressing the heart.
The nurse assesses a client three hours following cardiac surgery. Assessment findings were a blood pressure of 88/52 mm Hg, jugular venous distention, and muffled heart sounds. The nurse anticipates that this client will need an immediate
- A. thoracentesis.
- B. pericardiocentesis.
- C. arthrocentesis.
- D. paracentesis.
Correct Answer: B
Rationale: These findings suggest cardiac tamponade, requiring pericardiocentesis to remove fluid compressing the heart.