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    Sp26 504w advanced med surg proctored exam (Massachusetts college)

    The client's telemetry reading shows a "P" wave before each QRS complex and has a heart rate of 70. Which action would the nurse implement?

    Explanation & Rationale

    A. Document this as normal sinus rhythm: A P wave preceding each QRS complex with a heart rate of 60–100 beats per minute indicates normal sinus rhythm. This reflects appropriate electrical conduction from the sinoatrial node through the atria and ventricles, and no immediate interventions are required beyond routine monitoring. B. Prepare to administer intravenous atropine: Atropine is indicated for symptomatic bradycardia or heart block, not for a heart rate of 70 bpm with normal sinus rhythm. Administering atropine in this situation is unnecessary and could cause tachycardia or other complications. C. Request a 12-lead electrocardiogram: While a 12-lead ECG can provide a more comprehensive assessment, it is not required for documentation of uncomplicated normal sinus rhythm in a stable client. Telemetry reading alone is sufficient to identify NSR in this context. D. Assess the client's cardiac enzymes: Cardiac enzymes are indicated for suspected myocardial injury or infarction. Normal sinus rhythm with a heart rate of 70 does not suggest myocardial ischemia, so evaluating cardiac enzymes is not warranted based solely on the telemetry reading.

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