Exam 2 Flashcards
The nurse is assessing the client’s cardiac rhythm and notes the following: HR 64, regular rhythm, PR interval 0.20; QRS 0.10. How will the nurse document this rhythm interpretation in the electronic health record?
A. Sinus tachycardia
B. Sinus bradycardia
C. Normal sinus rhythm
D. Sinus arrhythmia
C. Normal Sinus Rhythm
Upon entering a client’s room, the nurse finds the client unresponsive. In what order will the nurse provide care?
A. Begin chest compressions
B. Check carotid pulse
C. Notify the Rapid Response Team
D. Get the crash cart/AED
E. Provide rescue breaths
C, D, B, A, E
While suctioning a client with a tracheostomy, the client becomes diaphoretic and nauseous and the heart rate decreases to 37 beats/min. What is the priority nursing action?
A. Continue to clear the airway.
B. Stop suctioning the patient.
C. Administer atropine.
D. Call the health care provider immediately.
B
A client in the telemetry unit is on a cardiac monitor. The monitor technician alerts the nurse that there are no ECG complexes, and the alarm is sounding. What is the first action by the nurse?
A. Suspend the alarm.
B. Call the emergency response team.
C. Press the record button to get an ECG strip.
D. Assess the client and check lead placement.
D
The primary health care provider prescribes warfarin for a client with atrial fibrillation. Which client statement indicates that additional education is needed?
A. “I need to go to the clinic once a week to have my blood level checked.”
B. “If my stools turn black, I will be sure to call my primary health care provider.”
C. “I’m glad I don’t need to change my diet. Salads are my favorite food.”
D. “I need to stop taking my herbal supplement.”
C
The nurse is preparing a male patient to have a 12-lead ECG performed. When prepping the skin, the nurse notices that the patient has abundant chest hair. What is the most appropriate nursing intervention to improve adhesion of the ECG leads?
A. Use alcohol swabs to clean the skin before applying the leads B. Clip the chest hair with the patient’s permission before applying the leads C. Apply the leads to the arms and legs only
Reschedule the ECG
Clip the chest hair with the patient’s permission before applying the leads.
Rationale: Alcohol should not be used to prep the skin because it increases the skin’s electrical impedance, thereby hindering the detection of the cardiac electrical signal. Clipping the hair would provide access to the skin to assist with adhesion. The ECG would not be performed correctly if the leads were only placed on the extremities, and there is no need to reschedule the ECG at this time
A 28-year-old woman with a history of hypertension and tachycardia comes to the hospital clinic stating that she doesn’t feel well. You connect her to a cardiac monitor and observe that she is in SVT with a rate varying between 160 and 180. She reports shortness of breath, palpitations, and weakness. She appears very nervous and anxious, and her BP is 88/56 mm Hg.
What is your priority intervention?
Oxygen Administration
Ten minutes later, the patient is still in SVT and reports substernal chest pain and dizziness.
Which action will you expect the physcian to take to treat the dysrhythmia?
A. Order a 12-lead ECG. B. Perform carotid massage/ vagal maneuver C. Administer amiodarone (Cordarone) IV push.
Instruct the patient to take several deep breaths.
B.
The patient’s SVT returns after 30 minutes. What medication do you anticipate will be ordered for the patient?
A. Magnesium sulfate 1 g IVP B. Lidocaine (Xylocaine) 75 mg IVP C. Adenosine (Adenocard) 6 mg IVP
Mexiletine (Mexitil) 300 mg PO q8h
C. Adenosine over 1-3 secs followed by 20 ml flush
Have crash cart
The SVT resolves immediately after IV adenosine (Adenocard) is administered. Because the patient has experienced repeated episodes of symptomatic SVT, a cardiologist has been consulted and treatment options discussed.
What is the preferred treatment for recurrent SVT?
A. Atrial overdrive pacing B. Synchronized electrical shock C. Radiofrequency catheter ablation
Daily administration of diltiazem (Cardizem)
C
The nurse working in the outpatient setting identifies which dysrhythmia as the most commonly diagnosed?
A. Atrial fibrillation B. Sinus tachycardia C. Sinus bradycardia
D. Ventricular fibrillation
Afib
On a telemetry monitor, the nurse observes that a patient’s heart rhythm is sustained ventricular tachycardia (VT). Upon assessment, the patient is alert and oriented with no reports of chest pain, but expresses feeling slightly short of breath. His blood pressure is 108/70. What is the nurse’s first action?
A. Synchronized cardioversion B. CPR and immediate defibrillation C. Administration of IV amiodarone (Cordarone) and dextrose
Administration of oxygen and observation of the heart rhythm
ANS: D
Current advanced cardiac life support (ACLS) guidelines recommend administration of oxygen and observation of heart rhythm first, followed by administration of an IV antidysrhythmic agent such as amiodarone mixed with dextrose 5%. Synchronized cardioversion would be the next step. CPR and immediate defibrillation would be used only to treat unstable VT.
A patient is admitted to a telemetry unit with a new diagnosis of atrial fibrillation (AF). The patient states, “I feel fine, this rhythm won’t hurt me.” Which nursing response is appropriate?
A. “AF can cause clots to form from the irregular blood flow in the heart.” B. “It’s important to monitor the AF for 24 hours.” C. “AF leads the death of the heart muscle.”
“AF can cause cardiac output to increase.”
ANS: A
Many times patients are found to have atrial fibrillation and they may be asymptomatic. While some patients do live with long-term atrial fibrillation, they need to be anticoagulated to decrease the risk of embolus formation due to the irregular cardiac rhythm. AF does not cause death of the heart muscle, nor does it cause the cardiac output to increase. Cardiac output will decrease due to the shortened filling time in the atria, which contributes to the development of heart failure due to altered conduction. While monitoring the patient is appropriate, it is not the best response to help educate the patient on the process of atrial fibrillation.
A client who recently had a heart valve replacement is preparing for discharge. Which client statement indicates that the nurse will need to do additional health teaching?
A. “I need to brush my teeth at least twice daily and rinse with water.”
B. “I will eat foods that are low in vitamin K, such as potatoes and iceberg lettuce.”
C. “I need to take a full course of antibiotics prior to my colonoscopy.”
D. “I will take my blood pressure every day and call if it is too high or low.”
C
The nurse is caring for a hospitalized client with infective endocarditis who has been receiving antibiotics for 2 days. The client is now experiencing flank pain with hematuria. What complication will the nurse suspect?
A. Pulmonary embolus
B. Renal infarction
C. Transient ischemic attack
D. Splenic infarction
B
