Exam 2 Review Questions- CV and HTN, Respiratory, Ostomy Flashcards
Which of the following terms is used to describe the ability of the heart to initiate an electrical impulse?
a) Automaticity
b) Excitability
c) Contractility
d) Conductivity
Automaticity
Automaticity is the ability of specialized electrical cells of the cardiac conduction system to initiate an electrical impulse.
Contractility refers to the ability of the specialized electrical cells of the cardiac conduction system to contract in response to an electrical impulse.
Conductivity refers to the ability of the specialized electrical cells of the cardiac conduction system to transmit an electrical impulse from one cell to another.
Excitability refers to the ability of the specialized electrical cells of the cardiac conduction system to respond to an electrical impulse.
Age-related changes associated with the cardiac system include which of the following?
Select all that apply.
a) Increase in the number of SA node cells
b) Myocardial thinning
c) Endocardial fibrosis
d) Increased size of the left atrium
Endocardial fibrosis Increased size of the left atrium
Age-related changes associated with the cardiac system include endocardial fibrosis, increased size of the left atrium, decreased number of SA node cells, and myocardial thickening.
For both outpatients and inpatients scheduled for diagnostic procedures of the cardiovascular system, the nurse performs a thorough initial assessment to establish accurate baseline data. Which of the following data is necessary to collect if the patient is experiencing chest pain?
a) Blood pressure in the left arm
b) Description of the pain
c) Sound of the apical pulses
d) Pulse rate in upper extremities
Description of the pain
If the patient is experiencing chest pain, a history of its location, frequency, and duration is necessary, as is a description of the pain, if it radiates to a particular area, what precipitates its onset, and what brings relief.
The nurse weighs the patient and measures vital signs. The nurse may measure BP in both arms and compare findings.
The nurse assesses apical and radial pulses, noting rate, quality, and rhythm. The nurse also checks peripheral pulses in the lower extremities.
The nurse is caring for a patient prescribed warfarin (Coumadin) orally. The nurse reviews the patient’s prothrombin time (PT) level to evaluate the effectiveness of the medication. The nurse should also evaluate which of the following laboratory values?
a) Partial thromboplastic time (PTT)
b) Complete blood count (CBC)
c) Sodium
d) International normalized ratio (INR)
International normalized ratio (INR)
The INR, reported with the PT, provides a standard method for reporting PT levels and eliminates the variation of PT results from different laboratories.
The INR, rather than the PT alone, is used to monitor the effectiveness of warfarin.
The therapeutic range for INR is 2 to 3.5, although specific ranges vary based on diagnosis.
The other laboratory values are not used to evaluate the effectiveness of Coumadin.
The nurse is caring for a patient in the ICU diagnosed with coronary artery disease (CAD). Which of the following assessment data indicates the patient is experiencing a decrease in cardiac output?
a) BP 108/60 mm Hg, ascites, and crackles
b) Disorientation, 20 mL of urine over the last 2 hours
c) Reduced pulse pressure and heart murmur
d) Elevated jugular venous distention (JVD) and postural changes in BP
Disorientation, 20 mL of urine over the last 2 hours
Assessment findings associated with reduced cardiac output include reduced pulse pressure, hypotension, tachycardia, reduced urine output, lethargy, or disorientation.
During the auscultation of a patient’s heart sounds, the nurse notes an S4. The nurse recognizes that an S4 is associated with which of the following?
a) Turbulent blood flow
b) Heart failure
c) Hypertensive heart disease
d) Diseased heart valves
Hypertensive heart disease
Auscultation of the heart requires familiarization with normal and abnormal heart sounds.
An extra sound just before S1 is an S4 heart sound, or atrial gallop.
An S4 sound often is associated with hypertensive heart disease.
A sound that follows S1 and S2 is called an S3 heart sound or a ventricular gallop.
An S3 heart sound is often an indication of heart failure in an adult.
In addition to heart sounds, auscultation may reveal other abnormal sounds, such as murmurs and clicks, caused by turbulent blood flow through diseased heart valves.
The nurse is screening a patient prior to a magnetic resonance angiogram (MRA) of the heart. Which of the following actions should the nurse complete prior to the patient undergoing the procedure? Select all that apply.
a) Sedate the patient prior to the procedure.
b) Remove the patient’s Transderm Nitro patch.
c) Offer the patient a headset to listen to music during the procedure.
d) Remove the patient’s jewelry.
e) Position the patient on his/her stomach for the procedure.
Remove the patient’s Transderm Nitro patch.
Offer the patient a headset to listen to music during the procedure.
Remove the patient’s jewelry.
Transdermal patches that contain a heat-conducting aluminized layer (e.g., NicoDerm, Androderm, Transderm Nitro, Transderm Scop, Catapres-TTS) must be removed before MRA to prevent burning of the skin.
A patient who is claustrophobic may need to receive a mild sedative before undergoing an MRA.
During an MRA, the patient is positioned supine on a table that is placed into an enclosed imager or tube containing the magnetic field.
Patients are instructed to remove any jewelry, watches, or other metal items (e.g., ECG leads).
An intermittent clanking or thumping that can be annoying is generated by the magnetic coils, so the patient may be offered a headset to listen to music.
The nurse is caring for a patient in the ED who has a B-type natriuretic peptide (BNP) level of 115 pg/mL. The nurse understands that this finding is most suggestive of which of the following?
a) Heart failure
b) Myocardial infarction
c) Ventricular hypertrophy
d) Pulmonary edema
Heart failure
A BNP level greater than 100 pg/mL is suggestive of HF. Because this serum laboratory test can be quickly obtained, BNP levels are useful for prompt diagnosis of HF in settings such as the ED.
Elevations in BNP can occur from a number of other conditions such as pulmonary embolus, myocardial infarction (MI), and ventricular hypertrophy.
Therefore, the clinician correlates BNP levels with abnormal physical assessment findings and other diagnostic tests before making a definitive diagnosis of HF.
The nurse is caring for a patient with an intra-arterial BP monitoring device. The nurse recognizes the most preventable complication associated with hemodynamic monitoring includes which of the following?
a) Catheter-related bloodstream infections (CRBSI)
b) Pneumothorax
c) Hemorrhage
d) Air embolism
Catheter-related bloodstream infections (CRBSI)
CRBSIs are the most common preventable complication associated with hemodynamic monitoring systems.
Comprehensive guidelines for the prevention of these infections have been published by Centers for Disease Control and Prevention (CDC).
Complications from use of hemodynamic monitoring systems are uncommon and can include pneumothorax, infection, and air embolism.
A pneumothorax may occur during the insertion of catheters using a central venous approach (CVP and pulmonary artery catheters).
Air emboli can be introduced into the vascular system if the stopcocks attached to the pressure transducers are mishandled during blood drawing, administration of medications, or other procedures that require opening the system to air.
The nurse is observing a patient during an exercise stress test (bicycle). Which of the following findings indicates a positive test and the need for further diagnostic testing?
a) ST-segment changes on the ECG
b) BP changes; 148/80 mm Hg to 166/90 mm Hg
c) Dizziness and leg cramping
d) Heart rate changes; 78 bpm to 112 bpm
ST-segment changes on the ECG
During the test, the following are monitored: two or more ECG leads for heart rate, rhythm, and ischemic changes; BP; skin temperature; physical appearance; perceived exertion; and symptoms, including chest pain, dyspnea, dizziness, leg cramping, and fatigue.
The test is terminated when the target heart rate is achieved or if the patient experiences signs of myocardial ischemia.
Further diagnostic testing, such as a cardiac catheterization, may be warranted if the patient develops chest pain, extreme fatigue, a decrease in BP or pulse rate, serious dysrhythmias or ST-segment changes on the ECG during the stress test. The other findings would not warrant the testing to be stopped.
The nurse is reviewing discharge instructions with a patient who underwent a left groin cardiac catheterization 8 hours ago. Which of the following instructions should the nurse include?
a) “Contact your primary care provider if you develop a temperature above 102°F.”
b) “Do not bend at the waist, strain, or lift heavy objects for the next 24 hours.”
c) “If any discharge occurs at the puncture site, call 911 immediately.”
d) “You can take a tub bath or a shower when you get home.”
“Do not bend at the waist, strain, or lift heavy objects for the next 24 hours.”
The nurse should instruct the patient to complete the following:
If the artery of the groin was used, for the next 24 hours, do not bend at the waist, strain, or lift heavy objects; the primary provider should be contacted if any of the following occur: swelling, new bruising or pain from your procedure puncture site, temperature of 101°F or more. If bleeding occurs, lie down (groin approach) and apply firm pressure to the puncture site for 10 minutes.
Notify the primary provider as soon as possible and follow instructions. If there is a large amount of bleeding, call 911. The patient should not drive to the hospital.
The nurse is caring for a patient with clubbing of the fingers and toes. The nurse should complete which of the following actions given these findings?
a) Obtain an oxygen saturation level.
b) Assess the patient for pitting edema.
c) Obtain a 12-lead ECG tracing.
d) Assess the patient’s capillary refill.
Obtain an oxygen saturation level.
Clubbing of the fingers and toes indicates chronic hemoglobin desaturation (decreased oxygen supply) and is associated with congenital heart disease.
The nurse should assess the patient’s O2 saturation level and intervene as directed. The other assessments are not indicated.
The nurse auscultates the PMI (point of maximal impulse) at which of the following anatomic locations?
a) Left midclavicular line, fifth intercostal space
b) 2 inches to the left of the lower end of the sternum
c) 1 inch to the left of the xiphoid process
d) Midsternum
Left midclavicular line, fifth intercostal space
The left ventricle is responsible for the apical impulse or the point of maximum impulse, which is normally palpable in the left midclavicular line of the chest wall at the fifth intercostal space.
The right ventricle lies anteriorly, just beneath the sternum. Use of inches to identify the location of the PMI is inappropriate based on variations in human anatomy.
Auscultation below and to the left of the xiphoid process will detect gastrointestinal sounds, but not the PMI.
When the balloon on the distal tip of a pulmonary artery catheter is inflated and a pressure is measured, the measurement obtained is referred to as which of the following?
a) Central venous pressure
b) Pulmonary artery wedge pressure
c) Cardiac output
d) Pulmonary artery pressure
Pulmonary artery wedge pressure
When the balloon is inflated, the tip of the catheter floats into smaller branches of the pulmonary artery until it can no longer be passed and the pressure is recorded, reflecting left atrial pressure and left ventricular end-diastolic pressure.
Central venous pressure is measured in the right atrium. Pulmonary artery pressure is measured when the balloon tip is not inflated.
Cardiac output is determined through thermodilution involving injection of fluid into the pulmonary artery catheter.
A nurse is preparing to assess a patient for postural BP changes. Which of the following indicates the need for further education?
a) Obtaining the supine measurements prior to the sitting and standing measurements
b) Taking the patient’s BP with the patient sitting on the edge of the bed with feet dangling
c) Positioning the patient supine for 10 minutes prior to taking the initial BP and HR
d) Letting 30 seconds elapse after each position change before measuring BP and heart rate (HR)
Letting 30 seconds elapse after each position change before measuring BP and heart rate (HR)
The following steps are recommended when assessing patients for postural hypotension:
Position the patient supine for 10 minutes before taking the initial BP and HR measurements; reposition the patient to a sitting position with legs in the dependent
position, wait 2 minutes then reassess both BP and HR measurements; if the patient is symptom free or has no significant decreases in systolic or diastolic BP, assist the patient into a standing position, obtain
measurements immediately and recheck in 2 minutes; continue measurements every 2 minutes for a total of 10 minutes to rule out postural hypotension.
Return the patient to supine position if postural hypotension is detected or if the patient becomes symptomatic.
Document HR and BP measured in each position (e.g., supine, sitting, and standing) and any signs or symptoms that accompany the postural changes.
The ability of the cardiac muscle to shorten in response to an electrical impulse is termed which of the following?
a) Contractility
b) Diastole
c) Depolarization
d) Repolarization
Contractility
Contractility is the ability of the cardiac muscle to shorten in response to an electrical impulse.
Depolarization is the electrical activation of a cell caused by the influx of sodium into the cell while potassium exits the cell.
Repolarization is the return of the cell to the resting state, caused by reentry of potassium into the cell while sodium exits the cell.
Diastole is the period of ventricular relaxation resulting in ventricular filling.
The nurse is caring for a patient who has undergone peripheral arteriography. How should the nurse assess the adequacy of peripheral circulation?
a) By hemodynamic monitoring
b) By checking peripheral pulses
c) By observing the patient for bleeding
d) By checking for cardiac dysrhythmias
By checking peripheral pulses
Peripheral arteriography is used to diagnose occlusive arterial disease in smaller arteries.
The nurse observes the patient for bleeding and cardiac dysrhythmias and assesses the adequacy of peripheral circulation by frequently checking the peripheral pulses.
Hemodynamic monitoring is used to assess the volume and pressure of blood in the heart and vascular system.
Decreased pulse pressure reflects which of the following?
a) Tachycardia
b) Reduced stroke volume
c) Elevated stroke volume
d) Reduced distensibility of the arteries
Reduced stroke volume
Decreased pulse pressure reflects reduced stroke volume and ejection velocity or obstruction to blood flow during systole.
Increased pulse pressure would indicate reduced distensibility of the arteries, along with bradycardia.
Which of the following is the term for the normal pacemaker of the heart?
a) Sinoatrial (SA) node
b) Atrioventricular (AV) node
c) Purkinje fibers
d) Bundle of His
Sinoatrial (SA) node
The sinoatrial node is the primary pacemaker of the heart.
The AV node coordinates the incoming electrical impulses from the atria and, after a slight delay, relays the impulse to the ventricles.
The Purkinje fibers rapidly conduct the impulses through the thick walls of the ventricles.
The nurse correctly identifies which of the following data as an example of BP and HR measurements in a patient with postural hypotension?
a) Supine: BP 114/82 mm Hg, HR 90 bpm; sitting: BP 110/76 mm Hg, HR 95 bpm; standing: BP 108/74 mm Hg, HR 98 bpm
b) Supine: BP 140/78 mm Hg, HR 72 bpm; sitting: BP 145/78 mm Hg, HR 74 bpm; standing: BP 144/78 mm Hg, HR 74 bpm
c) Supine: BP 130/70 mm Hg, HR 80 bpm; sitting: BP 128/70 mm Hg, HR 80 bpm; standing: BP 130/68 mm Hg, HR 82 bpm
d) Supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm
Supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm
Postural (orthostatic) hypotension is a sustained decrease of at least 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP within 3 minutes of moving from a lying or sitting to a standing position. The following is an example of BP and HR measurements in a patient with postural hypotension: supine:
BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm. Normal postural responses that occur when a person moves from a lying to a standing position include
(1) a HR increase of 5 to 20 bpm above the resting rate;
(2) an unchanged systolic pressure, or a slight decrease of up to 10 mm Hg; and (3) a slight increase of 5 mm Hg in diastolic pressure.
The area of the heart that is located at the third intercostal (IC) space to the left of the sternum is which of the following?
a) Epigastric area
b) Aortic area
c) Pulmonic area
d) Erb’s point
Erb’s point
Erb’s point is located at the third IC space to the left of the sternum.
The aortic area is located at the second IC space to the right of the sternum.
The pulmonic area is at the second IC space to the left of the sternum.
The epigastric area is located below the xiphoid process.
Which of the following findings indicates that hypertension is progressing to target organ damage?
a) Urine output of 60 cc/mL over 2 hours
b) Blood urea nitrogen (BUN) level of 12 mg/dL
c) Chest x-ray showing pneumonia
d) Retinal blood vessel damage
Retinal blood vessel damage
Symptoms suggesting that hypertension is progressing to the extent that target organ damage is occurring must be detected early so that appropriate treatment can be initiated.
All body systems must be assessed to detect any evidence of vascular damage.
An eye examination with an ophthalmoscope is important because retinal blood vessel damage indicates similar damage elsewhere in the vascular system.
The patient is questioned about blurred vision, spots in front of the eyes, and diminished visual acuity.
The heart, nervous system, and kidneys are also carefully assessed.
A BUN level and 60 cc/mL over 2 hours are normal findings.
The presence of pneumonia does not indicate target organ damage.
A 35-year-old female patient has been diagnosed with hypertension. The patient is a stock broker, smokes daily, and is also a diabetic. During a follow-up appointment, the patient states that she finds it cumbersome and time consuming to visit the doctor regularly just to check her blood pressure (BP). As the nurse, which of the following aspects of patient teaching would you recommend?
a) Advising a smoking cessation
b) Administering glycemic control
c) Purchasing a self-monitoring BP cuff
d) Discussing methods for stress reduction
Purchasing a self-monitoring BP cuff
Because this patient finds it time consuming to visit the doctor just for a blood pressure reading, as the nurse, you can suggest the use of an automatic cuff at a local pharmacy, or purchasing a self-monitoring cuff.
Discussing methods for stress reduction, advising a smoking cessation, and administering glycemic control would constitute patient education in managing hypertension.
Officially, hypertension is diagnosed when the patient demonstrates a systolic blood pressure greater than ______ mm Hg and a diastolic blood pressure greater than _____ mm Hg over a sustained period.
a) 120, 70
b) 140, 90
c) 110, 60
d) 130, 80
140, 90
According to the categories of blood pressure levels established by the Joint National Committee (JNC) VI, stage 1 hypertension is demonstrated by a systolic pressure of 140 to 159, or a diastolic pressure of 90 to 99. Pressure of 130 systolic and 80 diastolic falls within the normal range for an adult.
Pressure of 110 systolic and 60 diastolic falls within the normal range for an adult.
Pressure of 120 systolic and 70 diastolic falls within the normal range for an adult.
The nurse teaches the patient which of the following guidelines regarding lifestyle modifications for hypertension?
a) Reduce smoking to no more than four cigarettes per day
b) Stop alcohol intake
c) Limit aerobic physical activity to 15 minutes, three times per week
d) Maintain adequate dietary intake of fruits and vegetables
Maintain adequate dietary intake of fruits and vegetables
Guidelines include adopting the dietary approaches to stop hypertension (DASH) eating plan:
consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat, dietary sodium reduction: reduce dietary sodium intake to no more than 100 mmol/day (2.4 g sodium or 6 g sodium chloride),
and physical activity: engage in regular aerobic physical activity such as brisk walking (at least 30 min/day, most days of the week),
Moderate alcohol consumption: limit consumption to no more than two drinks (eg, 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men and to no more than 1 drink per day in women and lighter-weight people.
Tobacco: should be avoided because anyone with high blood pressure is already at increased risk for heart disease, and smoking amplifies this risk.
A 66-year-old client presents to the emergency room (ER) complaining of a severe headache and mild nausea for the last 6 hours. Upon assessment, the patient’s BP is 210/120 mm Hg. The patient has a history of HTN for which he takes 1.0 mg clonidine (Catapres) twice daily for. Which of the following questions is most important for the nurse to ask the patient next?
a) “Have you taken your prescribed Catapres today?”
b) ”Did you take any medication for your headache?”
c) “Are you having chest pain or shortness of breath?”
d) “Do you have a dry mouth or nasal congestion?”
“Have you taken your prescribed Catapres today?”
The nurse must ask if the patient has taken his prescribed Catapres.
Patients need to be informed that rebound hypertension can occur if antihypertensive medications are suddenly stopped.
Specifically, a side effect of Catapres is rebound or withdrawal hypertension. A
lthough the other questions may be asked, it is most important to inquire if the patient has taken his prescribed HTN medication given the patient’s severely elevated BP.
The nurse is administering medications on a medical surgical unit. A patient is ordered to receive 40 mg of oral Corgard (nadolol) for the treatment of hypertension. Prior to administering the medication, the nurse should complete which of the following?
a) Checking the patient’s heart rate
b) Weighing the patient
c) Checking the patient’s serum K+ level
d) Checking the patient’s urine output
Checking the patient’s heart rate
Corgard is a beta-blocker.
A desired effect of this medication is to reduce the pulse rate in patients with tachycardia and an elevated blood pressure (BP).
The nurse should check the patient’s heart rate (HR) prior to administering Corgard to ensure that the patient’s pulse rate is not below 60 (beats per minute (bpm). The other interventions are not indicated prior to administering a beta-blocker medication.
The nurse is caring for a client who is prescribed diuretic medication for the treatment of hypertension. The nurse recognizes that which of the following medications conserves potassium?
a) Chlorthalidone (Hygroton)
b) Chlorothiazide (Diuril)
c) Furosemide (Lasix)
d) Spironolactone (Aldactone)
Spironolactone (Aldactone)
Aldactone is known as a potassium-sparing diuretic. Lasix causes loss of potassium from the body. Diuril causes mild hypokalemia. Hygroton causes mild hypokalemia.
The nurse is conducting a service project for a local elderly community group on the topic of hypertension. The nurse will relay that risk factors and cardiovascular problems related to hypertension include which of the following? Select all that apply.
a) Elevated high-density lipoprotein (HDL) cholesterol
b) Decreased low-density lipoprotein (LDL) levels.
c) Smoking
d) Age ≥55 in men
e) Obesity (BMI ≥ 30 kg/m2)
Smoking
Age ≥55 in men
Obesity (BMI ≥ 30 kg/m2)
Major risk factors (in addition to hypotension) include smoking, dyslipidemia (high LDL, low HDL cholesterol), diabetes mellitus, impaired renal function, obesity, physical inactivity, age (older than 55 years for men, 65 years for women), and family history of cardiovascular disease.
A 77-year-old woman presents to the local community center for a blood pressure screening. The women’s blood pressure is recorded as 180/90 mm Hg. The woman has a history of hypertension, but she currently is not taking her medications. Which of the following questions is most appropriate for the nurse to ask the patient first?
a) “Are you able to get to your pharmacy to pick up your medications?”
b) “Why is it that you are not taking your medications?”
c) “Are you having trouble paying for your medication?”
d) “What medications are you prescribed?”
“Why is it that you are not taking your medications?”
It is important for the nurse to first ascertain if the reason why the patient is not taking her medications.
Adherence to the therapeutic program may be more difficult for older adults.
The medication regimen can be difficult to remember, and the expense can be a challenge. Monotherapy (treatment with a single agent), if appropriate, may simplify the medication regimen and make it less expensive.
The other questions are appropriate, but the priority is to determine why the medication regimen is not being followed.
The nurse understands that patient education related to antihypertensive medication should include all of the following instructions except which of the following?
a) Avoid over the counter (OTC) cold, weight reduction, and sinus medications.
b) Avoid hot baths, exercise, and alcohol within 3 hours of taking vasodilators.
c) If a dosage of medication is missed, double up on the next one to catch up.
d) Do not stop antihypertensive medication abruptly.
If a dosage of medication is missed, double up on the next one to catch up.
Doubling doses could cause serious hypotension (HTN) and is not recommended. Medications should be taken as prescribed.
Hot baths, strenuous exercise, and excessive alcohol are all vasodilators and should be avoided.
Many OTC preparations can precipitate HTN. Stopping antihypertensives abruptly can precipitate a severe hypertensive reaction and is not recommended.
Target organ damage from untreated/undertreated hypertension includes which of the following? Select all that apply.
a) Diabetes
b) Hyperlipidemia
c) Heart failure
d) Stroke
e) Retinal damage
Heart failure
Stroke
Retinal damage
Target organ systems include cardiac, cerebrovascular, peripheral vascular, renal, and the eye. Hyperlipidemia and diabetes are risk factors for development of hypertension.
A patient is admitted to the intensive care unit (ICU) with a diagnosis of hypertension emergency/crisis. The patient’s blood pressure (BP) is 200/130 mm Hg. The nurse is preparing to administer IV Nitropress (nitroprusside). Upon assessment, which of the following patient findings requires immediate intervention by the nurse?
a) Urine output of 40 cc/mL over the last hour
b) Chest pain score of 3/10 (on a scale of 1 to 10)
c) Left arm numbness and weakness
d) Nausea and severe headache
Left arm numbness and weakness
Hypertensive emergencies are acute, life-threatening BP elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that may occur.
The finding of left arm numbness and weakness may indicate the patient is experiencing neurological symptoms associated with an ischemic stroke because of the severely elevated BP and requires immediate interventions.
Aurine output of 40 mL/h is within normal limits. The other findings are likely caused by the hypertension and require intervention, but they do not require action as urgently as the neurologic changes.
The nurse is caring for a patient prescribed Bumex (bumetanide) for the treatment of stage 2 hypertension. Which of the following indicates the patient is experiencing an adverse effect of the medication?
a) Serum potassium value of 3.0 mEq/L
b) Electrocardiogram (EGG) tracing demonstrating peaked T waves
c) Blood glucose value of 160 mg/dL
d) Urine output of 90 cc/mL 1 hour after medication administration
Serum potassium value of 3.0 mEq/L
Bumex is a loop diuretic that can cause fluid and electrolyte imbalances.
Patients taking these medications may experience a low serum potassium level. ECG changes associated with an elevated serum potassium levels include peaked T waves.
Diuresis is a desired effect postadministration of Bumex.
The serum glucose level is elevated and requires intervention; however, this elevation is not associated with the administration of Bumex.
The nurse understands that an overall goal of hypertension management includes which of the following?
a) The patient maintains a normal blood pressure reading.
b) There is no complaint of postural hypotension.
c) There is no indication of target organ damage.
d) There are no complaints of sexual dysfunction.
There is no indication of target organ damage.
Prolonged blood pressure elevation gradually damages blood vessels throughout the body, particularly in target organs such as the heart, kidneys, brain, and eyes.
The overall goal of management is that the patient does not experience target organ damage.
The desired effects of antihypertensives are to maintain a normal BP.
Postural hypotension and sexual dysfunction are side effects of certain antihypertension medications.
A 55-year-old man newly diagnosed with hypertension returns to his physician’s office for a routine follow-up appointment after several months of treatment with Lopressor (metoprolol). During the nurse’s initial assessment the patient’s blood pressure (BP) is recorded as 180/90 mm Hg. The patient states he does not take his medication as prescribed. The best response by the nurse is which of the following?
a) “Your hypertension must be treated with medications; you need to take your Lopressor every day.”
b) “It is very important for you to take your medication as prescribed, or you could experience a stroke.”
c) “The medication you were prescribed may cause sexual dysfunction; are you experiencing this side effect?”
d) “Be certain to discuss your noncompliance with your medication regimen with the physician.”
“The medication you were prescribed may cause sexual dysfunction; are you experiencing this side effect?”
The nurse needs to understand why the patient is not taking his medication.
Lopressor is a beta-blocker. All patients should be informed that beta-blockers might cause sexual dysfunction and that other medications are available if problems with sexual function occur.
The other statements, although true, are nontherapeutic and would not elicit why the patient was not taking his medications as prescribed.
The nurse is caring for a patient with systolic blood pressure of 135 mm Hg. This finding would be classified as which of the following?
a) Prehypertension
b) Normal
c) Stage 1 hypertension
d) Stage 2 hypertension
Prehypertension
A systolic blood pressure of 135 mm Hg is classified as prehypertension. A systolic BP of less than 120 mm Hg is normal. A systolic BP of 140 to 159 mm Hg is stage I hypertension. A systolic BP of greater than or equal to 160 is classified as stage II hypertension.
The nurse is teaching a patient diagnosed with hypertension about the DASH diet. How many servings of meat, fish, and poultry should a patient consume per day?
a) 7 or 8
b) 4 or 5
c) 2 or 3
d) 2 or fewer
2 or fewer
Two or fewer servings of meat, fish, and poultry are recommended in the DASH diet.
Choose the statements that correctly match the hypertensive medication with its side effect. Select all that apply.
a) With ACE inhibitors, assess for bradycardia.
b) Beta-blockers may cause sedation.
c) With thiazide diuretics, monitor serum potassium levels.
d) With adrenergic inhibitors, cough is a common side effect.
e) Direct vasodilators may cause headache and tachycardia.
With thiazide diuretics, monitor serum potassium levels.
Direct vasodilators may cause headache and tachycardia.
Thiazide diuretics may deplete potassium; many clients will need potassium supplementation.
Angiotensin-converting enzyme (ACE) inhibitors can induce a mild to severe dry cough.
Beta-blockers may induce decreased heart rate; pulse rate should be assessed before administration.
Direct vasodilators may cause headache and increased heart rate.
Adrenergic inhibitors can cause sedation and fatigue.
It is important for the nurse to encourage the patient diagnosed with hypertension to rise slowly from a sitting or lying position for which of the following reasons?
a) Gradual changes in position provide time for the heart to reduce its rate of contraction to resupply oxygen to the brain.
b) Gradual changes in position provide time for the heart to increase rate of contraction to resupply oxygen to the brain.
c) Gradual changes in position help reduce the heart’s work to resupply oxygen to the brain.
d) Gradual changes in position help reduce the blood pressure to resupply oxygen to the brain
Gradual changes in position provide time for the heart to increase rate of contraction to resupply oxygen to the brain.
It is important for the nurse to encourage the patient to rise slowly from a sitting or lying position because gradual changes in position provide time for the heart to increase its rate of contraction to resupply oxygen to the brain and not blood pressure or heart rate.
When measuring the blood pressure in each of the patient’s arms, the nurse recognizes that in the healthy adult, which of the following is true?
a) Pressures may vary, with the higher pressure found in the left arm.
b) Pressures must be equal in both arms.
c) Pressures may vary 10 mm Hg or more between arms.
d) Pressures should not differ more than 5 mm Hg between arms.
Pressures should not differ more than 5 mm Hg between arms.
Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures.
The pressures in each arm do not have to be equal in order to be considered normal.
Pressures that vary more than 10 mm Hg between arms indicate an abnormal finding. The left arm pressure is not anticipated to be higher than the right as a normal anatomic variant.
The nurse is caring for a patient newly diagnosed with hypertension. Which of the following statements if made by the patient indicates the need for further teaching?
a) “I think I’m going to sign up for a yoga class twice a week to help reduce my stress.”
b) “When getting up from bed, I will sit for a short period prior to standing up.”
c) “I will consult a dietician to help get my weight under control.”
d) “If I take my blood pressure and it is normal, I don’t have to take my BP pills.”
“If I take my blood pressure and it is normal, I don’t have to take my BP pills.”
The patient needs to understand the disease process and how lifestyle changes and medications can control hypertension.
The patient must take his/her medication as directed.
A normal BP indicates the medication is producing its desired effect.
The other responses do not indicate the need for further teaching.
Hypertension that can be attributed to an underlying cause is termed which of the following?
Secondary
Secondary hypertension may be caused by a tumor of the adrenal gland (eg, pheochromocytoma).
Primary hypertension has no known underlying cause.
Essential hypertension has no known underlying cause.
Isolated systolic hypertension is demonstrated by readings in which the systolic pressure exceeds 140 mm Hg and the diastolic measurement is normal or near normal (less than 90 mm Hg).
Which of the following statements are true when the nurse is measuring blood pressure (BP)? Select all that apply.
a) Using a BP cuff that is too large will give a higher BP measurement.
b) The patient’s arm should be positioned at the level of the heart.
c) Using a BP cuff that is too small will give a higher BP measurement.
d) Ask the patient to sit quietly while the BP is being measured.
e) The patient’s BP should be taken 1 hour after the consumption of alcohol.
The patient’s arm should be positioned at the level of the heart.
Using a BP cuff that is too small will give a higher BP measurement.
Ask the patient to sit quietly while the BP is being measured.
These statements are all true when measuring a BP.
When using a BP cuff that is too large the reading will be lower than the actual BP.
The patient should avoid smoking cigarettes or drinking caffeine for 30 minutes before BP is measured.
The nurse is caring for a client newly diagnosed with secondary hypertension. Which of the following conditions contributes to the development of secondary hypertension?
a) Hepatic function
b) Renal disease
c) Acid-based imbalance
d) Calcium deficit
Renal disease
Secondary hypertension occurs when a cause for the high blood pressure can be identified.
These causes include renal parenchymal disease, narrowing of the renal arteries, hyperaldosteronism (mineralocorticoid hypertension), pheochromocytoma, certain medications (e.g., prednisone, epoietin alfa [Epogen]), and coarctation of the aorta.
High blood pressure can also occur with pregnancy; women who experience high blood pressure during pregnancy are at increased risk of ischemic heart disease, heart attacks, strokes, kidney disease, diabetes, and death from heart attack. Calcium deficiency or acid-based imbalance does not contribute to hypertension.
The nurse is caring for a female client who has had 25 mg of oral hydrochlorothiazide added to her medication regimen for the treatment of hypertension (HTN). Which of the following instructions should the nurse give the patient?
a) “You may drink alcohol while taking this medication.”
b) “Increase the amount of fruits and vegetables you eat.”
c) “Take this medication before going to bed.”
d) “You may develop dry mouth or nasal congestion while on this medication.”
“Increase the amount of fruits and vegetables you eat.
Thiazide diuretics cause loss of sodium, potassium, and magnesium.
The patient should be encouraged to eat fruits and vegetables which are high in potassium.
Diuretics cause increased urination; the patient should not take the medication prior to going to bed.
Thiazide diuretics to not cause dry mouth or nasal congestion.
Postural hypotension (side effect) may be potentiated by alcohol.
”
- Mr. Burke coughs up bloody sputum that Cyrus sends to the laboratory. Bloody sputum is referred to as ____________.
Answer: Hemoptysis
Rationale: Hemoptysis is bloody sputum that often accompanies respiratory illnesses such as pneumonia.
A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder:
Alcoholism and hypertension
Obesity and diabetes
Stress-related illnesses
Cardiopulmonary disease and lung cancer
Cardiopulmonary disease and lung cancer
Effects of nicotine on blood vessels and lung tissue have been proven to increase pathological changes, leading to heart disease and lung cancer.
A patient has been diagnosed with severe iron deficiency anemia. During physical assessment for which of the following symptoms would the nurse assess to determine the patient’s oxygen status?
Increased breathlessness but increased activity tolerance
Decreased breathlessness and decreased activity tolerance
Increased activity tolerance and decreased breathlessness
Decreased activity tolerance and increased breathlessness
Decreased activity tolerance and increased breathlessness
Hypoxia occurs because of decreased circulating blood volume, which leads to decreased oxygen to muscles, causing fatigue, decreased activity tolerance, and a feeling of shortness of breath
A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient’s color is ruddy, not cyanotic, the nurse understands that the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following:
Stimulates hyperventilation, causing respiratory alkalosis
Forms a strong bond with hemoglobin, creating a functional anemia.
Stimulates hypoventilation, causing respiratory acidosis
Causes alveoli to overinflate, leading to atelectasis
Forms a strong bond with hemoglobin, creating a functional anemia.
Carbon monoxide strongly binds to hemoglobin, making it unavailable for oxygen binding and transport.
A 6-year-old boy is admitted to the pediatric unit with chills and a fever of 104°F (40°C). What physiological process explains why the child is at risk for developing dyspnea?
Fever increases metabolic demands, requiring increased oxygen need.
Blood glucose stores are depleted, and the cells do not have energy to use oxygen.
Carbon dioxide production increases as result of hyperventilation.
Carbon dioxide production decreases as a result of hypoventilation.
Fever increases metabolic demands, requiring increased oxygen need
When the body cannot meet the increased oxygenation need, the increased metabolic rate causes breakdown of protein and wasting of respiratory muscles, increasing the work of breathing
A patient is admitted with the diagnosis of severe left-sided heart failure. The nurse expects to auscultate which adventitious lung sounds?
Sonorous wheezes in the left lower lung
Rhonchi midsternum
Crackles only in apex of lungs
Inspiratory crackles in lung bases
Decreased effective contraction of left side of heart leads to back up of fluid in the lungs, increasing hydrostatic pressure and causing pulmonary edema, resulting in crackles in lung bases.
The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion?
Antibiotics
Frequent change of position
Oxygen humidification
Chest physiotherapy
Frequent change of position
Movement not only mobilizes secretions but helps strengthen respiratory muscles by impacting the effectiveness of gas exchange processes.
A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning?
Coughing up thick sputum only occasionally
Coughing up thin, watery sputum easily after nebulization
Decreased independent ability to cough
Lung sounds clear only after coughing
Decreased independent ability to cough
Impaired ability to cough up mucus caused by weakness or very thick secretions indicates a need for suctioning when you know the patient has pneumonia.
A patient was admitted after a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax, which includes which of the following?
Sharp pleuritic pain that worsens on inspiration Crackles over lung bases of affected lung Tracheal deviation toward the affected lung Increased diaphragmatic excursion on side of rib fractures
Sharp pleuritic pain that worsens on inspiration
When the lung collapses, the thoracic space fills with air on each inspiration, and the atmospheric air irritates the parietal pleura, causing pain.
A patient has been newly diagnosed with emphysema. In discussing his condition with the nurse, which of his statements would indicate a need for further education?
“I’ll make sure that I rest between activities so I don’t get so short of breath.” “I’ll rest for 30 minutes before I eat my meal.” “If I have trouble breathing at night, I’ll use two to three pillows to prop up.” “If I get short of breath, I’ll turn up my oxygen level to 6 L/min.”
“If I get short of breath, I’ll turn up my oxygen level to 6 L/min.”
Hypoxia is the drive to breathe in a patient with chronic obstructive pulmonary disease who has become used to acidic pH and elevated CO2 levels. Turning up to 6 L/min increases the oxygen level, which turns off the drive to breathe.
The nurse goes to assess a new patient and finds him lying supine in bed. The patient tells the nurse that he feels short of breath. Which nursing action should the nurse perform first?
Raise the head of the bed to 45 degrees.
Take his oxygen saturation with a pulse oximeter.
Take his blood pressure and respiratory rate.
Notify the health care provider of his shortness of breath.
Raise the head of the bed to 45 degrees.
Raising the head of the bed brings the diaphragm down and allows for better chest expansion, thus improving ventilation.
The nurse is caring for a patient who exhibits labored breathing and uses accessory muscles. The patient has crackles in both lung bases and diminished breath sounds. Which would be priority assessments for the nurse to perform? (Select all that apply.)
SpO2 levels
Amount of sputum production
Change in respiratory rate and pattern
Pain in lower calf area
SpO2 levels
Amount of sputum production
Change in respiratory rate and pattern
Pain in the lower calf area indicates vascular, not respiratory, status.
Which of the following statements made by a student nurse indicates the need for further teaching about suctioning a patient with an endotracheal tube?
“Suctioning the patient requires sterile technique.”
“I’ll apply suction while rotating and withdrawing the suction catheter.”
“I’ll suction the mouth after I suction theendotracheal tube.”
“I’ll instill 5 mL of normal saline into the tube before hyperoxygenating the patient.”
“I’ll instill 5 mL of normal saline into the tube before hyperoxygenating the patient.” Corre
Saline has been found to cause more side effects when suctioning and does not increase the amount of secretions removed.
Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark-red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform?
Record the amount and continue to monitor drainage
Notify the health care provider
Strip the chest tube starting at the chest
Increase the suction by 10 mm Hg
Record the amount and continue to monitor drainage
Dark-red drainage after surgery (50 to 200 mL per hour in first 3 hours) is expected, but be aware of sudden increases greater than 100 mL per hour after the first 3 hours, especially if it becomes bright red in color.
Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient?
Postural drainage
Chest percussion
Incentive spirometer
Suctioning
Incentive spirometer
An incentive spirometer is used to encourage deep breathing to inflate alveoli and open pores of Kohn. The rest are used to treat atelectasis and increased mucus production.
The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen-delivery systems should the nurse select to administer the oxygen to the patient?
Nasal cannula Venturi mask Simple face mask without inflated reservoir bag Plastic face mask with inflated reservoir bag
Nasal cannula
A nasal cannula delivers precise, high-flow rates of oxygen.
Mr. Perry Burke is a 51-year-old African-American patient on the medical-surgical unit for management of chronic bronchitis that has turned into pneumonia.
He works in a paper mill factory where he inhales sawdust and chemicals on a daily basis. Working in an industrial environment causes his lungs to be constantly irritated and inflamed.
Cyrus is the nursing student assigned to Mr. Burke. After reviewing his care plan, the health care provider’s orders, and the nursing notes from the previous shift, Cyrus enters Mr. Burke’s room.
- Cyrus finds Mr. Burke restless, agitated, and confused. His pulse is 102 beats/min, and respirations are 42 breaths/min and shallow. He is sitting up in bed grasping the side rails and trying to catch his breath. He is most likely experiencing which of the following conditions?
A. Hyperventilation
B. Hypoventilation
C. Hypoxia
D. Dysrhythmia
C. Hypoxia
Rationale: Hypoxia is the decreased diffusion of oxygen from the alveoli to the blood, as in pneumonia.
Signs and symptoms of hypoxia include apprehension, restlessness, inability to concentrate, decreased level of consciousness, dizziness, and behavioral changes.
Vital sign changes include increased pulse rate and rate and depth of respiration.
- Mr. Burke’s condition is causing the clinical sign of shortness of breath. Shortness of breath is referred to as _______________.
Dyspnea
Dyspnea is shortness of breath often found in hypoxia
- Mr. Burke’s respiratory rate as determined by Cyrus is 42 breaths/min. This means that he is experiencing apnea.
A. True
B. False
B. False
Apnea is the absence of breath sounds. Tachypnea is more than 20 breaths/min.
- Mr. Burke coughs up bloody sputum that Cyrus sends to the laboratory. Bloody sputum is referred to as ____________.
Hemoptysis
: Hemoptysis is bloody sputum that often accompanies respiratory illnesses such as pneumonia.
The nurse is analyzing a 6-second electrocardiogram (ECG) tracing. The P waves and QRS complexes are regular. The PR interval is 0.18 seconds long, and the QRS complexes are 0.08 seconds long. The heart rate is calculated at 70 bpm. The nurse correctly identifies this rhythm as which of the following?
a) Sinus tachycardia
b) First-degree atrioventricular (AV) block
c) Junctional tachycardia
d) Normal sinus rhythm
Normal sinus rhythm
The ECG tracing shows normal sinus rhythm (NSR). NSR has the following characteristics: ventricular and atrial rate: 60 to 100 beats per minute (bpm) in the adult;
ventricular and atrial rhythm: regular; and QRS shape and duration:
usually normal, but may be regularly abnormal;
P wave: normal and consistent shape, always in front of the QRS;
PR interval: consistent interval between 0.12 and 0.20 seconds and P:QRS ratio: 1:1.
The nurse is participating in the care of a client requiring emergent defibrillation. The nurse will complete the following steps in which order?
a) Charge the defibrillator to the prescribed voltage.
b) Deliver the prescribed electrical charge.
c) Call “clear” three times ensuring patient and environmental safety.
d) Turn on the defibrillator and place it in “not sync” mode.
e) Apply the multifunction conductor pads to the patient’s chest.
This is the sequence of events the nurse should implement when delivering emergent defibrillation. If not followed correctly, the patient and health care team may be placed in danger.
A nurse is completing a shift assessment on a patient admitted to the telemetry unit with a diagnosis of syncope. The patient’s heart rate is 55 bpm with a blood pressure of 90/66 mm Hg. The patient is also experiencing dizziness and shortness of breath. Which of the following medications will the nurse anticipate administering to the patient based on these clinical findings?
a) Atropine
b) Cardizem
c) Lidocaine
d) Pronestyl
Atropine
The patient is demonstrating signs and symptoms of symptomatic sinus bradycardia.
Atropine is the medication of choice in treating symptomatic sinus bradycardia
. Lidocaine treats ventricular dysrhythmias.
Pronestyl treats and prevents atrial and ventricular dysrhythmias.
Cardizem is a calcium channel blocker and treats atrial dysrhythmias
The nurse is caring for a client who has developed junctional tachycardia with a heart rate (HR) of 80 bpm. Which of the following actions should the nurse complete?
a) Prepare to administer IV lidocaine.
b) Withhold the patient’s oral potassium supplement.
c) Prepare for emergent electrical cardioversion.
d) Request a digoxin level be ordered.
Request a digoxin level be ordered.
The nurse should request a digoxin level be obtained. Junctional tachycardia generally does not have any detrimental hemodynamic effect;
it may indicate a serious underlying condition, such as digitalis toxicity, myocardial ischemia, hypokalemia, or chronic obstructive pulmonary disease (COPD).
Potassium supplements do not cause junctional tachycardia.
Lidocaine is indicated for the treatment of premature ventricular contractions (PVCs).
Because junctional tachycardia is caused by increased automaticity, cardioversion is not an effective treatment; in fact, it causes an increase in ventricular rate.
The nurse is analyzing the electrocardiogram (ECG) tracing of a client newly admitted to the cardiac step-down unit with a diagnosis of chest pain. Which of the following findings indicate the need for follow-up?
a) PR interval that is 0.18 seconds long
b) ST segment that is isoelectric in appearance
c) QT interval that is 0. 46 seconds long
d) QRS complex that is 0.10 seconds long
QT interval that is 0. 46 seconds long
The QT interval that is 0.46 seconds long needs to be investigated.
The QT interval is usually 0.32 to 0.40 seconds in duration if the heart rate is 65 to 95 bpm.
If the QT interval becomes prolonged, the patient may be at risk for a lethal ventricular dysrhythmia called torsades de pointes. The other findings are normal.
A nurse is evaluating a client with a temporary pacemaker. The patient’s ECG tracing shows each P wave followed by the pacing spike. The nurse’s best response is which of the following?
a) Document the findings and continue to monitor the patient.
b) Obtain a 12-lead ECG and a portable chest x-ray.
c) Reposition the extremity and turn the patient to left side.
d) Check the security of all connections and increase the milliamperage.
Document the findings and continue to monitor the patient.
Capture is a term used to denote that the appropriate complex is followed by the pacing spike.
In this instance, the patient’s temporary pacemaker is functioning appropriately; all Ps wave followed by an atrial pacing spike.
The nurse should document the findings and continue to monitor the patient.
Repositioning the patient, placing the patient on the left side, checking the security of all connections, and increasing the milliamperage are nursing interventions used when the pacemaker has a loss of capture.
Obtaining a 12-lead ECG and chest x-ray are indicated when there is a loss of pacing-total absence of pacing spikes or when there is a change in pacing QRS shape.
A 26-year-old male patient, who has been diagnosed with paroxysmal supraventricular tachycardia (PSVT), is being treated in the emergency department. The patient is experiencing occasional runs of PSVT lasting up to several minutes at a time. During these episodes, the patient becomes lightheaded but does not lose consciousness. Which of the following maneuvers may be used to interrupt the patient’s atrioventricular nodal reentry tachycardia (AVNRT)? Select all that apply.
a) Placing the patient’s face in cold water
b) Instructing the patient to vigorously exercise
c) Performing carotid massage.
d) Stimulating the patient’s gag reflex
e) Instructing the patient to breathe deeply
Placing the patient’s face in cold water
Performing carotid massage.
Stimulating the patient’s gag reflex
The following vagal maneuvers can be used to interrupt AVNRT:
stimulating the patient’s gag reflex, having the patient hold his breath, cough, bear down, placing his face in cold water, or performing carotid massage.
These measures elicit a vagal response which will slow AV conduction time and help restore a regular rhythm. Because of the risk of a cerebral embolic event, carotid massage is contraindicated in patients with carotid bruits.
If the vagal maneuvers are ineffective, the patient may receive a bolus of adenosine to correct the rhythm; this is nearly 100% effective in terminating AVNRT.
Overexertion and deep inspirations are measures that could precipitate SVT.
A patient is being treated in the intensive care unit following an acute MI. During the nursing assessment, the patient states shortness of breath and chest pain. In addition, the patient’s blood pressure (BP) is 100/60 mm Hg with a heart rate (HR) of 53 bpm, and the electrocardiogram (ECG) tracing shows more P waves than QRS complexes. Which of the following actions should the nurse complete first?
a) Prepare for defibrillation.
b) Obtain a 12-lead ECG.
c) Initiate transcutaneous pacing.
d) Administer 1 mg of IV atropine.
Initiate transcutaneous pacing
The patient is experiencing a third-degree heart block. Transcutaneous pacing should be implemented first.
A permanent pacemaker may be indicated if the block continues.
Defibrillation is not indicated; third-degree heart block does not respond to atropine; a 12-lead ECG may be obtained, but is not completed first
A patient is admitted to the emergency department (ED) with complaints of chest pain and shortness of breath. The nurse notes an irregular rhythm on the bedside electrocardiograph (ECG) monitor. The nurse counts 9 RR intervals on the patient’s 6-second rhythm tracing. The nurse correctly identifies the patient’s heart rate as which of the following?
a) 90 bpm
b) 100 bpm
c) 70 bpm
d) 80 bpm
90 bpm
An alternative but less accurate method for estimating heart rate, which is usually used when the rhythm is irregular, is to count the number of RR intervals in 6 seconds and multiply that number by 10.
The RR intervals are counted, rather than QRS complexes, because a computed heart rate based on the latter might be inaccurately high.
The same methods may be used for determining atrial rate, using the PP interval instead of the RR interval. In this instance, 9 × 10 = 90.
The nurse is assigned to care for the following patients admitted to a telemetry unit. Which patient should the nurse assess first?
a) A patient who received elective cardioversion 1 hour ago with a heart rate (HR) is 115 bpm
b) A patient whose implantable cardioverter defibrillator (ICD) fired twice on the prior shift requiring amiodarone IV
c) A patient returned from an electrophysiology (EP) procedure 2 hours ago complaining of constipation
d) A patient diagnosed with new onset of atrial fibrillation requiring scheduled IV Cardizem
A patient whose implantable cardioverter defibrillator (ICD) fired twice on the prior shift requiring amiodarone IV
The patient’s ICD that has fired on the previous shift should be seen first.
This patient is in need of antidysrhythmic medication and this is the priority intervention. The remaining patients should be seen after this patient and are in no acute distress.
A patient tells the nurse “my heart is skipping beats again; I’m having palpitations.” After completing a physical assessment, the nurse concludes the patient is experiencing occasional premature atrial complexes (PACs). The nurse should instruct the patient to complete which of the following?
a) Request sublingual nitroglycerin.
b) Lie down and elevate the feet.
c) Apply supplemental oxygen.
d) Avoid caffeinated beverages
Avoid caffeinated beverages
If PACs are infrequent, no medical interventions are necessary.
Causes of PACs include caffeine, alcohol, nicotine, stretched atrial myocardium (e.g., as in hypervolemia),
anxiety, hypokalemia (low potassium level),
hypermetabolic states (e.g., with pregnancy),
or atrial ischemia, injury, or infarction. The nurse should instruct the patient to avoid caffeinated beverages.
A nurse is providing morning care for a patient in the ICU. Suddenly, the bedside monitor shows ventricular fibrillation and the patient becomes unresponsive. After calling for assistance, what action should the nurse take next?
a) Administer intravenous epinephrine.
b) Begin cardiopulmonary resuscitation.
c) Provide electrical cardioversion.
d) Prepare for endotracheal intubation.
Begin cardiopulmonary resuscitation.
In the acute care setting, when ventricular fibrillation is noted, the nurse should call for assistance and defibrillate the patient as soon as possible.
If defibrillation is not readily available, CPR is begun until the patient can be defibrillated, followed by advanced cardiovascular life support (ACLS) intervention,
which includes endotracheal intubation and administration of epinephrine.
Electrical cardioversion is not indicated for a patient in ventricular fibrillation.
