Exam 3 Lewis Review Questions Flashcards
A patient who has a history of heart failure and chronic obstructive lung disease is admitted with severe dyspnea. Which value would the nurse expect to be elevated if the cause of dyspnea was cardiac related?
a) Serum potassium
b) Serum homocysteine
c) High-density lipoprotein
d) B-type natriuretic peptide (BNP)
d) B-type natriuretic peptide (BNP)
Rationale: Elevation of BNP indicates the presence of heart failure. Elevations help to distinguish cardiac versus respiratory causes of dyspnea. Elevated potassium, homocysteine, or HDL levels may indicate increased risk for cardiovascular disorders but do not indicate that cardiac disease is present.
A patient presents to the emergency department reporting chest pain for 3 hours. What component of the blood work is most clearly indicative of a myocardial infarction (MI)?
a) CK-MB
b) Troponin
c) Myoglobin
d) C-reactive protein
b) Troponin
Rationale: Troponin is the biomarker of choice in the diagnosis of MI, with sensitivity and specificity that exceed those of CK-MB and myoglobin. CRP levels are not used to diagnose acute MI.
The nurse is providing care for a patient who has decreased cardiac output due to heart failure. As a basis for planning care, what should the nurse understand about cardiac output (CO)?
a) CO is calculated by multiplying the patient’s stroke volume by the heart rate.
b) CO is the average amount of blood ejected during one complete cardiac cycle.
c) CO is determined by measuring the electrical activity of the heart and the heart rate.
d) CO is the patient’s average resting heart rate multiplied by the mean arterial blood pressure.
a) CO is calculated by multiplying the patient’s stroke volume by the heart rate.
Rationale: Cardiac output is determined by multiplying the patient’s stroke volume by heart rate, thus identifying how much blood is pumped by the heart over a 1-minute period. Electrical activity of the heart and blood pressure are not direct components of cardiac output.
The nurse is admitting a patient who is scheduled to undergo a cardiac catheterization. What allergy information is most important for the nurse to assess and document before this procedure?
a) Iron
b) Iodine
c) Aspirin
d) Penicillin
b) Iodine
Rationale: The provider will usually use an iodine-based contrast to perform this procedure. Therefore, it is imperative to know whether the patient is allergic to iodine or shellfish. Knowledge of allergies to iron, aspirin, or penicillin will be secondary.
The nurse is performing an assessment for a patient with fatigue and shortness of breath. Auscultation reveals a heart murmur. What does this assessment finding indicate?
a) Increased viscosity of the patient’s blood
b) Turbulent blood flow across a heart valve
c) Friction between the heart and the myocardium
d) A deficit in conductivity impairs normal contractility
b) Turbulent blood flow across a heart valve
Rationale: Turbulent blood flow across the affected valve results in a murmur. A murmur is not a direct result of variances in blood viscosity, conductivity, or friction between the heart and myocardium.
While auscultating the patient’s heart sounds with the bell of the stethoscope, the nurse hears a ventricular gallop. How should the nurse document what is heard?
a) Diastolic murmur
b) Third heart sound (S3)
c) Fourth heart sound (S4)
d) Normal heart sounds (S1, S2)
b) Third heart sound (S3)
Rationale: The third heart sound is heard closely after the S2 and is known as a ventricular gallop because it is a vibration of the ventricular walls associated with decreased compliance of the ventricles during filling. It occurs with left ventricular failure. Murmurs sound like turbulence between normal heart sounds and are caused by abnormal blood flow through diseased valves. The S4 heart sound is a vibration caused by atrial contraction, precedes the S1, and is known as an atrial gallop. The normal S1 and S2 are heard when the valves close normally.
A nurse is caring for a patient immediately following a transesophageal echocardiogram (TEE). Which assessments are appropriate for this patient? (Select all that apply.)
a) Assess for return of gag reflex.
b) Assess groin for hematoma or bleeding.
c) Monitor vital signs and oxygen saturation.
d) Position patient supine with head of bed flat.
e) Assess lower extremities for circulatory compromise.
a) Assess for return of gag reflex.
c) Monitor vital signs and oxygen saturation.
Rationale: The patient undergoing a TEE has been given conscious sedation and has had the throat numbed with a local anesthetic spray, thus eliminating the gag reflex until the effects wear off. Therefore it is imperative that the nurse assess for gag reflex return before allowing the patient to eat or drink. Vital signs and oxygen saturation are important assessment parameters resulting from the use of sedation. A TEE does not involve invasive procedures of the circulatory blood vessels. Therefore it is not necessary to monitor the patient’s groin and lower extremities in relation to this procedure or to maintain a flat position.
Which action should the nurse implement with auscultation during a patient’s cardiovascular assessment?
a) Position the patient supine.
b) Ask the patient to hold their breath.
c) Palpate the radial pulse while auscultating the apical pulse.
d) Use the bell of the stethoscope when auscultating S1 and S2.
c) Palpate the radial pulse while auscultating the apical pulse.
Rationale: To detect a pulse deficit, simultaneously palpate the radial pulse when auscultating the apical area. The diaphragm is more appropriate than the bell when auscultating S1 and S2. A sitting or side-lying position is most appropriate for cardiac auscultation. It is not necessary to ask the patient to hold their breath during cardiac auscultation.
What position should the nurse place the patient in to auscultate for signs of acute pericarditis?
a) Supine without a pillow
b) Sitting and leaning forward
c) Left lateral side-lying position
d) Head of bed at a 45-degree angle
b) Sitting and leaning forward
Rationale: A pericardial friction rub indicates pericarditis. To auscultate a pericardial friction rub, the patient should be sitting and leaning forward. The nurse will hear the pericardial friction rub at the end of expiration.
A nurse is preparing to teach a group of women in a community volunteer group about heart disease. What should the nurse include in the teaching plan?
a) Women are less likely to delay seeking treatment than men.
b) Women are more likely to have noncardiac symptoms of heart disease.
c) Women are often less ill when presenting for treatment of heart disease.
d) Women have more symptoms of heart disease at a younger age than men.
b) Women are more likely to have noncardiac symptoms of heart disease.
Rationale: Women often have atypical angina symptoms and nonpain symptoms. Women experience the onset of heart disease about 10 years later than men. Women are often more ill on presentation and delay longer in seeking care than men.
The patient tells the nurse that he does not understand how there can be a blockage in the left anterior descending artery (LAD), but there is damage to the right ventricle. What is the best response by the nurse?
a) “One coronary vessel curves around and supplies the entire heart muscle.”
b) “The LAD supplies blood to the left side of the heart and part of the right ventricle.”
c) “The right ventricle is supplied during systole primarily by the right coronary artery.”
d) “It is actually on the right side of the heart, but we call it the left anterior descending vessel.”
b) “The LAD supplies blood to the left side of the heart and part of the right ventricle.”
Rationale: The best response is explaining that the lower portion of the right ventricle receives blood flow from the left anterior descending artery as well as the right coronary artery during diastole.
The blood pressure of an older adult patient admitted with pneumonia is 160/70 mm Hg. What is an age-related change that contributes to this finding?
a) Stenosis of the heart valves
b) Decreased adrenergic sensitivity
c) Increased parasympathetic activity
d) Loss of elasticity in arterial vessels
d) Loss of elasticity in arterial vessels
Rationale: An age-related change that increases the risk of systolic hypertension is a loss of elasticity in the arterial walls. Because of the increasing resistance to flow, pressure is increased within the blood vessel, and hypertension results. Valvular rigidity of aging causes murmurs, and decreased adrenergic sensitivity slows the heart rate. Blood pressure is not raised. Increased parasympathetic activity would slow the heart rate.
A patient is being admitted for valve replacement surgery. Which assessment finding is indicative of aortic valve stenosis?
a) Pulse deficit
b) Systolic murmur
c) Distended neck veins
d) Splinter hemorrhages
b) Systolic murmur
Rationale: The turbulent blood flow across a diseased valve results in a murmur. Aortic stenosis produces a systolic murmur. A pulse deficit indicates a cardiac dysrhythmia, most commonly atrial fibrillation. Right-sided heart failure may cause distended neck veins. Splinter hemorrhages occur in patients with infective endocarditis.
The nurse determines that a patient’s pedal pulses are absent. What factor could contribute to this finding?
a) Atherosclerosis
b) Hyperthyroidism
c) Atrial dysrhythmias
d) Arteriovenous fistula
a) Atherosclerosis
Rationale: Atherosclerosis can cause an absent peripheral pulse. The feet would also be cool and may be discolored. Hyperthyroidism causes a bounding pulse. Arteriovenous fistula gives a thrill or vibration to the vessel, although this would not be in the foot. Cardiac dysrhythmias cause an irregular pulse rhythm.
A patient with a history of myocardial infarction is scheduled for a transesophageal echocardiogram to visualize a suspected clot in the left atrium. What information should the nurse include when teaching the patient about this diagnostic study?
a) IV sedation may be administered to help the patient relax.
b) Food and fluids are restricted for 2 hours before the procedure.
c) Ambulation is restricted for up to 6 hours before the procedure.
d) Contrast medium is injected into the esophagus to enhance images.
a) IV sedation may be administered to help the patient relax.
Rationale: IV sedation is administered to help the patient relax and ease the insertion of the tube into the esophagus. Food and fluids are restricted for at least 6 hours before the procedure. Smoking and exercise are restricted for 3 hours before exercise or stress testing but not before TEE. Contrast medium is administered IV to evaluate the direction of blood flow if a septal defect is suspected.
Which instruction by the nurse to a patient who is about to undergo Holter monitoring is accurate?
a) “You may remove the monitor only to shower or bathe.”
b) “You should connect the monitor whenever you feel symptoms.”
c) “You should refrain from exercising while wearing this monitor.”
d) “You will need to keep a diary of your activities and symptoms.”
d) “You will need to keep a diary of your activities and symptoms.”
Rationale: A Holter monitor is worn continuously for at least 24 hours while a patient continues with usual activity and keeps a diary of activities and symptoms. The patient should not take a bath or shower while wearing this monitor.
Which anatomic feature of the heart directly stimulates ventricular contractions?
a) SA node
b) AV node
c) Bundle of His
d) Purkinje fibers
d) Purkinje fibers
Rationale: The Purkinje fibers move the electrical impulse or action potential through the walls of both ventricles triggering synchronized right and left ventricular contraction. The sinoatrial (SA) node initiates the electrical impulse that results in atrial contraction. The atrioventricular (AV) node receives the electrical impulse through internodal pathways. The bundle of His receives the impulse from the AV node.
What is an appropriate explanation for the nurse to give to a patient about the purpose of intermittent pneumatic compression devices after a surgical procedure?
a) The devices keep the legs warm while the patient is not moving much.
b) The devices maintain the blood flow to the legs while the patient is on bed rest.
c) The devices keep the blood pressure down while the patient is stressed after surgery.
d) The devices provide compression of the veins to keep the blood moving back to the heart.
d) The devices provide compression of the veins to keep the blood moving back to the heart.
Rationale: Intermittent pneumatic compression devices provide compression of the veins while the patient is not using skeletal muscles to compress the veins, which keeps the blood moving back to the heart and prevents blood pooling in the legs that could cause deep vein thrombosis. The warmth is not important. Blood flow to the legs is not maintained. Blood pressure is not decreased with the use of intermittent sequential compression stockings.
What age-related cardiovascular changes should the nurse assess for when providing care to an older adult patient? (Select all that apply.)
a) Systolic murmur
b) Diminished pedal pulses
c) Increased maximal heart rate
d) Decreased maximal heart rate
e) Increased recovery time from activity
a) Systolic murmur
b) Diminished pedal pulses
d) Decreased maximal heart rate
e) Increased recovery time from activity
Rationale: Well-documented cardiovascular effects of the aging process include valvular rigidity leading to systolic murmur, arterial stiffening leading to diminished pedal pulses or possible increased blood pressure, and an increased amount of time that is required for recovery from activity. Maximal heart rate tends to decrease rather than increase with age-related to cellular aging and fibrosis of the conduction system.
Which aspect of the heart’s action does the QRS complex on the ECG represent?
a) Depolarization of the atria
b) Repolarization of the ventricles
c) Depolarization from atrioventricular (AV) node throughout ventricles
d) The length of time it takes for the impulse to travel from the atria to the ventricles
c) Depolarization from atrioventricular (AV) node throughout ventricles
Rationale: The QRS recorded on the ECG represents depolarization from the AV node throughout the ventricles. The P wave represents depolarization of the atria. The T wave represents repolarization of the ventricles. The interval between the PR and QRS represents the length of time it takes for the impulse to travel from the atria to the ventricles.
The nurse is caring for a patient admitted with chronic obstructive pulmonary disease (COPD), angina, and hypertension. Before administering the prescribed daily dose of atenolol 100 mg PO, the nurse assesses the patient carefully. Which adverse effect is this patient at risk for given the patient’s health history?
a) Hypocapnia
b) Tachycardia
c) Bronchospasm
d) Nausea and vomiting
c) Bronchospasm
Rationale:
Atenolol is a cardioselective β1-adrenergic blocker that reduces blood pressure and could affect the β2-receptors in the lungs with larger doses or with drug accumulation. Although the risk of bronchospasm is less with cardioselective β-blockers than nonselective β-blockers, atenolol should be used cautiously in patients with COPD.
When teaching how lisinopril (Zestril) will help lower the patient’s blood pressure, which mechanism of action should the nurse explain?
a) Blocks β-adrenergic effects.
b) Relaxes arterial and venous smooth muscle.
c) Inhibits conversion of angiotensin I to angiotensin II.
d) Reduces sympathetic outflow from the central nervous system.
c) Inhibits conversion of angiotensin I to angiotensin II.
Rationale: Lisinopril is an angiotensin-converting enzyme inhibitor that inhibits the conversion of angiotensin I to angiotensin II, which reduces angiotensin II–mediated vasoconstriction and sodium and water retention. β-Blockers result in vasodilation and decreased heart rate. Direct vasodilators relax arterial and venous smooth muscle. Central-acting α-adrenergic antagonists reduce sympathetic outflow from the central nervous system to produce vasodilation and decreased systemic vascular resistance and blood pressure.
The nurse is caring for a patient admitted with a history of hypertension. The patient’s medication history includes hydrochlorothiazide daily for the past 10 years. Which parameter would indicate the optimal intended effect of this drug therapy?
a) BP 128/78 mm Hg
b) Weight loss of 2 lb
c) Absence of ankle edema
d) Output of 600 mL per 8 hours
a) BP 128/78 mm Hg
Rationale: Hydrochlorothiazide may be used alone as monotherapy to manage hypertension or in combination with other medications if not effective alone. After the first few weeks of therapy, the diuretic effect diminishes, but the antihypertensive effect remains. Because the patient has been taking this medication for 10 years, the most direct measurement of its intended effect would be the blood pressure.
A patient with a history of chronic hypertension is being evaluated in the emergency department for a blood pressure of 200/140 mm Hg. Which patient assessment question is the priority?
a) Is the patient pregnant?
b) Does the patient need to urinate?
c) Does the patient have a headache or confusion?
d) Is the patient taking antiseizure medications as prescribed?
c) Does the patient have a headache or confusion?
Rationale: The nurse’s priority assessments include neurologic deficits, retinal damage, heart failure, pulmonary edema, and renal failure. The headache or confusion could be seen with hypertensive encephalopathy from increased cerebral capillary permeability leading to cerebral edema. In addition, headache or confusion could represent signs and symptoms of a hemorrhagic stroke. Pregnancy can lead to secondary hypertension. Needing to urinate and taking antiseizure medication do not support a hypertensive emergency.
When teaching a patient about dietary management of stage 1 hypertension, which instruction is appropriate?
a) Increase water intake.
b) Restrict sodium intake.
c) Increase protein intake.
d) Use calcium supplements.
b) Restrict sodium intake.
Rationale: The patient should decrease intake of sodium. This will help to control hypertension, which can be aggravated by excessive salt intake, which in turn leads to fluid retention. Protein intake does not affect hypertension. Calcium supplements are not recommended to lower blood pressure.
The nurse is teaching a women’s group about ways to prevent hypertension. What information should the nurse include? (Select all that apply.)
a) Lose weight.
b) Limit beef consumption.
c) Limit sodium and fat intake.
d) Increase fruits and vegetables.
e) Exercise 30 minutes most days.
b) Limit beef consumption.
c) Limit sodium and fat intake.
d) Increase fruits and vegetables.
e) Exercise 30 minutes most days.
Rationale:
Primary prevention of hypertension is to make lifestyle modifications that prevent or delay the increase in BP. Along with exercise for 30 minutes on most days, the DASH eating plan is a healthy way to lower BP by limiting sodium and fat intake, increasing fruits and vegetables, and increasing nutrients that are associated with lowering BP. Beef includes saturated fats, which should be limited. Weight loss may or may not be necessary, depending on the person.
The nurse supervises an unlicensed assistant personnel (UAP) who is taking the blood pressure of an obese patient admitted with heart failure. Which action by the UAP will require the nurse to intervene?
a) Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg/sec
b) Waiting 2 minutes after position changes to take orthostatic pressures
c) Taking the blood pressure with the patient’s arm at the level of the heart
d) Taking a forearm blood pressure if the largest cuff will not fit the patient’s upper arm
a) Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg/sec
Rationale: The cuff should be deflated at a rate of 2 to 3 mm Hg/sec. The arm should be supported at the level of the heart for accurate blood pressure measurements. Using a cuff that is too small causes a falsely high reading and too large causes a falsely low reading. If the maximum size blood pressure cuff does not fit the upper arm, the forearm may be used. Orthostatic blood pressures should be taken within 1 to 2 minutes of repositioning the patient.
A 67-yr-old woman with hypertension is admitted to the emergency department with a blood pressure of 234/148 mm Hg and was started on nitroprusside (Nitropress). After 1 hour of treatment, the mean arterial blood pressure (MAP) is 55 mm Hg. Which nursing action is a priority?
a) Start an infusion of 0.9% normal saline at 100 mL/hr.
b) Maintain the current administration rate of the nitroprusside.
c) Request insertion of an arterial line for accurate blood pressure monitoring.
d) Stop the nitroprusside infusion and assess the patient for potential complications.
d) Stop the nitroprusside infusion and assess the patient for potential complications.
Rationale: Nitroprusside is a potent vasodilator medication. A blood pressure of 234/118 mm Hg would have a calculated MAP of 177 mm Hg. Subtracting 25% (or 44 mm Hg) = 133 mm Hg. The initial treatment goal is to decrease MAP by no more than 25% within minutes to 1 hour. For this patient, the goal MAP would be around 133 mm Hg. Minimal MAP required to perfuse organs is around 60 to 65 mm Hg. Lowering the blood pressure too rapidly may decrease cerebral, coronary, or renal perfusion and could precipitate a stroke, myocardial infarction, or renal failure. The priority is to stop the nitroprusside infusion and then use fluids only if necessary to support restoration of MAP.
In caring for a patient admitted with poorly controlled hypertension, which laboratory test result should the nurse understand as indicating the presence of target organ damage?
a) Serum uric acid of 3.8 mg/dL
b) Serum creatinine of 2.6 mg/dL
c) Serum potassium of 3.5 mEq/L
d) Blood urea nitrogen of 15 mg/dL
b) Serum creatinine of 2.6 mg/dL
Rationale:
The normal serum creatinine level is 0.6 to 1.3 mg/dL. This elevated level indicates target organ damage to the kidneys. The other laboratory results are within normal limits.
When providing dietary teaching to a patient with hypertension, the nurse would teach the patient to restrict intake of which meat?
a) Broiled fish
b) Roasted duck
c) Roasted turkey
d) Baked chicken breast
b) Roasted duck
Rationale:
Roasted duck is high in fat, which should be avoided by the patient with hypertension. Weight loss may slow the progress of atherosclerosis and overall cardiovascular disease risk. The other meats are lower in fat and are therefore acceptable in the diet.
Which information should the nurse consider when planning care for older adult patients with hypertension? (Select all that apply.)
a) Systolic blood pressure increases with aging.
b) White coat syndrome is prevalent in older patients.
c) Volume depletion contributes to orthostatic hypotension.
d) Blood pressures should be maintained near 120/80 mm Hg.
e) Blood pressure drops 1 hour after eating in many older patients.
f) Older patients require higher doses of antihypertensive medications.
a) Systolic blood pressure increases with aging.
b) White coat syndrome is prevalent in older patients.
c) Volume depletion contributes to orthostatic hypotension.
d) Blood pressures should be maintained near 120/80 mm Hg.
e) Blood pressure drops 1 hour after eating in many older patients.
Rationale:
Systolic blood pressure increases with age and patients older than age 60 years should be maintained below 150/90 mm Hg. Older adults are more likely to have elevated blood pressure when taken by health care providers (white coat syndrome). Older patients have orthostatic hypotension related to dehydration, reduced compensatory mechanisms, and medications. One hour after eating, many older patients have a drop in blood pressure. Lower doses of medications may be needed to control blood pressures in older adults related to decreased absorption rates and excretion ability.
The UAP is taking orthostatic vital signs. In the supine position, the blood pressure (BP) is 130/80 mm Hg, and the heart rate (HR) is 80 beats/min. In the sitting position, the BP is 140/80, and the HR is 90 beats/min. Which action should the nurse instruct the UAP to take next?
a) Repeat BP and HR in this position.
b) Record the BP and HR measurements.
c) Take BP and HR with patient standing.
d) Return the patient to the supine position.
c) Take BP and HR with patient standing.
Rationale: The vital signs taken do not reflect orthostatic changes, so the UAP will continue with the measurements while the patient is standing. There is no need to repeat or delay the readings. The patient does not need to return to the supine position. When assessing for orthostatic changes, the UAP will take the BP and pulse in the supine position, then place the patient in a sitting position for 1 to 2 minutes and repeat the readings, and then reposition to the standing position for 1 to 2 minutes and repeat the readings. Results consistent with orthostatic changes would have a decrease of 20 mm Hg or more in systolic BP, a decrease of 10 mm Hg or more in diastolic BP, and/or an increase in HR of greater than or equal to 20 beats/min with position changes.
The nurse admits a 73-yr-old male patient with dementia for treatment of uncontrolled hypertension. The nurse will closely monitor for hypokalemia if the patient receives which medication?
a) Clonidine (Catapres)
b) Bumetanide (Bumex)
c) Amiloride (Midamor)
d) Spironolactone (Aldactone)
b) Bumetanide (Bumex)
Rationale: Bumetanide is a loop diuretic. Hypokalemia is a common adverse effect of this medication. Amiloride is a potassium-sparing diuretic. Spironolactone is an aldosterone-receptor blocker. Hyperkalemia is an adverse effect of both amiloride and spironolactone. Clonidine is a central-acting α-adrenergic antagonist and does not cause electrolyte abnormalities.
Despite a high dosage, a male patient who is taking nifedipine (Procardia XL) for antihypertensive therapy continues to have blood pressures over 140/90 mm Hg. What should the nurse do next?
a) Assess his adherence to therapy.
b) Ask him to make an exercise plan.
c) Teach him to follow the DASH diet.
d) Request a prescription for a thiazide diuretic.
a) Assess his adherence to therapy.
Rationale: A long-acting calcium-channel blocker such as nifedipine causes vascular smooth muscle relaxation, resulting in decreased systemic vascular resistance and arterial blood pressure and related side effects. The patient data the nurse has about this patient is very limited, so the nurse needs to begin by assessing adherence to therapy.
The nurse teaches a 28-yr-old man newly diagnosed with hypertension about lifestyle modifications to reduce his blood pressure. Which patient statement requires reinforcement of teaching?
a) “I will avoid adding salt to my food during or after cooking.”
b) “If I lose weight, I might not need to continue taking medications.”
c) “I can lower my blood pressure by switching to smokeless tobacco.”
d) “Diet changes can be as effective as taking blood pressure medications.”
c) “I can lower my blood pressure by switching to smokeless tobacco.”
Rationale:
Nicotine contained in tobacco products (smoking and chew) cause vasoconstriction and increase blood pressure. Persons with hypertension should restrict sodium to 1500 mg/day by avoiding foods high in sodium and not adding salt in preparation of food or at meals. Weight loss can decrease blood pressure between 5 to 20 mm Hg. Following dietary recommendations (e.g., the DASH diet) lowers blood pressure, and these decreases compare with those achieved with blood pressure–lowering medication.
The nurse is caring for a patient with hypertension who is scheduled to receive a dose of metoprolol (Lopressor). The nurse should withhold the dose and consult the prescribing provider for which vital sign taken just before administration?
a) O2 saturation 93%
b) Pulse 48 beats/min
c) Respirations 24 breaths/min
d) Blood pressure 118/74 mm Hg
b) Pulse 48 beats/min
Rationale:
Because metoprolol is a β1-adrenergic blocking agent, it can cause hypotension and bradycardia as adverse effects. The nurse should withhold the dose and consult with the health care provider for parameters regarding pulse rate limits.
The nurse teaches a patient with hypertension that uncontrolled hypertension may damage organs in the body primarily by which mechanism?
a) Hypertension promotes atherosclerosis and damage to the walls of the arteries.
b) Hypertension causes direct pressure on organs, resulting in necrosis and scar tissue.
c) Hypertension causes thickening of the capillary membranes, leading to hypoxia of organ systems.
d) Hypertension increases blood viscosity, which causes intravascular coagulation and tissue necrosis distal to occlusions.
a) Hypertension promotes atherosclerosis and damage to the walls of the arteries.
Rationale:
Hypertension is a major risk factor for the development of atherosclerosis by mechanisms not yet fully known. However, when atherosclerosis develops, it damages the walls of arteries and reduces circulation to target organs and tissues.
A 44-yr-old man is diagnosed with hypertension and receives a prescription for benazepril (Lotensin). After providing teaching, which statement by the patient indicates correct understanding?
a) “If I take this medication, I will not need to follow a special diet.”
b) “It is normal to have some swelling in my face while taking this medication.”
c) “I will need to eat foods such as bananas and potatoes that are high in potassium.”
d) “If I develop a dry cough while taking this medication, I should notify my doctor.”
d) “If I develop a dry cough while taking this medication, I should notify my doctor.”
Rationale: Benazepril is an angiotensin-converting enzyme inhibitor. The medication inhibits breakdown of bradykinin, which may cause a dry, hacking cough. Other adverse effects include hyperkalemia. Swelling in the face could indicate angioedema and should be reported immediately to the prescriber. Patients taking drug therapy for hypertension should also attempt lifestyle modifications to lower blood pressure such as a reduced sodium diet.
A patient who had bladder surgery 2 days ago develops acute decompensated heart failure (ADHF) with severe dyspnea. Which action by the nurse would be indicated first?
a) Review urinary output for the previous 24 hours.
b) Restrict the patient’s oral fluid intake to 500 mL/day.
c) Assist the patient to a sitting position with arms on the overbed table.
d) Teach the patient to use pursed-lip breathing until the dyspnea subsides.
c) Assist the patient to a sitting position with arms on the overbed table.
Rationale:
The nurse should place the patient with ADHF in a high Fowler’s position with the feet horizontal in the bed or dangling at the bedside. This position helps decrease venous return because of the pooling of blood in the extremities. This position also increases the thoracic capacity, allowing for improved ventilation. Pursed-lip breathing helps with obstructive air trapping but not with acute pulmonary edema. Restricting fluids takes considerable time to have an effect.
What should the nurse recognize as an indication for the use of dopamine in the care of a patient with heart failure?
a) Acute anxiety
b) Hypotension and tachycardia
c) Peripheral edema and weight gain
d) Paroxysmal nocturnal dyspnea (PND)
b) Hypotension and tachycardia
Rationale:
Dopamine is a β-adrenergic agonist whose inotropic action is used for treatment of severe heart failure accompanied by hemodynamic instability. Such a state may be indicated by tachycardia accompanied by hypotension. PND, anxiety, edema, and weight gain are common signs and symptoms of heart failure, but these do not necessarily warrant the use of dopamine.
An older adult patient with chronic heart failure (HF) and atrial fibrillation asks the nurse why warfarin (Coumadin) has been prescribed to continue at home. What is the best response by the nurse?
a) “The medication prevents blood clots from forming in your heart.”
b) “The medication dissolves clots that develop in your coronary arteries.”
c) “The medication reduces clotting by decreasing serum potassium levels.”
d) “The medication increases your heart rate so that clots do not form in your heart.”
a) “The medication prevents blood clots from forming in your heart.”
Rationale:
Chronic HF causes enlargement of the chambers of the heart and an altered electrical pathway, especially in the atria. When numerous sites in the atria fire spontaneously and rapidly, atrial fibrillation occurs. Atrial fibrillation promotes thrombus formation within the atria with an increased risk of stroke and requires treatment with cardioversion, antidysrhythmics, and/or anticoagulants. Warfarin is an anticoagulant that interferes with hepatic synthesis of vitamin K–dependent clotting factors.
At a clinic visit, the nurse provides dietary teaching for a patient recently hospitalized with an exacerbation of chronic heart failure. The nurse determines that teaching is successful if the patient makes which statement?
a) “I will limit the amount of milk and cheese in my diet.”
b) “I can add salt when cooking foods but not at the table.”
c) “I will take an extra diuretic pill when I eat a lot of salt.”
d) “I can have unlimited amounts of foods labeled as reduced sodium.”
a) “I will limit the amount of milk and cheese in my diet.”
Rationale:
Milk products should be limited to 2 cups per day for a 2500-mg sodium-restricted diet. Salt should not be added during food preparation or at the table. Diuretics should be taken as prescribed (usually daily) and not based on sodium intake. Foods labeled as reduced sodium contain at least 25% less sodium than regular.
What is the priority assessment by the nurse caring for a patient receiving IV nesiritide (Natrecor) to treat heart failure?
a) Urine output
b) Lung sounds
c) Blood pressure
d) Respiratory rate
c) Blood pressure
Rationale:
Although all identified assessments are appropriate for a patient receiving IV nesiritide, the priority assessment would be monitoring for hypotension, the main adverse effect of nesiritide.
A patient is scheduled for a heart transplant. What is a major cause of death beyond the first year after a heart transplant?
a) Infection
b) Acute rejection
c) Immunosuppression
d) Cardiac vasculopathy
d) Cardiac vasculopathy
Rationale:
Beyond the first year after a heart transplant, cancer (especially lymphoma) and cardiac vasculopathy (accelerated coronary artery disease) are the major causes of death. During the first year after transplant, infection and acute rejection are the major causes of death. Immunosuppressive therapy will be used for posttransplant management to prevent rejection and increases the patient’s risk of an infection.
The nurse is administering a dose of Digitalis (digoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom?
a) Muscle aches
b) Constipation
c) Loss of appetite
d) Pounding headache
c) Loss of appetite
Rationale:
Anorexia, nausea, vomiting, blurred or yellow vision, and dysrhythmias are all signs of digitalis toxicity. The nurse would become concerned and notify the health care provider if the patient exhibited any of these symptoms.
The nurse is preparing to administer a nitroglycerin patch to a patient. When providing teaching about the use of the patch, what should the nurse include?
a) Avoid drugs to treat erectile dysfunction.
b) Increase diet intake of high-potassium foods.
c) Take an over-the-counter H2-receptor blocker.
d) Avoid nonsteroidal antiinflammatory drugs (NSAIDS).
a) Avoid drugs to treat erectile dysfunction.
Rationale:
The use of erectile drugs concurrent with nitrates creates a risk of severe hypotension and possibly death. NSAIDs do not pose a risk in combination with nitrates. There is no need to take an H2-receptor blocker or increase the dietary intake of high-potassium foods.
The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are reviewed with the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What is the priority action by the nurse?
a) Withhold the daily dose until the following day.
b) Withhold the dose and report the potassium level.
c) Give the digoxin with a salty snack, such as crackers.
d) Give the digoxin with extra fluids to dilute the sodium level.
b) Withhold the dose and report the potassium level.
Rationale:
The normal potassium level is 3.5 to 5.0 mEq/L. The patient is hyperkalemic, which makes the patient more prone to digoxin toxicity. For this reason, the nurse should withhold the dose and wait for the potassium level to normalize. The provider may order the digoxin to be given once the potassium level has been treated and decreases to within normal range.
The patient with chronic heart failure is being discharged from the hospital. What information should the nurse emphasize in the patient’s discharge teaching to prevent progression of the disease to acute decompensated heart failure (ADHF)?
a) Take medications as prescribed.
b) Use oxygen when feeling short of breath.
c) Direct questions only to the health care provider.
d) Encourage most activity in the morning when rested.
a) Take medications as prescribed.
Rationale:
The goal for the patient with chronic HF is to avoid exacerbations and hospitalization. Taking the medications as prescribed along with nondrug therapies such as alternating activity with rest will help the patient meet this goal. If the patient needs to use oxygen at home, it will probably be used all the time or with activity to prevent respiratory acidosis. Many HF patients are monitored by a care manager or in a transitional program to assess the patient for medication effectiveness and monitor for patient deterioration and encourage the patient. This nurse manager can be asked questions or can contact the health care provider if there is evidence of worsening HF.
An asymptomatic patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic. Before dangling the patient on the bedside, what should the nurse assess first?
a) Urine output
b) Heart rhythm
c) Breath sounds
d) Blood pressure
d) Blood pressure
Rationale:
The nurse should evaluate the blood pressure before dangling the patient on the bedside because the blood pressure can decrease as blood pools in the periphery and preload decreases. If the patient’s blood pressure is low or marginal, the nurse should put the patient in the semi-Fowler’s position and use other measures to improve gas exchange.
The nurse prepares to administer digoxin 0.125 mg to a patient admitted with influenza and a history of chronic heart failure. What should the nurse assess before giving the medication?
a) Prothrombin time
b) Urine specific gravity
c) Serum potassium level
d) Hemoglobin and hematocrit
c) Serum potassium level
Rationale:
Serum potassium should be monitored because hypokalemia increases the risk for digoxin toxicity. Changes in prothrombin time, urine specific gravity, and hemoglobin or hematocrit would not require holding the digoxin dose.
After having a myocardial infarction (MI), the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108 beats/min. What should the nurse suspect is happening?
a) Chronic HF
b) Left-sided HF
c) Right-sided HF
d) Acute decompensated HF
c) Right-sided HF
Rationale:
An MI is a primary cause of heart failure. The jugular venous distention, weight gain, peripheral edema, and increased heart rate are manifestations of right-sided heart failure.
The patient has heart failure (HF) with an ejection fraction of less than 40%. What core measures should the nurse expect to include in the plan of care for this patient? (Select all that apply.)
a) Left ventricular function is documented
b) Controlling dysrhythmias will eliminate HF
c) Prescription for digoxin (Lanoxin) at discharge
d) Prescription for angiotensin-converting enzyme inhibitor at discharge
e) Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen
a) Left ventricular function is documented
d) Prescription for angiotensin-converting enzyme inhibitor at discharge
e) Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen
Rationale:
The Joint Commission has identified these 3 core measures for heart failure patients. Although controlling dysrhythmias will improve CO and workload, it will not eliminate HF. Prescribing digoxin for all HF patients is no longer done because there are newer effective drugs and digoxin toxicity occurs easily related to electrolyte levels and the therapeutic range must be maintained.
A patient with a long-standing history of heart failure recently qualified for hospice care. What measure should the nurse now prioritize when providing care for this patient?
a) Taper the patient off his current medications.
b) Continue education for the patient and his family.
c) Pursue experimental therapies or surgical options.
d) Choose interventions to promote comfort and prevent suffering.
d) Choose interventions to promote comfort and prevent suffering.
Rationale:
The central focus of hospice care is the promotion of comfort and the prevention of suffering. Patient education should continue, but providing comfort is paramount. Medications should be continued unless they are not tolerated. Experimental therapies and surgeries are not used in the care of hospice patients.
A patient admitted with heart failure is anxious and reports shortness of breath. Which nursing actions would be appropriate to alleviate this patient’s anxiety? (Select all that apply.)
a) Administer ordered morphine sulfate.
b) Position patient in a semi-Fowler’s position.
c) Position patient on left side with head of bed flat.
d) Instruct patient on the use of relaxation techniques.
e) Use a calm, reassuring approach while talking to patient.
a) Administer ordered morphine sulfate.
b) Position patient in a semi-Fowler’s position.
d) Instruct patient on the use of relaxation techniques.
e) Use a calm, reassuring approach while talking to patient.
Rationale:
Morphine sulfate reduces anxiety and may assist in reducing dyspnea. The patient should be positioned in semi-Fowler’s position to improve ventilation that will reduce anxiety. Relaxation techniques and a calm reassuring approach will also serve to reduce anxiety.
A patient with a recent diagnosis of heart failure has been prescribed furosemide (Lasix). What outcome would demonstrate medication effectiveness?
a) Promote vasodilation.
b) Reduction of preload.
c) Decrease in afterload.
d) Increase in contractility.
b) Reduction of preload.
Rationale:
Diuretics such as furosemide are used in the treatment of heart failure to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload. They do not directly influence afterload, contractility, or vessel tone.
The home care nurse visits a patient with chronic heart failure. Which assessment findings would indicate acute decompensated heart failure (pulmonary edema)?
a) Fatigue, orthopnea, and dependent edema
b) Severe dyspnea and blood-streaked, frothy sputum
c) Temperature is 100.4° F and pulse is 102 beats/min
d) Respirations 26 breaths/min despite oxygen by nasal cannula
b) Severe dyspnea and blood-streaked, frothy sputum
Rationale:
Manifestations of pulmonary edema include anxiety, pallor, cyanosis, clammy and cold skin, severe dyspnea, use of accessory muscles of respiration, a respiratory rate greater than 30 breaths/min, orthopnea, wheezing, and coughing with the production of frothy, blood-tinged sputum. Auscultation of the lungs may reveal crackles, wheezes, and rhonchi throughout the lungs. The heart rate is rapid, and blood pressure may be elevated or decreased.
The nurse prepares to defibrillate a patient. Which dysrhythmia has the nurse observed in this patient?
a) Ventricular fibrillation
b) Third-degree AV block
c) Uncontrolled atrial fibrillation
d) Ventricular tachycardia with a pulse
a) Ventricular fibrillation
Rationale:
Defibrillation is always indicated in the treatment of ventricular fibrillation. Drug treatments are normally used in the treatment of uncontrolled atrial fibrillation and for ventricular tachycardia with a pulse (if the patient is stable). Otherwise, synchronized cardioversion is used (if the patient has a pulse). Pacemakers are the treatment of choice for third-degree heart block.
The nurse performs discharge teaching for a patient with an implantable cardioverter-defibrillator (ICD). Which statement by the patient indicates that further teaching is needed?
a) “The device may set off the metal detectors in an airport.”
b) “My family needs to keep up to date on how to perform CPR.”
c) “I should not stand next to antitheft devices at the exit of stores.”
d) “I can expect redness and swelling of the incision site for a few days.”
d) “I can expect redness and swelling of the incision site for a few days.”
Rationale:
Patients should be taught to report any signs of infection at incision site (e.g., redness, swelling, drainage) or fever to their primary care providers immediately. Teach patients to inform TSA airport security of the presence of the ICD because it may set off metal detectors. If a handheld screening wand is used, it should not be placed directly over the ICD. Teach patients to avoid standing near antitheft devices in doorways of stores and public buildings and to walk through them at a normal pace. Caregivers should learn cardiopulmonary resuscitation.
A patient reporting dizziness and shortness of breath is admitted with a dysrhythmia. Which medication, if ordered, requires the nurse to carefully monitor the patient for asystole?
a) Digoxin
b) Adenosine
c) Metoprolol
d) Atropine sulfate
b) Adenosine
Rationale:
IV adenosine is the first drug of choice to convert supraventricular tachycardia to a normal sinus rhythm. Adenosine is administered IV rapidly (over 1 or 2 seconds) followed by a rapid, normal saline flush. The nurse should monitor the patient’s electrocardiogram continuously because a brief period of asystole after adenosine administration is common and expected. Atropine sulfate increases heart rate, while lanoxin and metoprolol slow the heart rate.
A patient develops third-degree heart block and reports feeling chest pressure and shortness of breath. Which instructions should the nurse provide to the patient before initiating emergency transcutaneous pacing?
a) “The device will convert your heart rate and rhythm back to normal.”
b) “The device uses overdrive pacing to slow the heart to a normal rate.”
c) “The device is inserted through a large vein and threaded into your heart.”
d) “The device delivers a current through your skin that can be uncomfortable.”
d) “The device delivers a current through your skin that can be uncomfortable.”
Rationale:
Before initiating transcutaneous pacing therapy, it is important to tell the patient what to expect. The nurse should explain that the muscle contractions created by the pacemaker when the current passes through the chest wall are uncomfortable. Pacing for complete heart block will not convert the heart rhythm to normal. Overdrive pacing is used for very fast heart rates. Transcutaneous pacing is delivered through pacing pads adhered to the skin.
The nurse observes ventricular tachycardia (VT) on the patient’s monitor. What evaluation made by the nurse led to this interpretation?
a) Unmeasurable rate and rhythm
b) Rate 150 beats/min; inverted P wave
c) Rate 200 beats/min; P wave not visible
d) Rate 125 beats/min; normal QRS complex
c) Rate 200 beats/min; P wave not visible
Rationale:
VT is associated with a rate of 150 to 250 beats/min; the P wave is not normally visible. Rate and rhythm are not measurable in ventricular fibrillation. P wave inversion and a normal QRS complex are not associated with VT.
When computing a heart rate from the electrocardiography (ECG) tracing, the nurse counts 15 of the small blocks between the R waves of a patient whose rhythm is regular. What does the nurse calculate the patient’s heart rate to be?
a) 60 beats/min
b) 75 beats/min
c) 100 beats/min
d) 150 beats/min
c) 100 beats/min
Rationale:
Because each small block on the ECG paper represents 0.04 seconds, 1500 of these blocks represents 1 minute. By dividing the number of small blocks (15, in this case) into 1500, the nurse can calculate the heart rate in a patient whose rhythm is regular (in this case, 100).
The patient has atrial fibrillation with a rapid ventricular response. What electrical treatment option does the nurse prepare the patient for?
a) Defibrillation
b) Synchronized cardioversion
c) Automatic external defibrillator (AED)
d) Implantable cardioverter-defibrillator (ICD)
b) Synchronized cardioversion
Rationale:
Synchronized cardioversion is planned for a patient with supraventricular tachydysrhythmias (atrial fibrillation with a rapid ventricular response). Defibrillation or AEDs are the treatment of choice to end ventricular fibrillation and pulseless ventricular tachycardia (VT). An ICD is used with patients who have survived sudden cardiac death, have spontaneous sustained VT, and are at high risk for future life-threatening dysrhythmias.
The nurse is caring for a patient who is 24 hours after pacemaker insertion. Which nursing intervention is appropriate at this time?
a) Reinforcing the pressure dressing as needed
b) Encouraging range-of-motion exercises of the involved arm
c) Assessing the incision for any redness, swelling, or discharge
d) Applying wet-to-dry dressings every 4 hours to the insertion site
c) Assessing the incision for any redness, swelling, or discharge
Rationale:
After pacemaker insertion, it is important for the nurse to observe signs of infection by assessing for any redness, swelling, or discharge from the incision site. The nonpressure dressing is kept dry until removed, usually 24 hours postoperatively. It is important for the patient to limit activity of the involved arm to minimize pacemaker lead displacement.
The nurse obtains a 6-second rhythm strip and charts the following analysis: Tab 1 Atrial data Rate: 70, regular Variable PR interval Independent beats
Tab 2
Ventricular data
Rate: 40, regular
Isolated escape beats
Tab 3
Additional data
QRS: 0.04 sec
P wave and QRS complexes unrelated
What is the correct interpretation of this rhythm strip?
a) Sinus dysrhythmia
b) Third-degree heart block
c) Wenckebach phenomenon
d) Premature ventricular contractions
b) Third-degree heart block
Rationale:
Third-degree heart block represents a loss of communication between the atrium and ventricles from atrioventricular node dissociation. This is depicted on the rhythm strip as no relationship between the P waves (representing atrial contraction) and QRS complexes (representing ventricular contraction). Whereas the atria are beating totally on their own at 70 beats/min, the ventricles are pacing themselves at 40 beats/min. Sinus dysrhythmia is seen with a slower heart rate with exhalation and an increased heart rate with inhalation. In Wenckebach heart block, there is a gradual lengthening of the PR interval until an atrial impulse is nonconducted and a QRS complex is blocked or missing. Premature ventricular contractions are the early occurrence of a wide, distorted QRS complex.
Which statement best describes the electrical activity of the heart represented by measuring the PR interval on the electrocardiogram (ECG)?
a) The length of time it takes to depolarize the atrium.
b) The length of time it takes for the atria to depolarize and repolarize.
c) The length of time for the electrical impulse to travel from the sinoatrial (SA) node to the Purkinje fibers.
d) The length of time it takes for the electrical impulse to travel from the sinoatrial (SA) node to the atrioventricular (AV) node.
c) The length of time for the electrical impulse to travel from the sinoatrial (SA) node to the Purkinje fibers.
Rationale:
The electrical impulse in the heart must travel from the SA node through the AV node and into the Purkinje fibers in order for synchronous atrial and ventricular contraction to occur. When measuring the PR interval (the time from the beginning of the P wave to the beginning of the QRS), the nurse is identifying the length of time it takes for the electrical impulse to travel from the SA node to the Purkinje fibers. The P wave represents the length of time it takes for the impulse to travel from the SA node through the atrium, causing depolarization of the atria (atrial contraction). Atrial repolarization occurs during ventricular depolarization and is hidden by the QRS complex. The length of time it takes for the electrical impulse to travel from the SA node to the AV node is the flat line between the end of the P wave and the beginning of the Q wave on the ECG and is not usually measured.
The nurse observes no P waves on the patients monitor strip. There are fine, wavy lines between the QRS complexes. The QRS complexes measure 0.08 seconds (narrow), but they occur irregularly with a rate of 120 beats/min. What does the nurse determine the rhythm to be?
a) Sinus tachycardia
b) Atrial fibrillation
c) Ventricular fibrillation
d) Ventricular tachycardia
b) Atrial fibrillation
Rationale:
Atrial fibrillation is represented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atria are not truly contracting, just fibrillating. Sinus tachycardia is a sinus rate above 100 beats/min with normal P waves. Ventricular fibrillation is seen on the ECG without a visible P wave; an unmeasurable heart rate, PR or QRS; and the rhythm is irregular and chaotic. Ventricular tachycardia is seen as three or more premature ventricular contractions that have distorted QRS complexes with regular or irregular rhythm, and the P wave is usually buried in the QRS complex without a measurable PR interval.
The nurse determines there is artifact on the patient’s telemetry monitor. Which factor should the nurse assess for that could correct this issue?
a) Disabled automaticity
b) Electrodes in the wrong lead
c) Too much hair under the electrodes
d) Stimulation of the vagus nerve fibers
c) Too much hair under the electrodes
Rationale:
Artifact is caused by muscle activity, electrical interference, or insecure leads and electrodes that could be caused by excessive chest wall hair. Disabled automaticity would cause an atrial dysrhythmia. Electrodes in the wrong lead will measure electricity in a different plane of the heart and may have a different wave form than expected. Stimulation of the vagus nerve fibers causes a decrease in heart rate, not artifact.
The nurse has obtained this rhythm strip from her patient’s monitor. What should the nurse document this rhythm indicates?
a) Sinus tachycardia
b) Sinus bradycardia
c) Ventricular fibrillation
d) Ventricular tachycardia
a) Sinus tachycardia
Rationale:
This rhythm strip shows sinus tachycardia because the rate on this strip is above 101 beats/min, and it displays normal P wave, PR interval, and QRS complex. Sinus bradycardia would look similar to sinus tachycardia but with a rate less than 60 beats/min. Ventricular fibrillation does not have a measureable heart rate, PR interval, or QRS. The P wave is not visible, and the rhythm is irregular and chaotic. Ventricular tachycardia has a rate of 150 to 250 beats/min, with a regular or irregular rhythm and P waves occurring independently of the QRS complex.
The nurse is monitoring the electrocardiograms of several patients on a cardiac telemetry unit. The patients are directly visible to the nurse, and all the patients are observed to be sitting up and talking with visitors. Which patient’s rhythm would require the nurse to take immediate action?
a) A 62-yr-old man with a fever and sinus tachycardia with a rate of 110 beats/min
b) A 72-yr-old woman with atrial fibrillation with 60 to 80 QRS complexes per minute
c) A 52-yr-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute
d) A 42-yr-old woman with first-degree AV block and sinus bradycardia at a rate of 56 beats/min
c) A 52-yr-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute
Rationale:
Frequent premature ventricular contractions (PVCs) (>1 every 10 beats) may reduce the cardiac output and precipitate angina and heart failure, depending on their frequency. Because PVCs in CAD or acute myocardial infarction indicate ventricular irritability, the patient’s physiologic response to PVCs must be monitored. Frequent PVCs may be treated with oxygen therapy, electrolyte replacement, or antidysrhythmic agents.
The patient has a potassium level of 2.9 mEq/L, and the nurse obtains the following measurements on the rhythm strip: Heart rate of 86 with a regular rhythm, the P wave is 0.06 seconds (sec) and normal shape, the PR interval is 0.24 seconds, and the QRS is 0.09 seconds. How should the nurse document this rhythm?
a) First-degree AV block
b) Second-degree AV block
c) Premature atrial contraction (PAC)
d) Premature ventricular contraction (PVC)
a) First-degree AV block
Rationale:
In first-degree atrioventricular (AV) block, there is prolonged duration of AV conduction that lengthens the PR interval above 0.20 seconds. In type I second-degree AV block, the PR interval continues to increase in duration until a QRS complex is blocked. In type II, the PR interval may be normal or prolonged, the ventricular rhythm may be irregular, and the QRS is usually greater than 0.12 seconds. PACs cause an irregular rhythm with a different-shaped P wave than the rest of the beats, and the PR interval may be shorter or longer. PVCs cause an irregular rhythm, and the QRS complex is wide and distorted in shape.
Cardioversion is attempted for a patient with atrial flutter and a rapid ventricular response. After delivering 50 joules by synchronized cardioversion, the patient develops ventricular fibrillation. Which action should the nurse take immediately?
a) Administer 250 mL of 0.9% saline solution IV by rapid bolus.
b) Assess the apical pulse, blood pressure, and bilateral neck vein distention.
c) Turn the synchronizer switch to the “off” position and recharge the device.
d) Ask the patient if there is any chest pain or discomfort and administer morphine sulfate.
c) Turn the synchronizer switch to the “off” position and recharge the device.
Rationale:
Ventricular fibrillation produces no effective cardiac contractions or cardiac output. If during synchronized cardioversion the patient becomes pulseless or the rhythm deteriorates to ventricular fibrillation, the nurse should turn the synchronizer switch off and initiate defibrillation. Fluids, additional assessment, or treatment of pain alone will not restore an effective heart rhythm.
The nurse is doing discharge teaching with the patient who received an implantable cardioverter-defibrillator (ICD) in the left side. Which statement by the patient indicates that further teaching is required?
a) “I will call the cardiologist if my ICD fires.”
b) “I cannot fly because it will damage the ICD.”
c) “I cannot move my left arm until it is approved.”
d) “I cannot drive until my cardiologist says it is okay.”
b) “I cannot fly because it will damage the ICD.”
Rationale:
The patient statement that flying will damage the ICD indicates misunderstanding about flying. The patient should be taught to inform TSA security screening agents at the airport about the ICD because it may set off the metal detector and if a hand-held screening wand is used, it should not be placed directly over the ICD. The other options indicate the patient understands the teaching.
A patient informs the nurse of experiencing syncope. Which priority nursing action should the nurse anticipate in the patient’s subsequent diagnostic workup?
a) Preparing to assist with a head-up tilt-test
b) Assessing the patient’s knowledge of pacemakers
c) Administering an IV dose of a β-adrenergic blocker
d) Teaching the patient about antiplatelet aggregators
a) Preparing to assist with a head-up tilt-test
Rationale:
In patients without structural heart disease, the head-up tilt-test is a common component of the diagnostic workup after episodes of syncope. IV β-blockers are not indicated, although an IV infusion of low-dose isoproterenol may be started in an attempt to provoke a response if the head-up tilt-test did not have a response. Addressing pacemakers is premature and inappropriate at this stage of diagnosis. Patient teaching surrounding antiplatelet aggregators is not directly relevant to the patient’s syncope at this time.
The nurse observes a flat line on the patient’s monitor and the patient is unresponsive without pulse. What medications does the nurse prepare to administer?
a) Lidocaine or amiodarone
b) Digoxin and procainamide
c) Epinephrine or vasopressin
d) β-Adrenergic blockers and dopamine
c) Epinephrine or vasopressin
Rationale:
Normally, the patient in asystole cannot be successfully resuscitated. However, administration of epinephrine or vasopressin may prompt the return of depolarization and ventricular contraction. Lidocaine and amiodarone are used for ventricular tachycardia or ventricular fibrillation. Digoxin and procainamide are used for ventricular rate control. β-Adrenergic blockers are used to slow heart rate, and dopamine is used to increase heart rate.
