NCLEX Flashcards
nurse is viewing the cardiac monitor in a client’s room and notes that the client has just gone into ventricular tachycardia. The client is awake and alert and has good skin color. The nurse would prepare to do which of the following?
A. Immediately defibrillate.
B. Prepare for pacemaker insertion.
C. Administer amiodarone (Cordarone) intravenously.
D. Administer epinephrine (Adrenaline) intravenously.
C. Administer amiodarone (Cordarone) IV
1st line defense against Stable V Tach is Antidysrythmics:
Amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl).
Cardioversion is recommended for stable ventricular tachycardia
A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs the client to do which of the following, if prescribed, during an episode of ventricular tachycardia?
A. Breathe deeply, regularly, and easily.
B. Inhale deeply and cough forcefully every 1 to 3 seconds.
C. Lie down flat in bed.
D. Remove any metal jewelry.
B. Inhale deeply and cough forcefully every 1 to 3 seconds.
Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented.
A client has developed atrial fibrillation, which has a ventricular rate of 150 beats per minute. A nurse assesses the client for:
A. Hypotension and dizziness
B. Nausea and vomiting
C. Hypertension and headache
D. Flat neck veins
A. Hypotension and dizziness
Uncontrolled atrial fibrillation, ventricular rate >150 beats
Risk for low cardiac output because of loss of atrial kick
A nurse is watching the cardiac monitor, and a client’s rhythm suddenly changes. There are no P waves; instead, there are wavy lines. The QRS complexes measure 0.08 second, but they are irregular, with a rate of 120 beats a minute. The nurse interprets this rhythm as:
A. Sinus tachycardia
B. Atrial fibrillation
C. Ventricular tachycardia
D. Ventricular fibrillation
B. A fib
client with rapid rate atrial fibrillation asks a nurse why the physician is going to perform carotid massage. The nurse responds that this procedure may stimulate the:
A. Vagus nerve to slow the heart rate.
B. Vagus nerve to increase the heart rate; overdriving the rhythm.
C. Diaphragmatic nerve to slow the heart rate.
D. Diaphragmatic nerve to overdrive the rhythm.
A. Vagus nerve to slow the heart rate.
Carotid massage
Valsalva maneuver
Inducing gag reflex
All slow down HR
Client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client’s rhythm suddenly changes to one with no P waves or definable QRS complexes. Instead, there are coarse wavy lines of varying amplitude. The nurse assesses this rhythm to be:
A. Ventricular tachycardia
B. Ventricular fibrillation
C. Atrial fibrillation
D. Asystole
B. Ventricular fibrillation
V fib = iirregular, chaotic undulations of varying amplitudes.
No measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles.
VF is a WCT
wide complex tachycardia (WCT) = Rate >100 bmp / QRS >0.12 (3 squares)
While caring for a client who has sustained an MI, the nurse notes eight PVCs in one minute on the cardiac monitor. The client is receiving an IV infusion of D5W and oxygen at 2 L/minute. The nurse’s first course of action should be to:
A. Increase the IV infusion rate.
B. Notify the physician promptly.
C. Increase the oxygen concentration.
D. Administer a prescribed analgesic.
B. Notify the physician promptly.
PVCs are precursors V Tach / Fib
An occasional PVC is not considered dangerous
PVCs occur at a rate greater than 5 or 6 per minute in the post-MI client, the physician should be notified immediately.
More than 6 PVCs per minute is considered serious
decrease ventricular irritability by administering Lidocaine
What are common causes for PVC
Stimulants
Lower levels of K or Mg
The adaptations of a client with complete heart block would most likely include:
A. Nausea and vertigo
B. Flushing and slurred speech
C. Cephalalgia and blurred vision
D. Syncope and slow ventricular rate
D. Syncope and slow ventricular rate
Complete AV block, the ventricles take over the pacemaker function in the heart but at a much slower rate than SA node.
Result, Decreased cerebral circulation, leading to Syncope
When ventricular fibrillation occurs in a CCU, the first person reaching the client should:
A. Administer oxygen.
B. Defibrillate the client.
C. Initiate CPR.
D. Administer sodium bicarbonate
B. Defib the client
Pulseless VT and VF are both shockable rhythms
Atherosclerosis impedes coronary blood flow by which of the following mechanisms?
A. Plaques obstruct the vein.
B. Plaques obstruct the artery.
C. Blood clots form outside the vessel wall.
D. Hardened vessels dilate to allow blood to flow through.
B. Plaques obstruct the artery.
Paradoxical pulse (systolic blood pressure drops abnormally when they inhale, and increases when they exhale)
occurs in a client who had a coronary artery bypass graft (CABG) surgery two (2) days ago. Which of the following surgical complications should the nurse suspect?
A. Left-sided heart failure
B. Aortic regurgitation
C. Complete heart block
D. Pericardial tamponade
D. Pericardial tamponade
Paradoxical pulse (a palpable decrease in pulse amplitude on quiet inspiration) = Pericardial tamponade
Complication of CABG surgery.
Cardiac tamponade
Fluid accumulates in the pericardial sac compressing the heart
Decrease in cardiac output and shock.
