Nokea
A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for be the expected therapeutic response?
- A. Decreased muscular pressure
- B. Increased heart rate
- C. Short period of asystole
- D. Dyspnea with crisis
Correct Answer: C
Rationale: Clients usually respond to adenosine with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain. Adenosine has no conclusive impact on intramuscular pressure.
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A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this clients medication administration record to prevent a common complication of this condition.
- A. Sotalol (Betapace)
- B. Warfarin (Coumadin)
- C. Atropine (Sal-Tropine)
- D. Lidocaine (Xylocaine)
Correct Answer: B
Rationale: Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication.
A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next?
- A. Pulmonary auscultation
- B. Pulse strength and amplitude
- C. Level of consciousness
- D. Mobility and gait stability
Correct Answer: C
Rationale: A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, lightheadedness, confusion, dyspnea, and seizure activity. Although the other assessments should be completed, the client's level of consciousness is the priority.
A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?
- A. Mid-sternal chest pain
- B. Increased urine output
- C. Mild orthostatic hypotension
- D. P wave touching the T wave
Correct Answer: A
Rationale: Chest pain, possibly angina, indicates that tachycardia may be increasing the client's myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates tachycardia and should be assessed to determine the underlying rhythm and cause, but this is not as critical as chest pain, which indicates cardiac cell death.
A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the clients electrocardiogram. Which action should the nurse take next?
- A. Administer intravenous diltiazem (Cardizem)
- B. Assess vital signs and level of consciousness
- C. Administer sublingual nitroglycerin
- D. Assess capillary refill and temperature
Correct Answer: B
Rationale: In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and correction. The nurse should assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture.
A nurse assesses a clients electrocardiograph tracing and observes that not all QRS complexes are preceded by type of nurse. How should the nurse interprets this observation?
- A. The client has hyperkalemia causing irregular QRS complexes.
- B. Ventricular tachycardia is overriding the normal atrial rhythm?
- C. The clients chest leads are not making significant contact with the skin.
- D. Ventricular and atrial depolarizations are initiated from different sites.
Correct Answer: D
Rationale: Normal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization. This findings on an electrocardiograph tracing is not an indication of hyperkalemia, ventricular tachycardia, or disconnection of leads.