Nokea
A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition?
- A. Sinus tachycardia
- B. Speech alterations
- C. Fatigue
- D. Dyspnea with activity
Correct Answer: B
Rationale: Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.
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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 supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure?
- A. Clean the skin and clip hairs if needed
- B. Add gel to the chest prior to applying them
- C. Place the electrodes on the posterior chest
- D. Turn off oxygen prior to monitoring the client
Correct Answer: A
Rationale: To ensure the best signal transmission, the skin should be clean and hairs clipped. Electrodes should be placed on the anterior chest, and no additional gel is needed. Oxygen has no impact on electrocardiographic monitoring.
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.
A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this clients teaching? (Select all that apply.)
- A. Smoking cessation
- B. Stress relaxation and management
- C. Avoiding vagal stimulation
- D. Adverse effects of medications
- E. Foods high in potassium
Correct Answer: A,B,D
Rationale: A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances.
A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should be performed prior to defibrillating the client?
- A. Make sure the defibrillator is set to the synchronous mode
- B. Administer 1 mg of intravenous epinephrine
- C. Assess that everyone is clear of contact with the client and the bed
- D. Assess that everyone is clear of contact with the client and the bed
Correct Answer: D
Rationale: To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump is not indicated when a defibrillator is available. Epinephrine administration is part of advanced cardiac life support but is not the priority before defibrillation.