Nokea
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.
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The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below. After calling for assistance and a defibrillator, which action should the nurse take next?
- A. Perform a pericardial thump
- B. Initiate cardiopulmonary resuscitation (CPR)
- C. Start an 8-gauge intravenous line
- D. Ask the clients family about code status
Correct Answer: B
Rationale: The client's rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. The pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The client's code status should already be known by the nurse prior to the event.
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 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.
The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, Why do you want to know if you is cause? How should the nurse respond?
- A. Substance abuse puts clients at risk for many health issues
- B. The hospital requires that I ask you about cocaine use
- C. Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias
- D. We can provide services for cessation of substance abuse
Correct Answer: C
Rationale: Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias. The other responses do not adequately address the client's question.
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.