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A nurse assesses a clients electrocardiogram (ECG) and observes the reading shown below: How should the nurse document this clients ECG strip?
- A. Ventricular rhythm
- B. Ventricular fibrillation
- C. Sinus rhythm with premature atrial contractions (PACs)
- D. Sinus rhythm with premature ventricular contractions (PVCs)
Correct Answer: D
Rationale: Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometimes precedes atrial depolarization. Ventricular dysrhythmias and ventricular fibrillation would not have sinus beats present. Premature atrial contractions are atrial contractions initiated from another region of the atria before the sinus node initiates atrial depolarization.
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A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion?
- A. Administer a sedative to reduce anxiety
- B. Turn off oxygen therapy
- C. Ensure a tongue blade is available
- D. Position the client on their side
Correct Answer: B
Rationale: For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client should be placed in a supine position.
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 congestive heart failure who has a regular cardiac rhythm of 128 Beats/min. What should the nurse assess? (Select all that apply.)
- A. Decrease in cardiac output
- B. Increase in cardiac output
- C. Increase in cardiac output
- D. Increase in blood pressure
- E. Decrease in urine output
- F. Increase in urine output
Correct Answer: A,D,E
Rationale: Tachycardia may initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall.
A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: Which action should the nurse take first?
- A. Assess airway, breathing, and level of consciousness
- B. Administer an amiodarone bolus followed by a drip
- C. Cardiovert the client with a biphasic defibrillator
- D. Begin cardiopulmonary resuscitation (CPR)
Correct Answer: A
Rationale: Ventricular dysrhythmias and ventricular fibrillation require immediate assessment of the client's airway, breathing, and level of consciousness to determine if the client is alert and breathing. If the client is pulseless, the nurse should call a Code Blue and begin CPR. Defibrillation is the treatment of choice for pulseless ventricular fibrillation. Amiodarone is the antiarrhythmic of choice, but it is not the first action.
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.