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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.
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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 teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously, without treatment. Which statement should the nurse include in this client needs category.
- A. Minimize or abstain from caffeine
- B. Lie on your side until the attack subsides
- C. Use your oxygen when you experience PACs
- D. Take amiodarone (Cordarone) daily to prevent PACs
Correct Answer: A
Rationale: PACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs, the nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be used to control symptomatic dysrhythmias, for infrequent PACs, the client should first try lifestyle changes to control them.
After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: [Vital signs data]. Based on the assessments, which action should the nurse take?
- A. Stop the infusion and flush the IV
- B. Slow the amiodarone infusion rate
- C. Administer IV normal saline
- D. Ask the client to cough and deep breathe
Correct Answer: B
Rationale: IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly stopping the medication could allow fatal dysrhythmias to occur.
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 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.