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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.
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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 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 nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care service. What interventions should the nurse include to the home health nurse upon discharge?
- A. Medication reconciliation
- B. Immunization history
- C. Medication history
- D. Nutrition preferences
Correct Answer: A
Rationale: The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a plan of care for the client.
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 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.