Nokea
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.
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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 cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this clients concerns?
- A. Administer oxygen therapy at 2 liters per nasal cannula
- B. Provide a sleeping aid prior to bedtime
- C. Schedule periods of exercise and rest during the day
- D. Ask unlicensed assistive personnel to help bathe the client
Correct Answer: C
Rationale: Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue when completing activities of daily living. The client should be encouraged to participate in self-care activities.
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 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 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.