Nokea
A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The clients blood pressure is 155/75 mm Hg and oxygen saturation is [missing data].
- A. Assess current medications
- B. Check oxygen saturation
- C. Evaluate dietary habits
- D. Review immunization history
Correct Answer: A
Rationale: The client is on multiple medications that can interact with each other. The nurse should assess the client's current medications first to identify potential interactions that could contribute to cardiac dysrhythmias or other complications.
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A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition?
- A. Sinus tachycardia
- B. Speech alterations
- C. Fatigue
- D. Dyspnea with activity
Correct Answer: B
Rationale: Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.
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 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.
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.
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.