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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.
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A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next?
- A. Pulmonary auscultation
- B. Pulse strength and amplitude
- C. Level of consciousness
- D. Mobility and gait stability
Correct Answer: C
Rationale: A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, lightheadedness, confusion, dyspnea, and seizure activity. Although the other assessments should be completed, the client's level of consciousness is the priority.
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 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 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 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.