Nokea
A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of how many beats/minute?
- A. 20-30
- B. 40-60
- C. 70-80
- D. 90-100
Correct Answer: B
Rationale: If the sinoatrial (SA) node fails to discharge, the atrioventricular (AV) node will automatically discharge at the normal rate of 40-60. The slower rates are typical of the bundle of His and the Purkinje system and may be seen with failure of both the SA and AV nodes to discharge. The normal SA node rate is 60-100 beats/minute.
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The nurse is caring for a patient who requires defibrillation. In which order will the nurse accomplish the following steps?
- A. Turn the defibrillator on.
- B. Deliver the electrical charge.
- C. Select the appropriate energy level.
- D. Place the paddles on the patient's chest.
- E. Check the location of other personnel and call out 'all clear.'
Correct Answer: A,C,D,E,B
Rationale: This order will result in rapid defibrillation without endangering hospital personnel. The sequence ensures the defibrillator is powered, set to the correct energy level, paddles are correctly placed, safety is confirmed, and then the charge is delivered.
The nurse is caring for a young adult patient who had a mandatory electrocardiogram (ECG) before participating on a college swim team and is found to have sinus bradycardia, rate 52. BP is 114/54 mm Hg, and the student denies any health problems. Which of the following actions by the nurse is best?
- A. Allow the student to participate on the swim team.
- B. Refer the student to a cardiologist for further assessment.
- C. Obtain more detailed information about the student's health history.
- D. Tell the student to stop swimming immediately if any dyspnea occurs.
Correct Answer: A
Rationale: In an aerobically trained individual, sinus bradycardia is normal. The student's normal BP and negative health history indicate that there is no need for a cardiology referral or for more detailed information about the health history. Dyspnea during an aerobic activity such as swimming is normal.
The nurse is analyzing an electrocardiogram rhythm strip of a patient with a regular cardiac rhythm and finds there are 25 small blocks from one R wave to the next. The nurse calculates the patient's heart rate as beats per minute.
Correct Answer: 60
Rationale: There are 1500 small blocks in a minute, and the nurse will divide 1500 by 25 to calculate the heart rate, resulting in 60 beats per minute.
The nurse is caring for a patient whose cardiac monitor has a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious and pulseless. Which of the following actions should the nurse take first?
- A. Defibrillate at maximum energy.
- B. Give O2 per bag-valve-mask.
- C. Give epinephrine (Adrenalin) IV.
- D. Prepare for endotracheal intubation.
Correct Answer: A
Rationale: The patient's rhythm and assessment indicate ventricular fibrillation and cardiac arrest; the initial action should be to defibrillate. If a defibrillator is not immediately available or is unsuccessful in converting the patient to a better rhythm, the other actions may be appropriate.
The nurse is caring for a patient in the emergency department who has symptoms of a 'racing' heart and nervousness. The nurse places the patient on a cardiac monitor and obtains the following electrocardiogram tracing. Which of the following actions should the nurse take next?
- A. Get ready to perform electrical cardioversion.
- B. Have the patient perform the Valsalva manoeuvre.
- C. Obtain the patient's blood pressure and oxygen saturation.
- D. Prepare to give β-blocker medication to slow the heart rate.
Correct Answer: C
Rationale: The patient has sinus tachycardia, which may have multiple etiologies such as pain, dehydration, anxiety, and myocardial ischemia; further assessment is needed before determining the treatment. Vagal stimulation or β-blockade may be used after further assessment of the patient. Electrical cardioversion is used for some tachydysrhythmias, but would not be used for sinus tachycardia.