Nokea
A patient has returned to the cardiac care unit after having a permanent pacemaker implantation. For which potential complication should the nurse most closely assess this patient?
- A. Chest pain
- B. Bleeding at the implantation site
- C. Malignant hyperthermia
- D. Bradycardia
Correct Answer: B
Rationale: Bleeding, hematomas, local infections, perforation of the myocardium, and tachycardia are complications of pacemaker implantations. The nurse should monitor for chest pain and bradycardia, but bleeding is a more common immediate complication. Malignant hyperthermia is unlikely because it is a response to anesthesia administration.
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The nurse is caring for an adult patient who has gone into ventricular fibrillation. When assisting with defibrillating the patient, what must the nurse do?
- A. Maintain firm contact between paddles and patient skin.
- B. Apply a layer of water as a conducting agent.
- C. Call all clear once before discharging the defibrillator.
- D. Ensure the defibrillator is in the sync mode.
Correct Answer: A
Rationale: When defibrillating an adult patient, the nurse should maintain good contact between the paddles and the patients skin to prevent arcing, apply an appropriate conducting agent (not water) between the skin and the paddles, and ensure the defibrillator is in the nonsync mode. Clear should be called three times before discharging the paddles.
The ED nurse is caring for a patient who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform?
- A. Place gel pads over the apex and posterior chest for better conduction.
- B. Ensure no one is touching the patient at the time shock is delivered.
- C. Continue to ventilate the patient via endotracheal tube during the procedure.
- D. Allow at least 3 minutes between shocks.
Correct Answer: B
Rationale: In external defibrillation, both paddles may be placed on the front of the chest, which is the standard paddle placement. Whether using pads or paddles, the nurse must observe two safety measures. First, maintain good contact between the pads or paddles and the patients skin to prevent leaking. Second, ensure that no one is in contact with the patient or with anything that is touching the patient when the defibrillator is discharged, to minimize the chance that electrical current will be conducted to anyone other than the patient. Ventilation should be stopped during defibrillation.
The nurse is caring for a patient who has just undergone catheter ablation therapy. The nurse in the stepdown unit should prioritize what assessment?
- A. Cardiac monitoring
- B. Monitoring the implanted device signal
- C. Pain assessment
- D. Monitoring the patients level of consciousness (LOC)
Correct Answer: A
Rationale: Following catheter ablation therapy, the patient is closely monitored to ensure the dysrhythmia does not reemerge. This is a priority over monitoring of LOC and pain, although these are valid and important assessments. Ablation does not involve the implantation of a device.
A group of nurses are participating in orientation to a telemetry unit. What should the staff educator tell this class about ST segments?
- A. They are the part of an ECG that reflects systole.
- B. They are the part of an ECG used to calculate ventricular rate and rhythm.
- C. They are the part of an ECG that reflects the time from ventricular depolarization through repolarization.
- D. They are the part of an ECG that represents early ventricular repolarization.
Correct Answer: D
Rationale: ST segment is the part of an ECG that reflects the end of the QRS complex to the beginning of the T wave. The part of an ECG that reflects repolarization of the ventricles is the T wave. The part of an ECG used to calculate ventricular rate and rhythm is the RR interval. The part of an ECG that reflects the time from ventricular depolarization through repolarization is the QT interval.
A nurse is caring for a patient who is exhibiting ventricular tachycardia (VT). Because the patient is pulseless, the nurse should prepare for what intervention?
- A. Defibrillation
- B. ECG monitoring
- C. Implantation of a cardioverter defibrillator
- D. Angioplasty
Correct Answer: A
Rationale: Any type of VT in a patient who is unconscious and without a pulse is treated in the same manner as ventricular fibrillation: Immediate defibrillation is the action of choice. ECG monitoring is appropriate, but this is an assessment, not an intervention, and will not resolve the problem. An ICD and angioplasty do not address the dysrhythmia.