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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.
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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.
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.
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.
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.