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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.
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New nurses on the telemetry unit have been paired with preceptors. One new nurse asks her preceptor to explain depolarization. What would be the best answer by the preceptor?
- A. Depolarization is the mechanical contraction of the heart muscles.
- B. Depolarization is the electrical stimulation of the heart muscles.
- C. Depolarization is the electrical relaxation of the heart muscles.
- D. Depolarization is the mechanical relaxation of the heart muscles.
Correct Answer: B
Rationale: The electrical stimulation of the heart is called depolarization, and the mechanical contraction is called systole. Electrical relaxation is called repolarization, and mechanical relaxation is called diastole.
A patient converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin and Cardizem are given. The nurse caring for the patient understands that the main goal of treatment is what?
- A. Decrease SA node conduction
- B. Control ventricular heart rate
- C. Improve oxygenation
- D. Maintain anticoagulation
Correct Answer: B
Rationale: Treatment for atrial fibrillation is to terminate the rhythm or to control ventricular rate. This is a priority because it directly affects cardiac output. A rapid ventricular response reduces the time for ventricular filling, resulting in a smaller stroke volume. Control of rhythm is the initial treatment of choice, followed by anticoagulation with heparin and then Coumadin.
The nurse is planning discharge teaching for a patient with a newly inserted permanent pacemaker. What is the priority teaching point for this patient?
- A. Start lifting the arm above the shoulder right away to prevent chest wall adhesion.
- B. Avoid cooking with a microwave oven.
- C. Avoid exposure to high-voltage electrical generators.
- D. Avoid walking through store and library antitheft devices.
Correct Answer: C
Rationale: High-output electrical generators can reprogram pacemakers and should be avoided. Recent pacemaker technology allows patients to safely use most household electronic appliances and devices (e.g., microwave ovens). The affected arm should not be raised above the shoulder for 1 week following placement of the pacemaker. Antitheft alarms may be triggered so patients should be taught to walk through them quickly and avoid standing in or near these devices. These alarms generally do not interfere with pacemaker function.
The nurse is caring for a patient who is in the recovery room following the implantation of an ICD. The patient has developed ventricular tachycardia (VT). What should the nurse assess and document?
- A. ECG to compare time of onset of VT and onset of devices shock
- B. ECG so physician can see what type of dysrhythmia the patient has
- C. Patients level of consciousness (LOC) at the time of the dysrhythmia
- D. Patients activity at time of dysrhythmia
Correct Answer: A
Rationale: If the patient has an ICD implanted and develops VT or ventricular fibrillation, the ECG should be recorded to note the time between the onset of the dysrhythmia and the onset of the devices shock or antitachycardia pacing. This is a priority over LOC or activity at the time of onset.
The nurse caring for a patient whose sudden onset of sinus bradycardia is not responding adequately to atropine. What might be the treatment of choice for this patient?
- A. Implanted pacemaker
- B. Trancutaneous pacemaker
- C. ICD
- D. Asynchronous defibrillator
Correct Answer: B
Rationale: If a patient suddenly develops a bradycardia, is symptomatic but has a pulse, and is unresponsive to atropine, emergency pacing may be started with transcutaneous pacing, which most defibrillators are now equipped to perform. An implanted pacemaker is not a time-appropriate option. An asynchronous defibrillator or ICD would not provide relief.