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The nurse assessing a cardiac monitor notes that the cardiac complexes each have a P wave followed by a QRS and a T. The rate is 120. The nurse recognizes this as which arrhythmia?
- A. sinus bradycardia.
- B. atrial fibrillation.
- C. sinus tachycardia.
- D. ventricular tachycardia.
Correct Answer: C
Rationale: Sinus tachycardia has a P wave followed by the QRS and the T. All the components of the complex are present and in the correct order, but the rate is over 100 beats/min.
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The nurse caring for a patient recovering from a myocardial infarct who is on remote telemetry recognizes the need for added instruction when the patient makes which statement?
- A. I can ambulate in the hallway with this gadget on.'
- B. I always take off the telemetry device when I shower.'
- C. My EKG is being watched by one of the nurses in CCU on the home unit.'
- D. I am able to sleep just fine with this device on.'
Correct Answer: B
Rationale: Remote telemetry allows the patient to be on a separate unit, but be monitored in a central location. The patients can be ambulatory and can sleep with the monitor on. They should not remove the monitor to shower.
The nurse clarifies that which is the area of the heart that normally initiates electrical impulses?
- A. left ventricle.
- B. atrioventricular (AV) node.
- C. sinoatrial (SA) node.
- D. bundle of His.
Correct Answer: C
Rationale: The SA node is the master pacemaker of the heart.
When assessing a patient with a possible myocardial infarction (MI), which sign or symptom should the nurse assess for?
- A. Pain radiating to left arm and jaw
- B. Visual Hallucinations
- C. Pallor
- D. Diaphoresis
- E. Apprehension
- F. Dyspnea
Correct Answer: A,C,D,E,F
Rationale: Pain radiating to the left arm and jaw, pallor, diaphoresis, apprehension/anxiety and dyspnea are signs and symptoms present in patients with an MI.
The life support system that uses special techniques, ventilation equipment, and therapies for emergency situations is
Correct Answer: advanced cardiac life support (ACLS)
Rationale: ACLS is a life support system that uses special techniques, ventilation equipment, and therapies for emergency situations.
The cardiac marker rises 3 hours after a myocardial infarct and measures myocardial contractile protein.
Correct Answer: troponin I
Rationale: Troponin I is a serum cardiac marker that rises 3 hours after an MI and can measure myocardial contractile tissue. Troponin I is not affected by skeletal muscle injury as is troponin T.