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The nurse is assisting with a synchronized cardioversion on a client in atrial fibrillation. When the machine is activated, there is a pause. What action should the nurse take?
- A. Wait until the machine discharges.
- B. Shout 'all clear' and don’t touch the bed.
- C. Make sure the client is all right.
- D. Increase the joules and redischarge.
Correct Answer: A
Rationale: A pause in synchronized cardioversion is normal as the machine syncs with the QRS complex; wait for discharge (A). 'All clear' (B) is for defibrillation, checking client (C) is premature, and increasing joules (D) is incorrect.
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The client has just had a pericardiocentesis. Which interventions should the nurse implement? Select all that apply.
- A. Monitor vital signs every 15 minutes for the first hour.
- B. Assess the client's heart and lung sounds.
- C. Record the amount of fluid removed as output.
- D. Evaluate the client's cardiac rhythm.
- E. Keep the client in the supine position.
Correct Answer: A,B,C,D
Rationale: Post-pericardiocentesis, monitor vital signs (A), heart/lung sounds (B), fluid output (C), and rhythm (D) to detect complications. Supine position (E) is not required; semi-Fowler’s is preferred.
The client who has just had a percutaneous balloon valvuloplasty is in the recovery room. Which intervention should the Post Anesthesia Care Unit nurse implement?
- A. Assess the client's chest tube output.
- B. Monitor the client's chest dressing.
- C. Evaluate the client's endotracheal (ET) lip line.
- D. Keep the client's affected leg straight.
Correct Answer: D
Rationale: Valvuloplasty is performed via femoral access, so keeping the leg straight (D) prevents bleeding. Chest tubes (A), dressings (B), and ET tubes (C) are not involved.
According to the 2010 American Heart Association Guidelines, which steps of cardiopulmonary resuscitation for an adult suffering from a cardiac arrest should the nurse teach individuals in the community? Rank in order of performance.
- A. Place the hands over the lower half of the sternum.
- B. Look for obvious signs of breathing.
- C. Begin compressions at a ratio of 30:2.
- D. Call for an AED immediately.
- E. Position the victim on the back.
Correct Answer: E,B,D,A,C
Rationale: 1. Position on back (E): Ensures a firm surface. 2. Look for breathing (B): Confirms arrest. 3. Call for AED (D): Activates help. 4. Place hands on sternum (A): Prepares for compressions. 5. Begin compressions 30:2 (C): Starts CPR.
Which client would the nurse suspect of having a mitral valve prolapse?
- A. A 60-year-old female with congestive heart failure.
- B. A 23-year-old male with Marfan's syndrome.
- C. An 80-year-old male with atrial fibrillation.
- D. A 33-year-old female with Down syndrome.
Correct Answer: B
Rationale: Mitral valve prolapse is common in Marfan’s syndrome (B) due to connective tissue defects. CHF (A), atrial fibrillation (C), and Down syndrome (D) are not strongly associated.
The client's telemetry reading shows a P wave before each QRS complex and the rate is 78. Which action should the nurse implement?
- A. Document this as normal sinus rhythm.
- B. Request a 12-lead electrocardiogram.
- C. Prepare to administer the cardiotonic digoxin PO.
- D. Assess the client's cardiac enzymes.
Correct Answer: A
Rationale: P wave before QRS at rate 78 (A) is normal sinus rhythm, requiring documentation. ECG (B), digoxin (C), and enzymes (D) are unnecessary.