Nokea
The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below. After calling for assistance and a defibrillator, which action should the nurse take next?
- A. Perform a pericardial thump
- B. Initiate cardiopulmonary resuscitation (CPR)
- C. Start an 8-gauge intravenous line
- D. Ask the clients family about code status
Correct Answer: B
Rationale: The client's rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. The pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The client's code status should already be known by the nurse prior to the event.
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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 performs an admission assessment on a 75-year-old client with multiple chronic diseases. The clients blood pressure is 155/75 mm Hg and oxygen saturation is [missing data].
- A. Assess current medications
- B. Check oxygen saturation
- C. Evaluate dietary habits
- D. Review immunization history
Correct Answer: A
Rationale: The client is on multiple medications that can interact with each other. The nurse should assess the client's current medications first to identify potential interactions that could contribute to cardiac dysrhythmias or other complications.
A nurse assesses a clients electrocardiogram (ECG) and observes the reading shown below: How should the nurse document this clients ECG strip?
- A. Ventricular rhythm
- B. Ventricular fibrillation
- C. Sinus rhythm with premature atrial contractions (PACs)
- D. Sinus rhythm with premature ventricular contractions (PVCs)
Correct Answer: D
Rationale: Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometimes precedes atrial depolarization. Ventricular dysrhythmias and ventricular fibrillation would not have sinus beats present. Premature atrial contractions are atrial contractions initiated from another region of the atria before the sinus node initiates atrial depolarization.
A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition?
- A. Sinus tachycardia
- B. Speech alterations
- C. Fatigue
- D. Dyspnea with activity
Correct Answer: B
Rationale: Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.
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.