Nokea
The nurse is caring for a client with an arrhythmia. While assessing the data in the history of the chart, the nurse anticipates the cause of the arrhythmia to be which of the following?
- A. Peripheral vascular disease
- B. Ischemic heart disease
- C. Aortic stenosis
- D. Atherosclerotic heart disease
Correct Answer: B
Rationale: The nurse realizes that the most common cause of arrhythmias is ischemic heart disease. When the heart does not obtain sufficient blood to meet demands, the heart works harder to circulate body fluids and becomes inefficient in the process. Problems with the peripheral vessels, narrowing of the aorta and plaque build-up in the vessels may be a component of the disease process but not the best answer.
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For which client does the nurse anticipate cardioversion as a possible medical treatment?
- A. A new myocardial infarction client
- B. A client with poor kidney perfusion
- C. A client with third-degree heart block
- D. A client with atrial arrhythmias
Correct Answer: D
Rationale: The nurse is correct to identify a client with atrial arrhythmias as a candidate for cardioversion. The goal of cardioversion is to restore the normal pacemaker of the heart, as well as normal conduction. A client with a myocardial infarction has tissue damage. The client with poor perfusion has circulation problems. The client with heart block has an impairment in the conduction system and may require a pacemaker.
The nurse is caring for a client on the cardiac unit. The licensed practical nurse on the previous shift reported the following vital signs/assessment information: temperature, 100.6?°F; pulse, 56 beats/minute; respirations 24 breaths/minute; blood pressure, 116/60 mm Hg; pulse oximetry reading, 92%; and with 2+ edema noted in the lower extremities. Prior to 9 AM antiarrhythmic medication administration, which of the following will the nurse reassess?
- A. Temperature
- B. Pulse
- C. Blood pressure
- D. Edema
Correct Answer: B
Rationale: Of the vital signs noted, the pulse rate is found to be abnormal, below 60 beats/minute. Before administering an antiarrhythmic medication, which often slows the heart rate further, the pulse rate would be reassessed, and a rate of 60 beats/minute would need to be obtained.
The nurse is caring for a client who has premature ventricular contractions. What sign or symptom is observed in this client?
- A. Fluttering
- B. Nausea
- C. Hypotension
- D. Fever
Correct Answer: A
Rationale: Premature ventricular contractions usually cause a flip-flop sensation in the chest, sometimes described as 'fluttering.' Associated signs and symptoms include pallor, nervousness, sweating, and faintness. Symptoms of premature ventricular contractions are not nausea, hypotension, and fever.
A client presents to the emergency department via ambulance with a heart rate of 210 beats/minute and a sawtooth waveform pattern per cardiac monitor. The nurse is most correct to alert the medical team of the presence of a client with which disorder?
- A. Asystole
- B. Premature ventricular contraction
- C. Atrial flutter
- D. Ventricular fibrillation
Correct Answer: C
Rationale: Atrial flutter is a disorder in which a single atrial impulse outside the SA node causes the atria to contract at an exceedingly rapid rate. The atrioventricular (AV) node conducts only some impulses to the ventricle, resulting in a ventricular rate slower than the atrial rate, thus forming a sawtooth pattern on the heart monitor. Asystole is the absence of cardiac function and can indicate death. Premature ventricular contraction indicates an early electric impulse and does not necessarily produce an exceedingly rapid heart rate. Ventricular fibrillation is the inefficient quivering of the ventricles and indicative of a dying heart.
The nurse is preparing to defibrillate a client with no breathing or pulse. Which nursing action precedes the nurse pressing the discharge button?
- A. Placing gel on the chest
- B. Checking the ECG rhythm
- C. Shouting, 'All clear'
- D. Stating, 'Charging'
Correct Answer: C
Rationale: Preceding pressing the discharge button, the nurse shouts 'All clear' to ensure that no one is in contact with the client. The other options are correct but not the nursing action immediately preceding.