Nokea
The nurse is caring for a client with atrial fibrillation. Which of the following client findings requires immediate follow-up by the nurse?
- A. Irregular QRS complexes on telemetry reading
- B. Irregular peripheral pulse
- C. Reports of intermittent palpitations
- D. Blurred vision
Correct Answer: D
Rationale: Blurred vision may indicate a stroke, a serious complication of atrial fibrillation due to thromboembolism.
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The nurse in the emergency department (ED) is assessing a client who may have an acute myocardial infarction. Which of the following findings would support this diagnosis?
- A. U-waves
- B. T-wave inversion
- C. ST-segment elevation
- D. Prolonged PR-interval
Correct Answer: C
Rationale: ST-segment elevation on ECG is a hallmark of acute myocardial infarction, indicating myocardial ischemia.
The nurse is caring for a client receiving a continuous infusion of diltiazem who has the below tracing on the electrocardiogram (ECG). On assessment, the client has irregular peripheral pulses, an S3 heart sound, and 2+ pedal edema. The nurse should plan to take which priority action? See the image below.
- A. Assess the client for chest pain
- B. Perform a 12-lead electrocardiogram
- C. Stop the infusion
- D. Obtain an immediate troponin level
Correct Answer: C
Rationale: S3 and edema suggest heart failure, possibly exacerbated by diltiazem's negative inotropic effect. Stopping the infusion is the priority.
Which of the following would cause an increase in cardiac output? Select all that apply.
- A. Increased stroke volume
- B. Increased blood volume
- C. Increased sympathetic stimulation
- D. Administration of positive inotropic drugs
- E. Increased systemic vascular resistance (SVR)
Correct Answer: A,B,C,D
Rationale: Increased stroke volume directly increases cardiac output. Increased blood volume enhances preload, boosting output. C: Correct - Sympathetic stimulation increases heart rate and contractility. D: Correct - Positive inotropes enhance contractility, increasing output. E: Incorrect - Increased SVR increases afterload, reducing cardiac output.
The nurse is assessing a client with systolic heart failure. Which of the following would be an expected finding of right-sided heart failure?
- A. ascites
- B. tachypnea
- C. cough
- D. orthopnea
Correct Answer: A
Rationale: Right-sided heart failure causes systemic congestion, leading to ascites due to fluid accumulation in the abdomen.
The nurse observes the following tracing on the telemetry monitor. The nurse should take which initial action? See the image below.
- A. Assess the client's level of consciousness
- B. Prepare the client for immediate defibrillation
- C. Administer a dose of intravenous epinephrine
- D. Evaluate the client's cardiac lead placement
Correct Answer: B
Rationale: A life-threatening rhythm like ventricular fibrillation requires immediate defibrillation to restore normal rhythm.