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The nurse is caring for a patient who has a ST segment change that indicates an acute inferior wall myocardial infarction. Which of the following leads is best for monitoring the patient?
- A. I
- B. II
- C. V6
- D. MCL1
Correct Answer: B
Rationale: Lead II reflects the inferior area of the heart that is experiencing the ST segment changes and will best reflect any electrocardiographic changes that indicate further damage to the myocardium. The other leads do not reflect the inferior part of the myocardial wall and will not provide data about further ischemic changes.
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The nurse is caring for a patient whose cardiac monitor shows sinus rhythm, rate 60-70. The P-R interval is 0.18 seconds at 1:00 A.M., 0.20 seconds at 2:30 P.M., and 0.23 seconds at 4:00 P.M. Which of the following actions should the nurse take at this time?
- A. Prepare for possible temporary pacemaker insertion.
- B. Administer atropine sulphate 1 mg IV per agency protocol.
- C. Document the patient's rhythm and assess the patient's response to the rhythm.
- D. Hold the dose of metoprolol and call the health care provider.
Correct Answer: D
Rationale: The patient has progressive first-degree atrioventricular (AV) block, and the β-blocker should be held until discussing the medication with the health care provider. Documentation and assessment are appropriate but not fully adequate responses. The patient with first-degree AV block usually is asymptomatic, and a pacemaker is not indicated. Atropine is sometimes used for symptomatic bradycardia, but there is no indication that this patient is symptomatic.
When analyzing the waveforms of a patient's electrocardiogram (ECG), the nurse will need to investigate further upon assessing which of the following findings?
- A. T wave of 0.16 second
- B. P-R interval of 0.18 second
- C. Q-T interval of 0.34 second
- D. QRS interval of 0.14 second
Correct Answer: D
Rationale: Because the normal QRS interval is 0.04-0.10 seconds, the patient's QRS interval of 0.14 seconds indicates that the conduction through the ventricular conduction system is prolonged. The P-R interval, Q-T interval, and T-wave interval are within the normal range.
A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of how many beats/minute?
- A. 20-30
- B. 40-60
- C. 70-80
- D. 90-100
Correct Answer: B
Rationale: If the sinoatrial (SA) node fails to discharge, the atrioventricular (AV) node will automatically discharge at the normal rate of 40-60. The slower rates are typical of the bundle of His and the Purkinje system and may be seen with failure of both the SA and AV nodes to discharge. The normal SA node rate is 60-100 beats/minute.
The nurse is caring for a patient whose cardiac monitor shows sinus tachycardia, rate 102, and is apneic with no pulses palpable by the nurse. Which of the following actions should the nurse do first?
- A. Start CPR.
- B. Defibrillate.
- C. Administer atropine per hospital protocol.
- D. Give 100% oxygen per nonbreather mask.
Correct Answer: A
Rationale: The patient's clinical manifestations indicate pulseless electrical activity and the nurse should immediately start CPR. The other actions would not be of benefit to this patient.
The nurse is caring for a patient who requires defibrillation. In which order will the nurse accomplish the following steps?
- A. Turn the defibrillator on.
- B. Deliver the electrical charge.
- C. Select the appropriate energy level.
- D. Place the paddles on the patient's chest.
- E. Check the location of other personnel and call out 'all clear.'
Correct Answer: A,C,D,E,B
Rationale: This order will result in rapid defibrillation without endangering hospital personnel. The sequence ensures the defibrillator is powered, set to the correct energy level, paddles are correctly placed, safety is confirmed, and then the charge is delivered.