Nokea
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.
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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 interpreting an ECG strip to determine whether there is a delay in impulse conduction above the ventricles. Which of the following components of an ECG strip should the nurse measure?
- A. P-wave
- B. P-R interval
- C. Q-T interval
- D. QRS complex
Correct Answer: B
Rationale: The P-R interval represents depolarization of the atria, atrioventricular (AV) node, bundle of His, bundle branches, and the Purkinje fibres. The QRS represents ventricular depolarization. The Q-T interval represents depolarization and repolarization of the entire conduction system.
The nurse notes that a patient's cardiac monitor shows that every other beat is earlier than expected, has no P wave, and has a QRS complex with a wide and bizarre shape. How should the nurse document the rhythm?
- A. Ventricular couplets
- B. Ventricular bigeminy
- C. Ventricular R-on-T phenomenon
- D. Ventricular multifocal contractions
Correct Answer: B
Rationale: Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking. Pairs of wide QRS complexes are described as couplets. There is no indication that the premature ventricular contractions (PVCs) are multifocal or that the R-on-T phenomenon is occurring.
The nurse is caring for a patient with dilated cardiomyopathy who has an atrial fibrillation that has been unresponsive to drug therapy for several days. Which of the following actions should the nurse anticipate?
- A. Electrical cardioversion
- B. IV adenosine
- C. Anticoagulant therapy with warfarin
- D. Insertion of an implantable cardioverter-defibrillator
Correct Answer: C
Rationale: Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant treatment for 3 weeks before attempting cardioversion; this is done to prevent embolization of clots from the atria. Adenosine is not used to treat atrial fibrillation. Cardioversion may be done after several weeks of warfarin therapy. ICDs are used for patients with recurrent ventricular fibrillation.
Which of the following information will the nurse include when teaching a patient who is scheduled to have a permanent pacemaker inserted for treatment of chronic atrial fibrillation with slow ventricular response?
- A. The pacemaker prevents or minimizes ventricular irritability.
- B. The pacemaker paces the atria at rates up to 500 impulses/minute.
- C. The pacemaker discharges if ventricular fibrillation and cardiac arrest occur.
- D. The pacemaker stimulates a heartbeat if the patient's heart rate drops too low.
Correct Answer: D
Rationale: The permanent pacemaker will discharge when the ventricular rate drops below the set rate. The pacemaker will not decrease ventricular irritability or discharge if the patient develops ventricular fibrillation. Since the patient has a slow ventricular rate, overdrive pacing will not be used.