Nokea
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.
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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.
The nurse administers IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block. Which of the following findings indicate that the medication has been effective?
- A. Increase in the patient's heart rate
- B. Decrease in premature contractions
- C. Increase in peripheral pulse volume
- D. Decrease in ventricular ectopic beats
Correct Answer: A
Rationale: Atropine will increase the heart rate and conduction through the AV node. Because the medication increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have ventricular ectopy or premature contractions.
The nurse obtains a monitor strip on a patient who has had a myocardial infarction and makes the following analysis. P wave not apparent, ventricular rate 162, R-R interval regular, P-R interval not measurable, and QRS complex wide and distorted, QRS duration 0.18 second. Which of the following cardiac rhythms should the nurse interpret from these findings?
- A. Atrial fibrillation
- B. Sinus tachycardia
- C. Ventricular fibrillation
- D. Ventricular tachycardia
Correct Answer: D
Rationale: The absence of P waves, wide QRS, rate >150, and the regularity of the rhythm indicate ventricular tachycardia. Atrial fibrillation is grossly irregular, has a narrow QRS configuration, and has fibrillatory atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration.
Which of the following actions should the nurse take when preparing for cardioversion of a patient with supraventricular tachycardia who is alert and has a blood pressure of 110/66 mm Hg?
- A. Turn the synchronizer switch to the 'off' position.
- B. Perform cardiopulmonary resuscitation (CPR) until the paddles are in correct position.
- C. Set the defibrillator/cardioverter energy to 300 J.
- D. Administer a sedative before cardioversion is implemented.
Correct Answer: D
Rationale: When a patient has a nonemergency cardioversion, sedation is used just before the procedure. The synchronizer switch is turned on for cardioversion. The initial level of joules for cardioversion is low (e.g., 50). CPR is not indicated for this patient.
The nurse is caring for a patient who was admitted with a myocardial infarction and experiences a 50-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute. Which of the following actions should the nurse take next?
- A. Notify the health care provider.
- B. Perform synchronized cardioversion.
- C. Administer the PRN IV lidocaine.
- D. Document the rhythm and monitor the patient.
Correct Answer: C
Rationale: The burst of sustained ventricular tachycardia indicates that the patient has significant ventricular irritability, and antidysrhythmic medication administration is needed to prevent further episodes and accelerate repolarization. The nurse should notify the health care provider after the medications are administered. Defibrillation is not indicated given that the patient is currently in a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation.