Nokea
The nurse is caring for clients on a telemetry unit. Which nursing consideration best represents concerns of altered rhythmic patterns of the heart?
- A. Altered patterns frequently turn into life-threatening arrhythmias.
- B. Altered patterns frequently produce neurological deficits.
- C. Altered patterns frequently cause a variety of home safety issues.
- D. Altered patterns frequently affect the heart's ability to pump blood effectively.
Correct Answer: D
Rationale: The best representation of a nursing concern related to a cardiac arrhythmia is the inability of the heart to fill the chambers and eject blood flow efficiently. Lack of an efficient method to circulate blood and bodily fluids produces a variety of complications such as tissue ischemia, pulmonary edema, hypotension, decreased urine output, and impaired level of consciousness. The other options can occur with arrhythmias, but the cause stemming from the altered pattern is the best answer.
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The nurse knows that a pacemaker is the treatment of choice for what cardiac arrhythmia?
- A. Supraventricular tachycardia
- B. Atrial flutter
- C. Ventricular fibrillation
- D. Complete heart block
Correct Answer: D
Rationale: Pacemaker insertion is the treatment for complete heart block. Treatments for supraventricular tachycardia are: Valsalva maneuver, unilateral carotid massage, immersion of face in ice water, administration of IV adenosine, cardioversion, and radiofrequency ablation. Cardioversion and drug therapy are used for the treatment of atrial flutter. Treatment for ventricular fibrillation is defibrillation preceded by or followed with epinephrine.
Which of the following medications does the nurse anticipate administering to a client preparing for cardioversion?
- A. Atropine
- B. Digoxin
- C. Enalapril
- D. Diazepam
Correct Answer: D
Rationale: Prior to cardioversion, cardiac medications are held, and the client is sedated with a medication such as diazepam.
The client has returned to the floor with a transthoracic pacemaker ready to be connected. The nurse knows that a transthoracic pacemaker is a temporary pacemaker used in what situation?
- A. Transthoracic pacemakers are used in a client who has had open heart surgery.
- B. Transthoracic pacemakers are used when a client has an MI.
- C. Transthoracic pacemakers are used after a coronary bypass graft surgery.
- D. Transthoracic pacemakers are used for tachyarrhythmias.
Correct Answer: A
Rationale: The leads of a transthoracic pacemaker are inserted during open heart surgery. They extend from the chest incision. If the client requires cardiac pacing during postoperative recovery, the leads are connected to a temporary pacing unit.
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.
The client has just been diagnosed with a arrhythmia. The client asks the nurse to explain normal sinus rhythm. What would the nurse explain is the characteristic of normal sinus rhythm?
- A. Heart rate between 60 and 150 beats/minute.
- B. Impulse travels to the atrioventricular (AV) node in 0.15 to 0.5 second.
- C. The ventricles depolarize in 0.5 second or less.
- D. The sinoatrial (SA) node initiates the impulse.
Correct Answer: D
Rationale: The characteristics of normal sinus rhythm are heart rate between 60 and 100 beats/minute, the SA node initiates the impulse, the impulse travels to the AV node in 0.12 to 0.2 second, the ventricles depolarize in 0.12 seconds or less, and each impulse occurs regularly.