Nokea
The nurse is preparing to defibrillate a client with no breathing or pulse. Which nursing action precedes the nurse pressing the discharge button?
- A. Placing gel on the chest
- B. Checking the ECG rhythm
- C. Shouting, 'All clear'
- D. Stating, 'Charging'
Correct Answer: C
Rationale: Preceding pressing the discharge button, the nurse shouts 'All clear' to ensure that no one is in contact with the client. The other options are correct but not the nursing action immediately preceding.
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The nurse reports to the cardiac nurse practitioner that the client is consistently exhibiting a normal sinus rhythm. What characteristic(s) has the nurse noted to determine the rhythm is normal? Select all that apply.
- A. Heart rate 106 beats/minute
- B. Upright P wave before each QRS complex
- C. Each impulse occurs regularly.
- D. Impulse travels to the SA node from the AV node.
- E. Wave ends with a T wave
- F. Ventricles depolarize in the QRS complex.
Correct Answer: B,C,E,F
Rationale: Characteristics of normal sinus rhythm include a regular impulse originating in the SA node and with impulses continuing to the AV node. There is a P wave initially with depolarization at the QRS complex and ending with a T wave. Normal heart rate is between 60 to 100 beats/minute.
The nurse is caring for a client with an arrhythmia. While assessing the data in the history of the chart, the nurse anticipates the cause of the arrhythmia to be which of the following?
- A. Peripheral vascular disease
- B. Ischemic heart disease
- C. Aortic stenosis
- D. Atherosclerotic heart disease
Correct Answer: B
Rationale: The nurse realizes that the most common cause of arrhythmias is ischemic heart disease. When the heart does not obtain sufficient blood to meet demands, the heart works harder to circulate body fluids and becomes inefficient in the process. Problems with the peripheral vessels, narrowing of the aorta and plaque build-up in the vessels may be a component of the disease process but not the best answer.
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.
The nurse is caring for a client on the cardiac unit. The licensed practical nurse on the previous shift reported the following vital signs/assessment information: temperature, 100.6?°F; pulse, 56 beats/minute; respirations 24 breaths/minute; blood pressure, 116/60 mm Hg; pulse oximetry reading, 92%; and with 2+ edema noted in the lower extremities. Prior to 9 AM antiarrhythmic medication administration, which of the following will the nurse reassess?
- A. Temperature
- B. Pulse
- C. Blood pressure
- D. Edema
Correct Answer: B
Rationale: Of the vital signs noted, the pulse rate is found to be abnormal, below 60 beats/minute. Before administering an antiarrhythmic medication, which often slows the heart rate further, the pulse rate would be reassessed, and a rate of 60 beats/minute would need to be obtained.
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.