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The nurse is writing a plan of care for a patient with a cardiac dysrhythmia. What would be the most appropriate goal for the patient?
- A. Maintain a resting heart rate below 70 bpm.
- B. Maintain adequate control of chest pain.
- C. Maintain adequate cardiac output.
- D. Maintain normal cardiac structure.
Correct Answer: C
Rationale: For patient safety, the most appropriate goal is to maintain cardiac output to prevent worsening complications as a result of decreased cardiac output. A resting rate of less than 70 bpm is not appropriate for every patient. Chest pain is more closely associated with acute coronary syndrome than with dysrhythmias. Nursing actions cannot normally influence the physical structure of the heart.
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The nursing educator is presenting a case study of an adult patient who has abnormal ventricular depolarization. This pathologic change would be most evident in what component of the ECG?
- A. P wave
- B. T wave
- C. QRS complex
- D. U wave
Correct Answer: C
Rationale: The QRS complex represents the depolarization of the ventricles and, as such, the electrical activity of that ventricle.
The nurse is caring for a patient who is in the recovery room following the implantation of an ICD. The patient has developed ventricular tachycardia (VT). What should the nurse assess and document?
- A. ECG to compare time of onset of VT and onset of devices shock
- B. ECG so physician can see what type of dysrhythmia the patient has
- C. Patients level of consciousness (LOC) at the time of the dysrhythmia
- D. Patients activity at time of dysrhythmia
Correct Answer: A
Rationale: If the patient has an ICD implanted and develops VT or ventricular fibrillation, the ECG should be recorded to note the time between the onset of the dysrhythmia and the onset of the devices shock or antitachycardia pacing. This is a priority over LOC or activity at the time of onset.
The nurse is providing care to a patient who has just undergone an electrophysiologic (EP) study. The patient states that she is nervous about things going wrong during the procedure. What is the nurses best response?
- A. This is basically a risk-free procedure.
- B. Thousands of patients undergo EP every year.
- C. Remember that this is a step that will bring you closer to enjoying good health.
- D. The whole team will be monitoring you very closely for the entire procedure.
Correct Answer: D
Rationale: Patients who are to undergo an EP study may be anxious about the procedure and its outcome. A detailed discussion involving the patient, the family, and the electrophysiologist usually occurs to ensure that the patient can give informed consent and to reduce the patients anxiety about the procedure. It is inaccurate to state that EP is risk-free and stating that it is common does not necessarily relieve the patients anxiety. Characterizing EP as a step toward good health does not directly address the patients anxiety.
The nurse is caring for a patient who has just undergone catheter ablation therapy. The nurse in the stepdown unit should prioritize what assessment?
- A. Cardiac monitoring
- B. Monitoring the implanted device signal
- C. Pain assessment
- D. Monitoring the patients level of consciousness (LOC)
Correct Answer: A
Rationale: Following catheter ablation therapy, the patient is closely monitored to ensure the dysrhythmia does not reemerge. This is a priority over monitoring of LOC and pain, although these are valid and important assessments. Ablation does not involve the implantation of a device.
A patient is scheduled for catheter ablation therapy. When describing this procedure to the patients family, the nurse should address what aspect of the treatment?
- A. Resetting of the hearts contractility
- B. Destruction of specific cardiac cells
- C. Correction of structural cardiac abnormalities
- D. Clearance of partially occluded coronary arteries
Correct Answer: B
Rationale: Catheter ablation destroys specific cells that are the cause or central conduction route of a tachydysrhythmia. It does not reset the hearts contractility and it does not address structural or vascular abnormalities.