Nokea
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.
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The licensed practical nurse is setting up the room for a client arriving at the emergency department with ventricular arrhythmias. The nurse is most correct to place which of the following in the room for treatment?
- A. A suction machine
- B. A defibrillator
- C. Cardioversion equipment
- D. An ECG machine
Correct Answer: B
Rationale: The nurse is most correct to place a defibrillator close to the client room if not in the room. The nurse realizes that clients with ventricular arrhythmias are at a high risk for fatal heart arrhythmia and death. A suction machine is used to remove respiratory secretions. Cardioversion is used in a planned setting for atrial arrhythmias. An ECG machine records tracings of the heart for diagnostic purposes. Most clients with history of cardiac disorders have an ECG completed.
The nurse is working on a monitored unit assessing the cardiac monitor rhythms. Which waveform pattern needs attention first?
- A. Sustained asystole
- B. Supraventricular tachycardia
- C. Atrial fibrillation
- D. Ventricular fibrillation
Correct Answer: D
Rationale: Ventricular fibrillation is called the rhythm of a dying heart. It is the rhythm that needs attention first because there is no cardiac output, and it is an indication for CPR and immediate defibrillation. Sustained asystole either is from death, or the client is off of the cardiac monitor. Supraventricular tachycardia and atrial fibrillation are monitored and reported to the physician but not addressed first.
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 licensed practical nurse is co-assigned with a registered nurse in the care of a client admitted to the cardiac unit with chest pain. The licensed practical nurse is assessing the accuracy of the cardiac monitor, which notes a heart rate of 34 beats/minute. The client appears anxious and states not feeling well. The licensed practical nurse confirms the monitor reading. When consulting with the registered nurse, which of the following is anticipated?
- A. The registered nurse stating to administer digoxin
- B. The registered nurse administering atropine sulfate intravenously
- C. The registered nurse stating to hold all medication until the pulse rate returns to 60 beats/minute
- D. The registered nurse stating to administer all medications except those which are cardiotonics
Correct Answer: B
Rationale: The licensed practical nurse and registered nurse both identify that client's bradycardia. Atropine sulfate, a cholinergic blocking agent, is given intravenously (IV) to increase a dangerously slow heart rate. Lanoxin is not administered when the pulse rate falls under 60 beats/minute. It is dangerous to wait until the pulse rate increases without nursing intervention or administering additional medications until the imminent concern is addressed.
The nurse enters the client's room and finds the client pulseless and unresponsive. What would be the treatment of choice for this client?
- A. IV lidocaine
- B. Chemical cardioversion
- C. Immediate defibrillation
- D. Electric cardioversion
Correct Answer: C
Rationale: Defibrillation is used during pulseless ventricular tachycardia and ventricular fibrillation.