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When planning the care of a patient with an implanted pacemaker, what assessment should the nurse prioritize?
- A. Core body temperature
- B. Heart rate and rhythm
- C. Blood pressure
- D. Oxygen saturation level
Correct Answer: B
Rationale: For patients with pacemakers, close monitoring of the heart rate and rhythm is a priority, even though each of the other listed vital signs must be assessed.
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Following cardiac resuscitation, a patient has been placed in a state of mild hypothermia before being transferred to the cardiac intensive care unit. The nurses assessment reveals that the patient is experiencing neuromuscular paralysis. How should the nurse best respond?
- A. Administer hypertonic IV solution.
- B. Administer a bolus of warmed normal saline.
- C. Reassess the patient in 15 minutes.
- D. Document this as an expected assessment finding.
Correct Answer: D
Rationale: The nurse caring for a patient with hypothermia (passive or induced) needs to monitor for appropriate level of cooling, sedation, and neuromuscular paralysis to prevent seizures; myoclonus; and shivering. Neuromuscular paralysis is an expected finding and does not necessitate further interventions.
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.
The ED nurse is caring for a patient who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform?
- A. Place gel pads over the apex and posterior chest for better conduction.
- B. Ensure no one is touching the patient at the time shock is delivered.
- C. Continue to ventilate the patient via endotracheal tube during the procedure.
- D. Allow at least 3 minutes between shocks.
Correct Answer: B
Rationale: In external defibrillation, both paddles may be placed on the front of the chest, which is the standard paddle placement. Whether using pads or paddles, the nurse must observe two safety measures. First, maintain good contact between the pads or paddles and the patients skin to prevent leaking. Second, ensure that no one is in contact with the patient or with anything that is touching the patient when the defibrillator is discharged, to minimize the chance that electrical current will be conducted to anyone other than the patient. Ventilation should be stopped during defibrillation.
The nurse is caring for a patient who has had an ECG. The nurse notes that leads I, II, and III differ from one another on the cardiac rhythm strip. How should the nurse best respond?
- A. Recognize that the view of the electrical current changes in relation to the lead placement.
- B. Recognize that the electrophysiological conduction of the heart differs with lead placement.
- C. Inform the technician that the ECG equipment has malfunctioned.
- D. Inform the physician that the patient is experiencing a new onset of dysrhythmia.
Correct Answer: A
Rationale: Each lead offers a different reference point to view the electrical activity of the heart. The lead displays the configuration of electrical activity of the heart. Differences between leads are not necessarily attributable to equipment malfunction or dysrhythmias.
New nurses on the telemetry unit have been paired with preceptors. One new nurse asks her preceptor to explain depolarization. What would be the best answer by the preceptor?
- A. Depolarization is the mechanical contraction of the heart muscles.
- B. Depolarization is the electrical stimulation of the heart muscles.
- C. Depolarization is the electrical relaxation of the heart muscles.
- D. Depolarization is the mechanical relaxation of the heart muscles.
Correct Answer: B
Rationale: The electrical stimulation of the heart is called depolarization, and the mechanical contraction is called systole. Electrical relaxation is called repolarization, and mechanical relaxation is called diastole.