Chapter 25 Nursing Assessment and Care of Patients with Cardiac Dysrhythmias

A client started having chest pain 2 hours ago. After the health-care provider explains to the client that her cardiac troponin level is normal," the client states, "I'm so happy that I didn't have a heart attack." Which response by the nurse is the priority?

"The troponin level may be normal right now even if you have had a heart attack."- Elevates within 4 to 6 hours

A client recovering from cardiopulmonary bypass states, "I'm afraid something went wrong. I have tubes coming from my chest." Which response should the nurse make?

"The tubes drain remaining blood and fluid from the chest."

A client with heart failure has a resting heart rate of 70 beats per minute. The client's stroke volume is 60 mL/beat. The client weighs 220 pounds. Calculate the client's cardiac output per minute. Record your answer in liters (L). Enter the numeral only.

60 mL/beat multiplied by 70 beats/minute = 4,200 mL, or 4.2 L

The nurse provides postprocedural care for a client who underwent a transesophageal echocardiogram (TEE). Which action should the nurse take?

Determine whether gag reflex is intact

After a pacemaker placement, a client is ready for discharge. Which client statement indicates additional teaching is needed? Select all that apply.

"I can no longer use a cell phone or microwave." "Dizziness and chest pain are normal sensations." "Discharge at the incision site is a sign of healing."

The nurse reinforces preoperative teaching for a client scheduled for cardiac surgery in 1 hour. Which client statement most concerns the nurse?

"I stopped taking warfarin and aspirin 2 days ago."- Warfarin is often stopped 4 to 5 days preoperatively, and aspirin is often stopped 3 to 7 days preoperatively. The nurse should immediately notify the health-care provider.

A client reporting palpitations has multiple premature ventricular contractions (PVCs) on an electrocardiogram (ECG) tracing. Which client statement indicates teaching is effective?

"I will drink decaffeinated coffee."

The nurse is reinforcing discharge teaching for a client being prescribed metoprolol succinate. Which client statement indicates teaching is effective?

"I will move slowly when I get out of bed each morning."

A client is being discharged with Holter monitoring for 48 hours. Which client statement indicates teaching is effective?

"I will push the event button when I start having symptoms."

The nurse reinforces preoperative teaching for a client scheduled for cardiopulmonary bypass. Which client statement indicates teaching is effective? Select all that apply.

"I'll be given a blood thinner before surgery." "My heart will be stopped during surgery." "I need to cough and take deep breaths after surgery."

A client with atrial fibrillation is prescribed apixaban to reduce blood clot risk. Which client statement indicates teaching is successful?

"I'm glad that frequent blood monitoring will not be needed."

The nurse is reinforcing discharge teaching for a client with an implantable cardioverter defibrillator (ICD). Which client statement indicates that teaching is effective?

"It will feel like a kick in the chest when the ICD delivers a shock."

The nurse reinforces teaching for a client scheduled for a cardiac catheterization. Which client statement indicates that teaching is effective?

"My skin will become flushed and feel warm."

A client is scheduled to have a leadless pacemaker implanted. Which client statement indicates additional teaching is needed?

"The pacemaker will be inserted through an incision in my chest."

A client undergoing cardiopulmonary bypass is ready to come off the pump. Which medication should the nurse prepare to administer?

. Protamine sulfate- Prior to cardiopulmonary bypass, the client receives heparin to achieve a partial thromboplastin time (PTT) that is 5 to 6 times greater than normal. Immediately before coming off the pump, the client receives protamine sulfate to reverse the effects of heparin.

A client with a regular heart rhythm of 155 bpm reports dyspnea and angina. Which prescribed medications will the nurse expect to administer?

Adenosine

A client scheduled for an exercise stress test states, "I am not able to exercise." The nurse should assess the client for an allergy to which medication?

Adenosine- the nurse should anticipate that the health-care provider will order a medication stress test. During this test, a coronary vasodilator (adenosine or dipyridamole) is given to increase blood flow in healthy vessels and reveal unhealthy areas with reduced blood flow.

The nurse is assigned to care for four clients. Which client should the nurse see first?

An older adult client who has an S4 heart sound- S4 heart sound in an older adult client can occur with hypertension, coronary artery disease, and pulmonary stenosis.

A client who is asymptomatic has an irregularly irregular rhythm with no identifiable P waves. Which initial order should the nurse expect? Select all that apply.

Anticoagulant therapy Beta blocker Calcium channel blocker

A client's electrocardiogram (ECG) tracing shows ventricular fibrillation (VF). What action should the nurse make the first priority?

Apply external defibrillation

A client's electrocardiogram (ECG) tracing reveals ventricular fibrillation. Which action should the nurse take first?

Apply self-adhesive pads to the client's chest- Self-adhesive pads should be applied to the client's chest in preparation for immediate defibrillation.

The nurse is teaching a colleague about blood flow through the heart. Which teaching should the nurse include?

Blood flows from the right atrium through the tricuspid valve.

A client's sinoatrial (SA) and atrioventricular (AV) nodes have failed to fire. Which of these results should the nurse expect as the ventricles take over and initiate impulses? Select all that apply.

Change in level of consciousness Dyspnea

A 75-year-old client is undergoing an exercise stress test. Which symptom experienced by the client should cause the stress test be stopped? Select all that apply.

Complaints of chest pain Report of leg pain Electrocardiogram (ECG) changes Report of inability to exercise further -The test should be stopped when the client's peak heart rate is reached (client's age subtracted from 220). This client's peak heart rate is 145 bpm.

A client is scheduled for a cardiac catheterization in 1 hour. Which action should the nurse take? Select all that apply.

Ensure informed consent is obtained Report a client allergy to shellfish

The nurse is preparing to measure orthostatic blood pressures on a client who fell. In which order should the nurse perform the following actions?

Explain the procedure to the client Measure the blood pressure (BP) and HR in the supine position Measure the BP and HR in the sitting position Report abnormal findings to the health-care provider

A client is scheduled for a computed tomography (CT) scan with contrast to view blood vessels in the heart. Which laboratory tests should the nurse prepare to check?

Glomerular filtration rate and creatinine

. A client's electrocardiogram (ECG) tracing reveals a regular rhythm with a rate of 130 bpm. For which etiology should the nurse assess? Select all that apply.

Hypoxia Shock Dehydration Atropine use Anxiety

The nurse teaches a colleague about the effect of epinephrine on the heart. Which teaching should the nurse include? Select all that apply.

Increased cardiac output Increased force of cardiac contractions Increased heart rate

The nurse receives laboratory results on multiple clients. Which laboratory value should be immediately reported to the health-care provider?

Magnesium level 1.1 mg/dL

The nurse is caring for a client undergoing an angiography. After injection of the dye, the client states, "I have a hot, burning feeling." Which action by the nurse is the priority?

Monitor the client

A client scheduled for the next dose of atenolol has a blood pressure (BP) of 94/60 mm Hg. Which action should the nurse take next?

Notify the health-care provider

The nurse reviews a client's electrocardiogram (ECG) tracing.Which action should the nurse take? U wave on an ECG tracing

Obtain the client's potassium level- Hypokalemia can cause a U wave on an ECG tracing, so the client's potassium level should be checked.

A client returns to the unit immediately after a cardiac catheterization in which the femoral artery was used. Which action should the nurse take first?

Palpate peripheral pulses

The nurse is reviewing a client's electrocardiogram (ECG) tracing. Which of the following are characteristics of normal sinus rhythm (NSR)? for testing

QRS interval less than or equal to 0.10 seconds

The nurse assists with discharge planning of a client with cardiovascular disease. Which teaching should the nurse reinforce? Select all that apply.

Smoking reduces blood flow and can worsen symptoms. The top of elastic stockings should be 1 to 2 inches below the bottom of the kneecap. Avoid open flames when oxygen is in use.

A client has no palpable pulse and no waveform activity on an electrocardiogram (ECG) tracing. Which action should the nurse make the top priority?

Start chest compressions

A client with flutter waves on a recent electrocardiogram (ECG) reports syncopal episode, dyspnea, and angina. Which treatment should the nurse expect to be prescribed?

Synchronized cardioversion- flutter waves on the ECG tracing are indicative of atrial flutter. The client is symptomatic, so synchronized cardioversion should be used to immediately convert the rhythm to normal sinus rhythm.

A client's electrocardiogram (ECG) tracing reveals no relationship between P waves and QRS complexes. The client is confused, and blood pressure is 60/30 mmHg. Which order should the nurse expect?

Transcutaneous pacing- No relationship between P waves and QRS complexes describes complete heart block, which is a medical emergency. Immediate transcutaneous pacing is required because the client has signs of poor perfusion.

The nurse is caring for a client who is at risk for orthostatic hypotension. Which action should the nurse take?

Use a walking belt when ambulating the client

A client taking warfarin for atrial fibrillation has a critically high international normalized ratio (INR). Which order should the nurse expect?

Vitamin K

A client is scheduled to be placed on a cardiopulmonary bypass pump (CBP). Which of the following causes the nurse to intervene immediately

Warfarin is administered for anticoagulation-Heparin, not warfarin, is administered before the client goes on the CBP.