AC Exam 4
How would the nurse best interpret the electrocardiogram (ECG) of a younger athletic client which shows sinus bradycardia with a rate of 54 BPM?
The sinus bradycardia provides an adequate stroke volume that is associated with cardiac conditioning.
based on the etiology and main cause of HF, the nurse knows that which pt has the greatest need for health promotion measures to prevent HF
pt with HTN
Which client assessment takes priority when the nurse begins his or her shift?
-Client with atrial fibrillation and sustained rapid ventricular response
Which safety precaution must be taken before defibrillating a client with ventricular fibrillation (VF)
-Command all health care team members to stand clear of the client's bed
What is the first step when the nurse analyzes a client's ECG rhythm strip?
-Determine the heart rate
Which questions would the nurse use to assess a client's P wave on an ECG rhythm strip?
-Do all P waves look similar? -Are P waves present? -Are P waves occurring regularly? -Are P waves smooth, rounded, and upright?
Which nursing actions have priority when a client with acute supraventricular tachycardia (SVT) is to be administered adenosine by the health care provider?
-Ensure that emergency equipment is at the bedside -Follow the drug injection with a normal saline bolus -Monitor the client for bradycardia, nausea, and vomiting
What does the nurse determine is the client's heart rate when assessing a 6-second telemetry ECG strip with five QRS complexes?
-50 BPM, bradycardia
Which normal heart rates does the nurse expect to be initiated by the primary pacemaker of the heart (SA Node) in clients when the heart rate is regular?
-62 BPM -74 BPM -86 BPM -98 BPM
Which ECG strip pattern is evidence to the nurse that a client's temporary transvenous pacemaker has successfully depolarized the ventricles
-A pacer spike followed by a QRS complex
Which actions are essential nursing care for a client immediately after elective cardioversion?
-Administer oxygen -Assess vital signs and level of consciousness -Monitor for dysrhythmias -Maintain an open airway
What is the priority action for the nurse when the monitor technician states that a client's telemetry monitor shows a rhythm that appears as a wandering or fuzzy baseline?
-Assess the client to differentiation artifact from an actual lethal rhythm
Which would be the best method for the nurse to confirm a report from the monitor technician about a change in a monitored client's heart rate?
-Assess the client's heart rate directly by checking the apical pulse
Which are nursing responsibilities for the care of a client with a newly implanted permanent pacemaker?
-Assess the implantation site for bleeding, swelling, redness, tenderness, or infection -Monitor the ECG rhythm strip to ensure that the pacemaker is working correctly -Assess that the implantation site dressing is clean and dry -Teach the client about initial activity restrictions
Which criteria support the nurse's assessment that a client's ECG rhythm strip shows a normal sinus rhythm (NSR)?
-Atrial and ventricular rates are regular -P waves are present before every QRS complex -QRS duration is consistent at 0.08 second -Atrial and ventricular rates are 82 bpm
After calling for help, when the nurse finds a client in his or her room without a pulse, apneic and unconscious, which action should be taken next?
-Begin cardiac compressions
Which causes would the nurse recognize as leading to increased atrial irritability and premature atrial contractions (PACs) in a client's myocardium?
-Caffeine intake -Anxiety -Stress in life -Infection
Which actions would the nurse take when the monitor technician states that a client's telemetry ECG signal transmission is not very clear?
-Ensure that the gel on each electrode is moist and fresh -Clean the skin and clip hairs if necessary -Make sure that the skin is free of lotion or any other substance -Check to be sure that electrodes are not placed over scar tissue
Which signs and symptoms would the nurse expect to assess in a client with sinus tachycardia?
-Fatigue -SOB -Decreased oxygen saturation -Decreased blood pressure -Anginal pain
To best perform a 12-lead ECG on a client, how does the nurse place the leads on the client?
-Four leads are placed on the limbs and six are placed on the chest.
Which risk factors for atrial fibrillation would the nurse monitor for in a client?
-Hypertension -Diabetes mellitus -Excessive alcohol intake -Mitral valve disease
Which procedure would the nurse provide teaching about to a client who has chronic atrial fibrillation and is at increased risk for a stroke, but is not a candidate for anticoagulation?
-Left atrial appendage (LAA) occlusion
Which descriptions are characteristics of Class III antidysrhythmic drugs?
-Lengthen absolute refractory period -Include bradycardia as a side effect for some drugs -Prolong repolarization
Which condition is indicated when the nurse notes ST segment elevation or one to two dsmall blocks on a client's ECG
-Myocardial injury or ischemia
When would the telemetry unit nurse use temporary transcutaneous pacing for a client?
-Only as a temporary emergency measure until invasive pacing method can be started -Only until the client's heart rhythm returns to normal -When invasive pacing is not immediately available.
Which ECG waveforms and intervals are the normal measurements or positions?
-PR interval 0.12-0.20 second -QRS complex 0.06-0.10 seconds -PR segment isoelectric line -QT interval less than half of the R to R interval -U wave follows T wave if present
Which conditions would the nurse suspect when a client's telemetry ECG rhythm strip shows ST elevation of 1.5 mm (1.5 small blocks)?
-Pericarditis -Myocardial infarction -Hyperkalemia
Which statements about permanent pacemakers are accurate?
-Permanent pacemakers are available as pacemaker/defibrillator devices -Biventricular pacemakers allow synchronized depolarization of the ventricles -Permanent pacemakers are used to treat disorders such as complete heart block -The pulse generator for a permanent pacemaker is usually implanted in the left subclavian area.
Which serum electrolyte would the nurse check after noting tall and peaked T waves on a client's ECG?
-Potassium
What does the nurse suspect when assessing a client's telemetry ECG strip and noting a wide distorted QRS complex of 0.14 second followed by a P wave?
-Premature ventricular complex followed by atrial contraction
Which important teaching points would the nurse discuss with a client who receives a new permanent pacemaker?
-Report any pulse rate that is lower than the rate set on the pacemaker. -Avoid sources of strong electromagnetic fields such as magnets -Carry a pacemaker identification card and wear a medical alert bracelet -Avoid tight clothing to prevent pressure over the pacemaker generator
Which actions are responsibilities of the monitor technician?
-Report client rhythm and significant changes to the nurse -Print routine ECG strips for each monitored client -Watch the bank of cardiac monitors on a client care unit -Interpret rhythm strips for each monitored client
Where will the nurse place the leads on a client for a five-lead continuous monitoring system?
-Right arm electrode just below the right clavicle -Left arm electrode just below the left clavicle -Left leg electrode on the lowest palpable rib, on the left midclavicular line -Fifth electrode placed to obtain one of the six chest leads
What effect does the nurse expect a Class IV drug to have on a client's cardiac conduction system?
-Slow the flow of calcium into the cell during depolarization to depress automaticity
Which beta-blocker drug approved for treating dysrhythmias is also a class III antidysrhythmic drug?
-Sotalol
Which definition best describes the electrophysiologic property called automaticity of myocardial pacemaker cells?
-The ability of cardiac cells to generate an electrical impulse spontaneously and repetitively.
How does the nurse interpret a client's telemetry ECG strip that shows four successive premature ventricular contractions (PVCs)?
-The client had an episode of nonsustained ventricular tachycardia (NSVT).
Which dysrhythmia does the nurse consider life threatening because it causes the ventricles to quiver and results in the absence of cardiac output for a client?
-Ventricular fibrillation
For which cardiac dysrhythmia (s) would an automatic external defibrillator (AED) instruct the nurse to immediately defibrillate an unconscious client at an outpatient clinic?
-Ventricular fibrillation -Pulseless ventricular tachycardia
When a client has been in atrial fibrillation for 3 days and is scheduled for an elective cardioversion, what priority teaching does the nurse provide to the client?
-What for any signs of bleeding and report this to your healthcare provider
Which drug does the nurse prepare to administer to a client diagnosed with the dysrhythmia torsade's de pointes?
-magnesium
which factors would the nurse note as increasing risk of atherosclerosis with an older African American pt
20 year hx of type 2 DM sedentary lifestyle 25 lbs overweight grandmother died after heart attack
To determine if a client has a pulse deficit, what procedure would the nurse follow?
Assess the apical and radial pulses for a full minute and calculate the difference.
which statement by a pt with HF indicates to the nurse the additional need for teaching
I must weigh myself once a week and watch for signs of fluid retention
which statement by a pt with a hx of HTN and heart problems would cause the nurse to suspect development of HF
I've had to remove all of my rings for he past month
which pt are at greatest risk for development of infective endocarditis
IV drug uses poor dental health opined addicts systemic alterations in immunity post valve replacement
Which waveform does the nurse recognize as atrial depolarization when a client is placed on a cardiac monitor?
P wave
which assessment findings would suggest to the nurse that a pt who received a heart transplant was experience organ rejection
SOB hypotension decreased activity tolerance fluid gain Afib or Aflutter
what does the nurse suspect when a pt describes substernal pain that radiates to left shoulder is grating and worsens with inspiration and coughing
acute pericarditis
what is the priority intervention when a pt comes to the ER with extreme anxiety, tachycardia, struggling for air, a moist cough productive of frothy and blood tinged sputum
administer high flow O2 therapy by face mask
which criteria are appropriate for a pt with dilated cardiomyopathy to become a candidate for heart transplant surgery
age generally less than 65 New York heart association class 3 or 4 normal or only slightly increased pulmonary vascular resistance absence of active infection
which are the potential causes of dilated cardiomyopathy
alcohol abuse infection chemotherapy poor nutrition
for which finding in a pt with mitral valve stenosis would the nurse immediately notify the HCP because of the potential of decompensation
an irregular heart rhythm and ECG strip that indicate atrial fibrillation
which essential medication would the nurse provide teaching about post for a pt who received a prosthetic valve replacement
anticoagulant
which control systems play an important role in maintaining a pt BP
arterial baroreceptor system regulation of body fluid volume vascular auto-regulation renin-angiotensin aldosterone system
what is the nurses best response when a pt asks about the difference between arteriosclerosis and atherosclerosis
atherosclerosis is forming plaques in arteries but arteriosclerosis is thinking of arterial walls associated with aging
which complication is at the most risk when the nurse notes that excessive fluid was seen in the pericardial cavity on echocardiogram
cardiac tamponade
which key points would then use include when teaching a pt s/s of worsening HF
cold symptoms lasting more than 3-5 days excessive awakening at night to urinate development of dyspnea or angina increased swelling in feet, ankles, hands
which early symptoms indicate to the nurse that the pt HF is getting worse and pulmonary edema is developing
crackles in lungs dyspnea at rest disorientation
which findings would the nurse expect in a pt with mitral valve stenosis
might be asymptomatic classic signs- dyspnea, angina, syncope rumbling apical diastolic murmur right sided HF with jugular vein distention
what assessment findings would the nurse expect to find in a pt with right HF
dependent edema neck vein distention hepatomegaly
which s/s would the nurse expect to assess when a pt is dx with aortic stenosis
dyspnea on exertion angina harsh systolic cresendo-decresendo murmur orthopnea
when the pt asks the nurse about the best method of dx HF, what teaching would the nurse provide
echocardiography
which type of heart valvular disease does the nurse suspect when the pt assessment reveals pitting edema
mitral valve stenosis and regurgitation
which s/s would the nurse expect when assessing a pt which chronic constrictive pericarditis
exertion fatigue and dyspnea crackles and wheezes hepatic engorgement
which treatment best applies to care of pt newly dx with infective endocarditis
hospitalization for initial IV antibiotics, followed by continued IV antibiotics at home
which type of cardiomyopathy may present with sudden death as the first symptom
hypertrophic
when a pt has an ejection fraction of less than 30% about which potential treatment does the nurse prepare to educate the pt
implantable cardioverter/defibrillator
what are the priority nursing action r/t caring for an older adult pt with HF who is prescribed digoxin
monitor for early signs of toxicity, like bradycardia auscultate the apical pulse full min prior to administering observe signs of toxicity: anorexia, fatigue, blurred vision report changes in HR or rhythm to HCP monitor digoxin and potassium levels check for parameters to hold drugs
which assessment findings would cause the nurse to suspect cardiac tamponade
neck vein distention paradoxical pulse muffled heart sounds tachycardia
which drugs would the nurse prepare to administer to a pt with HF who has developed pulmonary edema
nitroglycerin sublingual furosemide IV nitroglycerin IV
what early sign of left ventricular failure is a pt most likely to report to the nurse
nocturnal coughing
which pt with valvular heart disease would benefit from the nonsurgical invasive procedure balloon valvuloplasty
older adult who is not a surgical candidate
which findings does the nurse expect when assessing a pt with infective endocarditis
osler nodes on palms of hands and soles of feet splinter hemorrhages janeway lesions on the hands and feet anoressia and weight loss
What is the priority concept for a pt who has HF
perfusion
Which priority concept does the nurse focus on when a client is diagnosed with dysrhythmias?
perfusion
what are the priority nursing care concepts for pt with vascular problems
perfusion and clotting
which are proposed criteria for dx of a pt with acute pericarditis
pericardial chest pain presence of pericardial friction rub new ST elevation in all ECG leads or PR segment depression new or worsening pericardial effusion
what is the best method for the nurse to use when auscultating at pt pericardial friction rub with a stethoscope
place the diaphragm at the left lower sternal border
when the nurse performs a BP screening, which pt would be referred for further eval
pt with heart disease and BP of 148/90 renal failure pt with BP of 180/90 pt with muscle cramping taking a statin with BP of 124/82 COPD pt with BP of 158/8
what does the nurse suspect when assessment of a pt with HF reveals pulses that alternate in strength
pulses alternans
which are potential benefits of pt receiving the drug digoxin
reduced HR increased contractility slows conduction through AV node inhibition of sympathetic activity with enhanced parasympathetic activity
which priority teaching would the nurse provide to a pt with infective endocarditis who is scheduled for an invasive dental procedure
remind your HCP to prove you with a rx of prophylactic ABX
which topics would the nurse be sure to cover when providing discharging instructions for a pt with prosthetic valve surgery
report dyspnea, syncope, dizziness, edema, palpitation use electron razor notify HCP for bleeding or excessive bruising watch and report for any fever or drainage and redness at surgical site
which instruction would the nurse give the AP who is helping a pt with HF and excessive aldosterone secretion
restrict the pt fluids to 2L per day and keep I/O
what does the nurse instruct a pt with pericarditis to do to make him or her feel more comfortable
sit up and lean forward
which interventions would the nurse expect to include in the care of a pt with pulmonary edema caused by HF
sodium restriciton position pt in semi or high fowler administer of loop diuretics
which urgent intervention is required when the nurse reviews the dx testing for a pt with aortic stenosis and discovers that the surface area of the valve is less than 1 cm
surgical aortic heart valve replacement
what is the definitive treatment for chronic constrictive pericarditis
surgical removal of the pericardium
When a pt develops HF, what initial compensatory mechanism of the heart does the nurse expect to occur that will maintain cardiac output
sympathetic stimulation
which major self management categories will the nurse include when teaching a pt, newly dx with HF how is about to be discharged
symptoms, what to do when they get worse medications activity weight diet
when a pt with HF walks 200ft down the hall and develops feeling of heaviness in the legs, how does the nurse interpret this finding
the activity is too stressful
which are the characteristic that the nurse would expect in a pt with mitral valve prolapse
valve leaflets enlarge and bulge up into left atrium during systole most pt are asymptomatic and abnormality is benign many pt have normal HR and BP a mid systolic click and late systolic murmur is best heard at apex of heart
what is the most reliable method of monitoring for fluid gain or loss in a pt with HF
weigh the pt daily at the same time using the same scale
which lifestyle changes would the nurse teach a pt to help control HTN
weight reduction implement healthy diet such as DASH use relaxation techniques to decrease stress increase activity
when a pt admits that he or she sometimes has trouble catching his or her breath, which question would the nurse ask to obtain more info about symptoms
what was you most strenuous activity during the past week
which assessment findings would the nurse expect to find in left HF
wheezes or crackles S3 heart sound paroxysmal nocturnal dyspnea oliguria during the day
when would the nurse expect the release of B-type natriuretic peptide (BNP) for a pt with HF
when a pt has fluid overload
to improve gas exchange, how much supplemental oxygen would the nurse provide a pt with HF
within the range prescribed by the HCP to keep saturation at 90% or more
which priority info would the nurse be sure to provide for a pt who is scheduled for mitral valve replacement with xenograft valve
your xenograft valve will need to be replaced in about 7-10 years
