NUR 215 Test 2

The nurse performs discharge teaching for a patient with an implantable cardioverter-defibrillator (ICD). Which statement by the patient indicates that further teaching is needed? "The device may set off the metal detectors in an airport." "My family needs to keep up to date on how to perform CPR." "I should not stand next to antitheft devices at the exit of stores." "I can expect redness and swelling of the incision site for a few days."

"I can expect redness and swelling of the incision site for a few days." Rationale: Patients should be taught to report any signs of infection at incision site (e.g., redness, swelling, drainage) or fever to their primary care providers immediately. Teach patients to inform TSA airport security of the presence of the ICD because it may set off metal detectors. If a handheld screening wand is used, it should not be placed directly over the ICD. Teach patients to avoid standing near antitheft devices in doorways of stores and public buildings and to walk through them at a normal pace. Caregivers should learn cardiopulmonary resuscitation.

The nurse is doing discharge teaching with the patient who received an implantable cardioverter-defibrillator (ICD) in the left side. Which statement by the patient indicates that further teaching is required? "I will call the cardiologist if my ICD fires." "I cannot fly because it will damage the ICD." "I cannot move my left arm until it is approved." "I cannot drive until my cardiologist says it is okay."

"I cannot fly because it will damage the ICD." Rationale: The patient statement that flying will damage the ICD indicates misunderstanding about flying. The patient should be taught to inform TSA security screening agents at the airport about the ICD because it may set off the metal detector and if a hand-held screening wand is used, it should not be placed directly over the ICD. The other options indicate the patient understands the teaching.

A patient develops third-degree heart block and reports feeling chest pressure and shortness of breath. Which instructions should the nurse provide to the patient before initiating emergency transcutaneous pacing? "The device will convert your heart rate and rhythm back to normal." "The device uses overdrive pacing to slow the heart to a normal rate." "The device is inserted through a large vein and threaded into your heart." "The device delivers a current through your skin that can be uncomfortable."

"The device delivers a current through your skin that can be uncomfortable." Rationale: Before initiating transcutaneous pacing therapy, it is important to tell the patient what to expect. The nurse should explain that the muscle contractions created by the pacemaker when the current passes through the chest wall are uncomfortable. Pacing for complete heart block will not convert the heart rhythm to normal. Overdrive pacing is used for very fast heart rates. Transcutaneous pacing is delivered through pacing pads adhered to the skin.

When computing a heart rate from the electrocardiography (ECG) tracing, the nurse counts 15 of the small blocks between the R waves of a patient whose rhythm is regular. What does the nurse calculate the patient's heart rate to be? 60 beats/min 75 beats/min 100 beats/min 150 beats/min

100 beats/min Rationale: Because each small block on the ECG paper represents 0.04 seconds, 1500 of these blocks represents 1 minute. By dividing the number of small blocks (15, in this case) into 1500, the nurse can calculate the heart rate in a patient whose rhythm is regular (in this case, 100).

A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is high, and cardiac output is low. Which treatment would the nurse expect to be prescribed? a. Furosemide b. Hydrocortisone c. Epinephrine drip d. 5% albumin infusion

A The PAWP indicates that the patient's preload is elevated. Furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase the heart rate and myocardial oxygen demand. 5% albumin would also increase the PAWP. Hydrocortisone might be considered for septic or anaphylactic shock

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patient's serum creatinine level is high. b. The patient reports intermittent chest pressure. c. The patient's extremities are cool, and pulses are 1+. d. The patient has bilateral crackles throughout lung fields.

A The high serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all symptoms consistent with the patient's diagnosis of cardiogenic shock

A patient reporting dizziness and shortness of breath is admitted with a dysrhythmia. Which medication, if ordered, requires the nurse to carefully monitor the patient for asystole? Digoxin Adenosine Metoprolol Atropine sulfate

Adenosine Rationale: IV adenosine is the first drug of choice to convert supraventricular tachycardia to a normal sinus rhythm. Adenosine is administered IV rapidly (over 1 or 2 seconds) followed by a rapid, normal saline flush. The nurse should monitor the patient's electrocardiogram continuously because a brief period of asystole after adenosine administration is common and expected. Atropine sulfate increases heart rate, while lanoxin and metoprolol slow the heart rate.

A patient has ST segment changes that suggest an acute inferior wall myocardial infarction. Which lead would be the most useful for monitoring the patient? a. I b. II c. V2 d. V6

B Leads II, III, and AVF reflect the inferior area of the heart and the ST segment changes. Lead II will best capture any electrocardiographic changes that indicate further damage to the myocardium. The other leads do not reflect the inferior part of the myocardial wall and will not provide data about further ischemic changes in that area.

The nurse is caring for a patient who is 24 hours after pacemaker insertion. Which nursing intervention is appropriate at this time? Reinforcing the pressure dressing as needed Encouraging range-of-motion exercises of the involved arm Assessing the incision for any redness, swelling, or discharge Applying wet-to-dry dressings every 4 hours to the insertion site

Assessing the incision for any redness, swelling, or discharge Rationale: After pacemaker insertion, it is important for the nurse to observe signs of infection by assessing for any redness, swelling, or discharge from the incision site. The nonpressure dressing is kept dry until removed, usually 24 hours postoperatively. It is important for the patient to limit activity of the involved arm to minimize pacemaker lead displacement.

A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention prescribed by the health care provider should the nurse implement first? a. Insert two large-bore IV catheters. b. Provide O2 at 100% per non-rebreather mask. c. Draw blood to type and crossmatch for transfusions. d. Initiate continuous electrocardiogram (ECG) monitoring.

B The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished but only after actions to maximize O2 delivery have been implemented

A patient has a sinus rhythm and a heart rate of 72 beats/min. The nurse determines that the PR interval is 0.24 seconds. What action should the nurse take? a. Notify the health care provider immediately. b. Document the finding and monitor the patient. c. Give atropine per agency dysrhythmia protocol. d. Prepare the patient for temporary pacemaker insertion.

B First-degree atrioventricular block is asymptomatic and requires ongoing monitoring because it may progress to more serious forms of heart block. The rate is normal, so there is no indication that atropine is needed. Immediate notification of the health care provider about an asymptomatic rhythm is not necessary

A patient's heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious, apneic, and pulseless. Which action should the nurse take first? a. Give epinephrine (Adrenalin) IV. b. Perform immediate defibrillation. c. Prepare for endotracheal intubation. d. Ventilate with a bag-valve-mask device

B The patient's rhythm and assessment indicate ventricular fibrillation and cardiac arrest; the initial action should be to defibrillate. If a defibrillator is not immediately available or is unsuccessful in converting the patient to a better rhythm, begin chest compressions. The other actions may also be appropriate but not first.

Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective? a. There are no signs of hemorrhage. b. Hemoglobin is within normal limits. c. Urine output 65 mL over the past hour. d. Mean arterial pressure (MAP) is 72 mm Hg.

C Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 mL/kg/hr. The hemoglobin level and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion. The absence of hemorrhage helps to prevent further fluid loss but does not reflect fluid balance.

Which finding from a newly admitted adult patient's electrocardiogram (ECG) requires further investigation by the nurse? a. Isoelectric ST segment b. PR interval of 0.18 second c. QT interval of 0.38 second d. QRS interval of 0.14 second

D Because the normal QRS interval is less than 0.12 seconds, the patient's QRS interval of 0.14 seconds indicates that the conduction through the ventricular conduction system is prolonged. The PR interval and QT interval are within normal range and ST segment should be isoelectric (flat)

When caring for a critically ill patient who is being mechanically ventilated, the nurse will monitor for which manifestation of multiple organ dysfunction syndrome (MODS)? Increased serum albumin Decreased respiratory compliance Increased gastrointestinal (GI) motility Decreased blood urea nitrogen (BUN)/creatinine ratio

Decreased respiratory compliance Rationale: Manifestations of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decreased GI motility, acute neurologic changes, myocardial dysfunction, disseminated intravascular coagulation (DIC), and changes in glucose metabolism.

The health care provider prescribes the following interventions for a 67-kg patient who has septic shock with a blood pressure of 70/42 mm Hg and O2 saturation of 90% on room air. In which order will the nurse implement the actions? a. Obtain blood and urine cultures. b. Give vancomycin by IV infusion. c. Start norepinephrine 0.5 mcg/min. d. Infuse normal saline 2000 mL over 30 minutes. e. Administer oxygen to keep O2 saturation above 95%.

E, D, C, A, B The initial action for this hypotensive and hypoxemic patient should be to improve the O2 saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before giving antibiotics

The nurse observes a flat line on the patient's monitor and the patient is unresponsive without pulse. What medications does the nurse prepare to administer? Lidocaine or amiodarone Digoxin and procainamide Epinephrine or vasopressin β-Adrenergic blockers and dopamine

Epinephrine or vasopressin Rationale: Normally, the patient in asystole cannot be successfully resuscitated. However, administration of epinephrine or vasopressin may prompt the return of depolarization and ventricular contraction. Lidocaine and amiodarone are used for ventricular tachycardia or ventricular fibrillation. Digoxin and procainamide are used for ventricular rate control. β-Adrenergic blockers are used to slow heart rate, and dopamine is used to increase heart rate.

1. A critical care nurse is planning assessment in the knowledge that the patients in shock are vulnerable to developing fluid replacement complications. For what sign and symptoms should the nurse monitor the patient? Select all that apply. a) Cardiovascular overload b) Difficulty breathing c) Pulmonary edema d) Hypovolemia e) Hypoglycemia

a, b, c

A patient with a suspected brain tumor is scheduled for a CT scan with contrast media. The nurse notifies the provider that the patient reported an allergy to shellfish. Which response by the provider should the nurse question? Complete the CT scan without contrast media. Give IV diphenhydramine before the procedure. Give IV lorazepam (Ativan) before the procedure. Premedicate with hydrocortisone sodium succinate.

Give IV lorazepam (Ativan) before the procedure. Rationale: A person with an allergy to shellfish is at an increased risk to develop anaphylactic shock if contrast media is injected for a CT scan. To prevent anaphylactic shock, the nurse should always confirm the patient's allergies before diagnostic procedures (e.g., CT scan with contrast media). Appropriate interventions may include cancelling the procedure, completing the procedure without contrast media, or premedication with diphenhydramine or hydrocortisone. IV fluids may be given to promote renal clearance of the contrast media and prevent renal toxicity and acute kidney injury. The use of an antianxiety agent such as lorazepam would not be effective in preventing an allergic reaction to the contrast media.

The nurse would recognize which assessment finding as suggestive of sepsis? Sudden diuresis unrelated to drug therapy Hyperglycemia in the absence of diabetes Respiratory rate of seven breaths per minute Bradycardia with sudden increase in blood pressure

Hyperglycemia in the absence of diabetes Rationale: Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis along with tachypnea and tachycardia

What laboratory finding is consistent with cardiogenic shock? Decreased liver enzymes Increased white blood cells Decreased red blood cells, hemoglobin, and hematocrit Increased blood urea nitrogen (BUN) and creatinine levels

Increased blood urea nitrogen (BUN) and creatinine levels Rationale: The renal hypoperfusion that accompanies cardiogenic shock results in increased BUN and creatinine levels. Impaired perfusion of the liver results in increased liver enzymes, but white blood cell levels do not typically increase in cardiogenic shock. Red blood cell indices are typically normal because of relative hypovolemia.

When caring for a patient in acute septic shock, what should the nurse anticipate? Infusing large amounts of IV fluids Administering osmotic and/or loop diuretics Administering IV diphenhydramine (Benadryl) Assisting with insertion of a ventricular assist device (VAD)

Infusing large amounts of IV fluids Rationale: Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. Administering diuretics is inappropriate. VADs are useful for cardiogenic shock, not septic shock. Diphenhydramine may be used for anaphylactic shock but would not be helpful with septic shock

The nurse is caring for a patient who was admitted 1 week ago with multiple rib fractures, pulmonary contusions, and a left femur fracture from a motor vehicle crash. The provider states the patient has developed sepsis, and the family members have many questions. Which information should the nurse include when explaining the early stage of sepsis? Weaning the patient from the ventilator is the top priority in sepsis. Antibiotics are not useful when an infection has progressed to sepsis. Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. The patient has recovered from sepsis if he has warm skin and ruddy cheeks.

Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. Rationale: Patients with sepsis may be normovolemic, but because of acute vasodilation, relative hypovolemia and hypotension occur. Patients in septic shock require large amounts of fluid replacement and may require frequent fluid boluses to maintain circulation. Antibiotics are an important component of therapy for patients with septic shock. They should be started after cultures (e.g., blood, urine) are obtained and within the first hour of septic shock. Oxygenating the tissues is the top priority in sepsis, so efforts to wean septic patients from mechanical ventilation halt until sepsis is resolving. Additional respiratory support may be needed during sepsis. Although cool and clammy skin is present in other early shock states, the patient in early septic shock may feel warm and flushed because of a hyperdynamic state.

The patient is admitted with acute coronary syndrome (ACS). The ECG shows ST-segment depression and T-wave inversion. What should the nurse know that this indicates? Myocardia injury Myocardial ischemia Myocardial infarction Normal pacemaker function.

Myocardial ischemia Rationale: The ST depression and T wave inversion on the ECG of a patient diagnosed with ACS indicate myocardial ischemia from inadequate supply of blood and oxygen to the heart. Myocardial injury is identified with ST-segment elevation. Myocardial infarction is identified with ST-segment elevation and a widened and deep Q wave. A pacemaker's presence is evident on the ECG by a spike leading to depolarization and contraction.

The nurse is caring for a patient in cardiogenic shock after an acute myocardial infarction. Which assessment findings would be most concerning? Restlessness, heart rate of 124 beats/min, and hypoactive bowel sounds Agitation, respiratory rate of 32 breaths/min, and serum creatinine of 2.6 mg/dL Mean arterial pressure of 54 mm Hg; increased jaundice; and cold, clammy skin PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site bleeding

PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site bleeding Rationale: Severe hypoxemia, lactic acidosis, and bleeding are manifestations of the irreversible state of shock. Recovery from this stage is not likely because of multiple organ system failure. Restlessness, tachycardia, and hypoactive bowel sounds are manifestations that occur during the compensatory stage of shock. Decreased mean arterial pressure, jaundice, cold and clammy skin, agitation, tachypnea, and increased serum creatinine are manifestations of the progressive stage of shock.

A patient informs the nurse of experiencing syncope. Which prioitiy nursing action should the nurse anticipate in the patient's subsequent diagnostic workup? Preparing to assist with a head-up tilt-test Assessing the patient's knowledge of pacemakers Administering an IV dose of a β-adrenergic blocker Teaching the patient about antiplatelet aggregators

Preparing to assist with a head-up tilt-test Rationale: In patients without structural heart disease, the head-up tilt-test is a common component of the diagnostic workup after episodes of syncope. IV β-blockers are not indicated, although an IV infusion of low-dose isoproterenol may be started in an attempt to provoke a response if the head-up tilt-test did not have a response. Addressing pacemakers is premature and inappropriate at this stage of diagnosis. Patient teaching surrounding antiplatelet aggregators is not directly relevant to the patient's syncope at this time.

After coronary artery bypass graft surgery, a patient has postoperative bleeding that requires returning to surgery for repair. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient parameter is the most important for planning nursing care? Cardiac index (CI) of 5 L/min/m2 Central venous pressure of 8 mm Hg Mean arterial pressure (MAP) of 86 mm Hg Pulmonary artery pressure (PAP) of 28/14 mm Hg

Pulmonary artery pressure (PAP) of 28/14 mm Hg Rationale: Pulmonary hypertension as indicated by an elevated PAP indicates impaired forward flow of blood because of left ventricular dysfunction or hypoxemia. Both can be a result of the MI. The CI, CVP, and MAP readings are normal.

A nurse is caring for a client following the insertion of a temporary venous pacemaker via the femoral artery that is set as a VVI pacemaker rate of 70/min. Which of the following findings should the nurse report to the provider? sata a. cool and clammy foot with capillary refill of 5 sec b. observed pacing spike followed by a QRS complex c. persistent hiccups d. heart rate 84/min e. blood pressure 104/62

a, c

The nurse observes ventricular tachycardia (VT) on the patient's monitor. What evaluation made by the nurse led to this interpretation? Unmeasurable rate and rhythm Rate 150 beats/min; inverted P wave Rate 200 beats/min; P wave not visible Rate 125 beats/min; normal QRS complex

Rate 200 beats/min; P wave not visible Rationale: VT is associated with a rate of 150 to 250 beats/min; the P wave is not normally visible. Rate and rhythm are not measurable in ventricular fibrillation. P wave inversion and a normal QRS complex are not associated with VT.

A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of the following clients as being at risk for the development of a dysrhythmia? (Select all that apply.) A. A client who has metabolic alkalosis B. A client who has a serum potassium level of 4.3 mEq/L C. A client who has an SaO2 of 96% D. A client who has COPD E. A client who underwent stent placement in a coronary artery

a, d, e

1. An elderly patient fell and had a hip fracture. The patient is 72 hours S/P hip repair and is confused and combative. Which of the following would indicate possible sepsis? Select all that apply a) WBC 18,000 b) Temp. 98.6 c) RR 10 d) Glucose 200 e) UO 0.3ml/kg/hr f) Lactate 4.0mmol/L

a, d, e, f

The patient has atrial fibrillation with a rapid ventricular response. What electrical treatment option does the nurse prepare the patient for? Defibrillation Synchronized cardioversion Automatic external defibrillator (AED) Implantable cardioverter-defibrillator (ICD)

Synchronized cardioversion Rationale: Synchronized cardioversion is planned for a patient with supraventricular tachydysrhythmias (atrial fibrillation with a rapid ventricular response). Defibrillation or AEDs are the treatment of choice to end ventricular fibrillation and pulseless ventricular tachycardia (VT). An ICD is used with patients who have survived sudden cardiac death, have spontaneous sustained VT, and are at high risk for future life-threatening dysrhythmias.

Which statement best describes the electrical activity of the heart represented by measuring the PR interval on the electrocardiogram (ECG)? The length of time it takes to depolarize the atrium. The length of time it takes for the atria to depolarize and repolarize. The length of time for the electrical impulse to travel from the sinoatrial (SA) node to the Purkinje fibers. The length of time it takes for the electrical impulse to travel from the sinoatrial (SA) node to the atrioventricular (AV) node.

The length of time for the electrical impulse to travel from the sinoatrial (SA) node to the Purkinje fibers. Rationale: The electrical impulse in the heart must travel from the SA node through the AV node and into the Purkinje fibers in order for synchronous atrial and ventricular contraction to occur. When measuring the PR interval (the time from the beginning of the P wave to the beginning of the QRS), the nurse is identifying the length of time it takes for the electrical impulse to travel from the SA node to the Purkinje fibers. The P wave represents the length of time it takes for the impulse to travel from the SA node through the atrium, causing depolarization of the atria (atrial contraction). Atrial repolarization occurs during ventricular depolarization and is hidden by the QRS complex. The length of time it takes for the electrical impulse to travel from the SA node to the AV node is the flat line between the end of the P wave and the beginning of the Q wave on the ECG and is not usually measured.

The nurse determines there is artifact on the patient's telemetry monitor. Which factor should the nurse assess for that could correct this issue? Disabled automaticity Electrodes in the wrong lead Too much hair under the electrodes Stimulation of the vagus nerve fibers

Too much hair under the electrodes Rationale: Artifact is caused by muscle activity, electrical interference, or insecure leads and electrodes that could be caused by excessive chest wall hair. Disabled automaticity would cause an atrial dysrhythmia. Electrodes in the wrong lead will measure electricity in a different plane of the heart and may have a different wave form than expected. Stimulation of the vagus nerve fibers causes a decrease in heart rate, not artifact.

Cardioversion is attempted for a patient with atrial flutter and a rapid ventricular response. After delivering 50 joules by synchronized cardioversion, the patient develops ventricular fibrillation. Which action should the nurse take immediately? Administer 250 mL of 0.9% saline solution IV by rapid bolus. Assess the apical pulse, blood pressure, and bilateral neck vein distention. Turn the synchronizer switch to the "off" position and recharge the device. Ask the patient if there is any chest pain or discomfort and administer morphine sulfate.

Turn the synchronizer switch to the "off" position and recharge the device. Rationale: Ventricular fibrillation produces no effective cardiac contractions or cardiac output. If during synchronized cardioversion the patient becomes pulseless or the rhythm deteriorates to ventricular fibrillation, the nurse should turn the synchronizer switch off and initiate defibrillation. Fluids, additional assessment, or treatment of pain alone will not restore an effective heart rhythm.

The nurse prepares to defibrillate a patient. Which dysrhythmia has the nurse observed in this patient? Ventricular fibrillation Third-degree AV block Uncontrolled atrial fibrillation Ventricular tachycardia with a pulse

Ventricular fibrillation Rationale: Defibrillation is always indicated in the treatment of ventricular fibrillation. Drug treatments are normally used in the treatment of uncontrolled atrial fibrillation and for ventricular tachycardia with a pulse (if the patient is stable). Otherwise, synchronized cardioversion is used (if the patient has a pulse). Pacemakers are the treatment of choice for third-degree heart block.

A nurse is caring for a client who has DIC. Which of the following medications should the nurse anticipate administering? a. heparin b. vitamin K c. mefoxin d. simvastatin

a

A nurse is caring for a client who has a prescription for an afterload reducing medication. The nurse should identify that this medication is administered for which of the following types of shock? a. cardiogenic b. obstructive c. hypovolemic d. distributive

a

A nurse is completing discharge teaching with a client who has a permanent pacemaker. Which of the following statements by the client indicates understanding of the teaching? a. i will notify the airport screeners about my pacemaker b. i will expect to have occasional hiccups c. i will have to disconnect my garage opener d. i will take my pulse every 2 - 3 days

a

1. The acute care nurse is providing care for an adult who is in hypovolemic shock. The nurse recognizes that antidiuretics hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe related to the role of ADH during hypovolemic shock? a) Decreased urinary output b) Increased capillary perfusion c) Decreased thirst d) Increased hunger

a) Decreased urinary output

A nurse is caring for a patient who has DIC. Which of the following lab values indicates the clients clotting factors are depleted? sata a. PLT 100,000 b. fibrinogen 120 c. fibrin degradation 4.3 d. d dimer 0.03 e. sed rate 38

a, b

A nurse is caring for a client who has a prescription for an afterload-reducing medication. The nurse should identify that this medication is administered for which of the following types of shock? a. cardiogenic b. obstructive c. hypovolemic d. distributive

a. cardiogenic identify that a prescription to reduce afterload will allow the heart to pump more effectively, which is needed for the client who has cardiogenic shock

Treatment modalities for the management of cardiogenic shock include (select all that apply) a. dobutamine to increase myocardial contractility. b. vasopressors to increase systemic vascular resistance. c. circulatory assist devices such as an intraaortic balloon pump. d. corticosteroids to stabilize the cell wall in the infarcted myocardium. e. Trendelenburg positioning to facilitate venous return and increase preload.

a. dobutamine to increase myocardial contractility. c. circulatory assist devices such as an intraaortic balloon pump. Dobutamine is used in patients in cardiogenic shock with severe systolic dysfunction. Dobutamine increases myocardial contractility, decreases ventricular filling pressures, decreases systemic vascular resistance and pulmonary artery wedge pressure, and increases cardiac output, stroke volume, and central venous pressure. It may increase or decrease the heart rate. The workload of the heart in cardiogenic shock may be reduced with the use of circulatory assist devices, such as an intraaortic balloon pump or ventricular assist device

A nurse is planning care for a client who has septic shock. Which of the following actions is the priority for the nurse to take? a. maintain adequate fluid volume with IV infusions b. administer antibiotic therapy c. monitor hemodynamic status d. administer vasopressor medication

b

Which patient teaching points should the nurse include when providing discharge instructions to a patient with a new permanent pacemaker and the caregiver? (select all that apply) a. Avoid or limit air travel. b. Take and record a daily pulse rate. c. Obtain and wear a Medic Alert ID device at all times. d. Avoid lifting arm on the side of the pacemaker above shoulder. e. Do not use a microwave oven because it interferes with pacemaker function.

b, c, d Pacemaker discharge teaching should include: Air travel is not restricted. The patient should tell airport security of the presence of a pacemaker because it may set off the metal detector. A hand-held screening wand should not pass directly over the pacemaker. Manufacturer information varies about the effect of metal detectors on pacemaker function. The patient should monitor the pulse and tell the HCP if it drops below a predetermined rate. The patient should have and wear a Medic Alert ID device at all times. The patient must avoid lifting the arm on the pacemaker side above the shoulder until approved by the HCP. Microwave ovens are safe to use. They do not interfere with pacemaker function.

A nurse in the emergency department is completing an assessment on a client who is in shock. Which of the following findings should the nurse expect? sata a. HR 60 b. seizure activity c. RR 42 d. increased UO e. weak, thready pulse

b, c, e

A 78-yr-old man with a history of diabetes has confusion and temperature of 104°F (40°C). There is a wound on his right heel with purulent drainage. After an infusion of 3 L of normal saline solution, his assessment findings are BP 84/40 mm Hg; heart rate 110; respiratory rate 42 and shallow; CO 8 L/min; and PAWP 4 mm Hg. This patient's symptoms are most likely indicative of a. sepsis. b. septic shock. c. multiple organ dysfunction syndrome. d. systemic inflammatory response syndrome.

b. septic shock. Septic shock is the presence of sepsis with hypotension despite fluid resuscitation along with the presence of inadequate tissue perfusion. To meet the diagnostic criteria for sepsis, the patient's temperature must be higher than 100.9° F (38.3° C), or the core temperature must be lower than 97.0° F (36° C). Hemodynamic parameters for septic shock include elevated heart rate; decreased pulse pressure, blood pressure, systemic vascular resistance, central venous pressure, and pulmonary artery wedge pressure; normal or increased pulmonary vascular resistance; and decreased, normal, or increased pulmonary artery pressure, cardiac output, and mixed venous O2 saturation.

A nurse is assessing a client and suspects the client is experiencing DIC. Which of the following physical findings should the nurse anticipate? a. bradycardia b. htn c. epistaxis d. xerostomia

c

A nurse is caring for a client who is experiencing wheezing and swelling of the tongue. Which of the following medications should the nurse anticipate administering first? a. methylprednisolone b. diphenhydramine c. epinephrine d. dobutamine

c

1. The nurse is caring for a patient whose progressing infection places her at risk for shock. What assessment finding would the nurse consider a potential sign of shock? a) Bradycardia b) Elevated mean arterial pressure (MAP) c) Shallow rapid respirations d) Elevated systolic blood pressure

c) Shallow rapid respirations

1. The nurse overseeing care in the ICU reviews the shift report on four patients. The nurse recognizes which patient to be at greatest risk for the development of cardiogenic shock? a) The patient with acute renal failure b) The patient admitted with malignant hypertension c) The patient admitted following an MI d) The patient admitted following a stroke

c) The patient admitted following an MI

A nurse is caring for a client who is experiencing wheezing and swelling of the tongue. Which of the following medications should the nurse anticipate administering first? a. methylprednisolone b. diphenhydramine c. epinephrine d. dobutamine

c. epinephrine when using the airway, breathing, circulation approach to client care, place the priority on administering epinephrine to the client. This is a rapid acting medication that promotes effective oxygenation and is used to treat anaphylactic shock

A patient admitted with syncope has continuous ECG monitoring. An examination of the rhythm strip reveals the following: atrial rate 74 beats/min and regular; ventricular rate 62 beats/min and irregular; P wave normal shape; PR interval lengthens progressively until a P wave is not conducted; QRS normal shape. The priority nursing intervention would be to a. give epinephrine 1 mg IV push. b. prepare for synchronized cardioversion. c. observe for symptoms of hypotension or angina. d. apply transcutaneous pacemaker pads on the patient.

c. observe for symptoms of hypotension or angina. The rhythm is a second-degree atrioventricular (AV) block, type I (i.e., Mobitz I or Wenckebach heart block). It is characterized by a gradual lengthening of the PR interval. Type I AV block is usually a result of myocardial ischemia or infarction. It is typically transient and well tolerated. The nurse should assess for bradycardia, hypotension, and angina. The symptomatic patient may need atropine or a temporary pacemaker.

A newly licensed nurse is observing a cardioversion procedure and hears the team leader call out "stand clear". This statement indicates which of the following events is occurring? a. the cardioverter is being charged to the appropriate setting b. the team should initiate CPR due to pulseless electrical activity c. team members cannot be in contact with equipment connected to the client d. a time out is being called to verify correct protocols

c. team members cannot be in contact with equipment connected to the client prevents the staff from also getting shocked

A nurse is caring for a group of clients. Which of the following clients is at risk for obstructive shock? a. a client who is having occasional PVCs on the ECG monitor b. a client who has been experiencing vomiting and diarrhea for several days c. a client who has a gram negative bacterial infection d. a client who has a pulmonary arterial stenosis

d

1. The patient experiencing an anaphylactic event, which medications will help improve ventilation? a) Benadryl b) NS c) Metoprolol d) Albuterol

d) Albuterol

1. A critical care nurse is aware of similarities and differences between the treatment for different types of shock. Which of the following interventions is used in all types of shock? a) Administration of hypertonic IV fluids b) Aggressive hypoglycemic control c) Aggressive antibiotic therapy d) Early provision of nutritional support

d) Early provision of nutritional support

1. When fluid resuscitation is used to treat hypovolemic and septic shock and it has NOT been sufficient to restore intravascular volume, the nurse would expect an order for? a) Mechanical ventilation b) Heparin drip c) Nitroglycerine drip d) Norepinephrine drip

d) Norepinephrine drip

A nurse is caring for a group of clients. Which of the following clients is at risk for obstructive shock? a. a client who is having occasional PVCs on the ECG monitor b. a client who has been experiencing vomiting and diarrhea for several days c. a client who has a gram-negative bacterial infection d. a client who has a pulmonary arterial stenosis

d. a client who has a pulmonary arterial stenosis obstructive shock results from decreased cardiac function by a noncardiac cause, such as with pulmonary arterial stenosis or hypertension, or thoracic tumor

A nurse is admitting a client who has complete heart block as demonstrated by ECG. The clients heart rate is 34/min and BP is 83/48. The client is lethargic and unable to complete sentences. Which of the following actions should the nurse perform first? a. transport the client to the cardiovascular laboratory b. prepare the client for insertion of a permanent pacemaker c. obtain consent for a pacemaker d. apply transcutaneous pacemaker pads

d. apply transcutaneous pacemaker pads The greatest risk to this client is injury or death from inadequate tissue perfusion; therefore, the first action the nurse should take is to apply transcutaneous pacemaker pads and begin external pacing of the heart until a permanent pacemaker can be placed

The nurse prepares a patient for synchronized cardioversion knowing that cardioversion differs from defibrillation in that a. defibrillation delivers a lower dose of electrical energy. b. cardioversion is a treatment for atrial bradydysrhythmias. c. defibrillation is synchronized to deliver a shock during the QRS complex. d. patients should be sedated if cardioversion is done on a nonemergency basis.

d. patients should be sedated if cardioversion is done on a nonemergency basis. Synchronized cardioversion is the therapy of choice for patients with hemodynamically unstable ventricular or supraventricular tachydysrhythmias. A synchronized circuit in the defibrillator delivers a countershock that is programmed to occur on the R wave of the QRS complex of the electrocardiogram. The synchronizer switch must be turned on when cardioversion is planned. The procedure for synchronized cardioversion is the same as for defibrillation with a few exceptions: If synchronized cardioversion is done on a nonemergency basis, the patient is sedated before the procedure, and the initial energy needed for synchronized cardioversion is less than the energy needed for defibrillation

When preparing to defibrillate a patient, in which order will the nurse perform the following steps? a. Turn the defibrillator on. b. Deliver the electrical charge. c. Select the appropriate energy level. d. Place the hands-free, multifunction defibrillator pads on the patient's chest. e. Check the location of other staff and call out "all clear."

A, C, D, E, B This order will result in rapid defibrillation without endangering hospital staff

When analyzing an electrocardiographic (ECG) rhythm strip of a patient with a regular heart rhythm, the nurse counts 30 small blocks from one R wave to the next. The nurse calculates the patient's heart rate as ____

50 There are 1500 small blocks in a minute, and the nurse will divide 1500 by 30.

A patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? a. New onset of confusion b. Decreased bowel sounds c. Heart rate 112 beats/min d. Pale, cool, and dry extremities

A The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.

After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the drug has been effective? a. Increase in the patient's heart rate b. Increase in strength of peripheral pulses c. Decrease in premature atrial contractions d. Decrease in premature ventricular contractions

A Atropine will increase the heart rate and conduction through the AV node. Because the drug increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have premature atrial or ventricular contractions

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? a. Skin cool and clammy b. Heart rate of 118 beats/min c. Blood pressure of 92/56 mm Hg d. O2 saturation of 93% on room air

A Because patients in the early stage of septic shock have warm and dry skin, the patient's cool and clammy skin indicates that shock is progressing. The other information will also be reported but does not indicate deterioration of the patient's status.

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital? (Select all that apply.) a. Ambulate postoperative patients as soon as possible after surgery. b. Use aseptic technique when manipulating invasive lines or devices. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Administer prescribed antibiotics within 1 hour for patients with possible sepsis. e. Advocate for parenteral nutrition for patients who cannot take in adequate calories.

A, B, C, D Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early ambulation should be included in the plan of care. Adequate nutrition is important in preventing SIRS. Enteral, rather than parenteral, nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine, thus decreasing infection risk. Antibiotics should be given within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS

A patient with supraventricular tachycardia who is alert and has a blood pressure of 110/66 mm Hg is being prepared for cardioversion. Which action should the nurse take? a. Turn the synchronizer switch to the "off" position. b. Give a sedative before cardioversion is implemented. c. Set the defibrillator/cardioverter energy to 360 joules. d. Provide assisted ventilations with a bag-valve-mask device.

B When a patient has a nonemergency cardioversion, sedation is used just before the procedure. The synchronizer switch is turned "on" for cardioversion. The initial level of joules for cardioversion is low (e.g., 50). Assisted ventilations are not indicated for this patient.

A nurse on a cardiac unit is caring for a client who is on telemetry. The nurse recognizes the client's heart rate is 46/min and notifies the provider. The nurse should anticipate that which of the following management strategies will be used for this client? A. Defibrillation B. Pacemaker insertion C. Synchronized cardioversion D. Administration of IV lidocaine

B. Pacemaker insertion A client who has bradycardia is a candidate for a pacemaker to increase his heart rate

After change-of-shift report in the progressive care unit, who should the nurse care for first? a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases. b. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/min. c. Patient with suspected urosepsis who has new prescriptions for urine and blood cultures and antibiotics. d. Patient admitted with anaphylaxis 3 hours ago who has clear lung sounds and a blood pressure of 108/58 mm Hg

C Antibiotics should be given within the first hour for patients who have sepsis or suspected sepsis to prevent progression to systemic inflammatory response syndrome and septic shock. The data on the other patients indicate that they are more stable. Crackles heard only at the lung bases do not need immediate intervention in a patient who has had a myocardial infarction. Mild bradycardia does not usually need treatment in patients with a spinal cord injury. The findings for the patient admitted with anaphylaxis show resolution of bronchospasm and hypotension.

Which action by a nurse caring for a patient after an implantable cardioverter-defibrillator (ICD) insertion indicates a need for more teaching about the care of patients with ICDs? a. The nurse administers amiodarone (Cordarone) to the patient. b. The nurse helps the patient fill out the application for obtaining a Medic Alert device. c. The nurse encourages the patient to do active range-of-motion exercises for all extremities. d. The nurse teaches the patient that sexual activity can be resumed when the incision is healed

C The patient should avoid moving the arm on the ICD insertion site until healing has occurred to prevent displacement of the ICD leads. The other actions by the new nurse are appropriate for this patient

The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be fastest to use? a. Count the number of large squares in the R-R interval and divide by 300. b. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes. c. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10. d. Calculate the number of small squares between one QRS complex and the next and divide into 1500

C Using the 3-second markers to count the number of QRS complexes in 6 seconds and multiplying by 10 is the quickest way to determine the ventricular rate for a patient with a regular rhythm. The other methods are accurate but take longer.

After a patient who has septic shock receives 2 L of normal saline intravenously, the central venous pressure is 10 mm Hg and the blood pressure is 82/40 mm Hg. What medication should the nurse anticipate? a. Furosemide b. Nitroglycerin c. Norepinephrine d. Sodium nitroprusside

C When fluid resuscitation is unsuccessful, vasopressor drugs are given to increase the systemic vascular resistance (SVR) and blood pressure and improve tissue perfusion. Furosemide would cause diuresis and further decrease the BP. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Nitroprusside is an arterial vasodilator and would further decrease SVR

The emergency department (ED) nurse receives report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. What should the nurse obtain in preparation for the patient's arrival? a. A dopamine infusion b. A hypothermia blanket c. Lactated Ringer's solution d. Two 16-gauge IV catheters

D A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large-bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and would not be prescribed until the patient has been assessed for liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool.

Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective? a. Heart rate b. Orientation c. Blood pressure d. Oxygen saturation

D Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the O2 saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.

A patient with a massive gastrointestinal bleed has developed hypovolemic shock. What is the priority nursing diagnosis? Anxiety Acute pain Impaired tissue integrity Ineffective tissue perfusion

Ineffective tissue perfusion Rationale: The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. This nursing diagnosis supersedes the other diagnoses.

The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first? a. A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due b. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating c. A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago d. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due

D The frequent firing of the ICD indicates that the patient's ventricles are very irritable. The priority is to assess the patient and give the amiodarone. The other patients can be seen after the amiodarone is given.

A patient develops sinus bradycardia at a rate of 32 beats/min, has a blood pressure (BP) of 80/42 mm Hg, and reports feeling faint. Which action should the nurse take? a. Reposition the patient on the left side. b. Have the patient perform the Valsalva maneuver. c. Give the scheduled dose of diltiazem (Cardizem). d. Apply the transcutaneous pacemaker (TCP) pads.

D The patient is experiencing symptomatic bradycardia and treatment with TCP is appropriate. Calcium channel blockers will further decrease the heart rate and the diltiazem should be held. The Valsalva maneuver will further decrease the rate. Repositioning on the left side may decrease cardiac output and blood pressure further

The nurse evaluates that discharge teaching about the management of a new permanent pacemaker has been effective when the patient states a. "It will be several weeks before I can return to my usual activities." b. "I will avoid cooking with a microwave oven or being near one in use." c. "I will notify the airlines when I make a reservation that I have a pacemaker." d. "I won't lift the arm on the pacemaker side until I see the health care provider."

D The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The patient should notify airport security about the presence of a pacemaker before going through the metal detector, but there is no need to notify the airlines when making a reservation. Microwave oven use does not affect the pacemaker. The insertion procedure involves minor surgery that will have a short recovery period

A patient's localized infection has become systemic and septic shock is suspected. What medication would be given to treat septic shock refractory to fluids? Insulin infusion Furosemide IV push Norepinephrine administered by titration Administration of nitrates and β-adrenergic blockers

Norepinephrine administered by titration Rationale: If fluid resuscitation using crystalloids is not effective, vasopressor medications, such as norepinephrine (Levophed) and dopamine, are indicated to restore mean arterial pressure (MAP). Nitrates and β-adrenergic blockers are most often used in the treatment of patients in cardiogenic shock. Furosemide (Lasix) is indicated for patients with fluid volume overload. Insulin infusion may be given to normalize blood sugar and improve overall outcomes, but it is not considered a medication used to treat shock.

A patient is admitted to the emergency department vomiting bright red blood. The patient's vital signs are BP of 78/58 mm Hg, pulse of 124 beats/min, respirations of 28 breaths/min, and temperature of 97.2° F (36.2° C). Which provider order should the nurse complete first? Obtain a 12-lead ECG and arterial blood gases. Rapidly administer 1000 mL normal saline solution IV. Start norepinephrine (Levophed) by continuous IV infusion. Insert a nasogastric tube and an indwelling bladder catheter.

Rapidly administer 1000 mL normal saline solution IV. Rationale: Isotonic crystalloids, such as normal saline solution, should be used in the initial resuscitation of hypovolemic shock. Vasopressor drugs (e.g., norepinephrine) may be considered if the patient does not respond to fluid resuscitation and blood products. Other orders (e.g., insertion of nasogastric tube and indwelling bladder catheter and obtaining the diagnostic studies) can be done after fluid resuscitation is started.

The nurse obtains a 6-second rhythm strip and charts the following analysis: atrial rate 70, regular; ventricular rate 40, regular; QRS 0.04 sec; no relationship between P waves and QRS complexes; atria and ventricles beating independently of each other. Which of the following would be a correct interpretation of this rhythm strip? A. Sinus dysrhythmias B. Third-degree heart block C. Wenckebach phenomenon D. Premature ventricular contractions

Third-degree heart block Rationale: Third-degree heart block represents a loss of communication between the atrium and ventricles from atrioventricular node dissociation. This is depicted on the rhythm strip as no relationship between the P waves (representing atrial contraction) and QRS complexes (representing ventricular contraction). Whereas the atria are beating totally on their own at 70 beats/min, the ventricles are pacing themselves at 40 beats/min. Sinus dysrhythmia is seen with a slower heart rate with exhalation and an increased heart rate with inhalation. In Wenckebach heart block, there is a gradual lengthening of the PR interval until an atrial impulse is nonconducted and a QRS complex is blocked or missing. Premature ventricular contractions are the early occurrence of a wide, distorted QRS complex.

A nurse is caring for a client who experienced defibrillation. Which of the following should be included in the documentation of this procedure? sata a. follow up ECG b. energy settings used c. IV fluid intake d. urinary output e. skin condition under electrodes

a, b, e

A nurse in the emergency department is completing an assessment on a client who is in shock. Which of the following findings should the nurse expect? sata a. HR 60 b. seizure activity c. RR 42 d. increased urine output e. weak, thready pulse

b, c, e seizure activity caused by progressive hypoxia can be present in a client who is in shock. tachypnea is an expected finding in a client who is in shock due to the body's attempt to increase oxygen intake a weak, thready pulse caused by low fluid volume, vasoconstriction, and hypotension is an expected finding in a client who is in shock

A nurse is planning care for a client who has septic shock. which of the following actions is the priority for the nurse to take? a. maintain adequate fluid volume with IV infusions b. administer antibiotic therapy c. monitor hemodynamic status d. administer vasopressor medication

b. administer antibiotic therapy the greatest risk to the client is injury from elimination endotoxins and mediators from bacteria. the priority intervention is to administer antibiotics, which will reduce vasodilation

1. The intensive care nurse is responsible for the care of a patient with shock. What cardiac signs or symptoms would suggest to the nurse that the patient may be experiencing acute organ dysfunction? Select all that apply a) Hypotension that responds to bolus fluid resuscitation b) Exaggerated response to vasoactive medications c) Mean arterial pressure (MAP) of <65mm Hg d) Serum lactate >4mmol/L e) Drop in systolic blood pressure of 40mmHg from baselines

c, d, e

The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are a. blood pressure, pulse, and respirations. b. breath sounds, blood pressure, and body temperature. c. pulse pressure, level of consciousness, and pupillary response. d. level of consciousness, urine output, and skin color and temperature.

d. level of consciousness, urine output, and skin color and temperature. Adequate tissue perfusion in a patient with multiple-organ dysfunction syndrome is assessed by the level of consciousness, urine output, capillary refill, peripheral sensation, skin color, extremity skin temperature, and peripheral pulses.

A 78-kg patient in septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. After initial fluid volume resuscitation, the patient's urine output has been 30 mL/hr for the past 3 hours. Which order by the health care provider should the nurse question? a. Administer furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 250 mL/hr. c. Give hydrocortisone (Solu-Cortef) 100 mg IV. d. Use norepinephrine to keep systolic BP above 90 mm Hg.

A Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. Patients in septic shock need large amounts of fluid replacement. If the patient is still hypotensive after initial volume resuscitation with minimally 30 mL/kg, vasopressors such as norepinephrine may be added. IV corticosteroids may be considered for patients in septic shock who cannot maintain an adequate BP with vasopressor therapy despite fluid resuscitation.

The nurse is monitoring the electrocardiograms of several patients on a cardiac telemetry unit. The patients are directly visible to the nurse, and all the patients are observed to be sitting up and talking with visitors. Which patient's rhythm would require the nurse to take immediate action? A 62-yr-old man with a fever and sinus tachycardia with a rate of 110 beats/min A 72-yr-old woman with atrial fibrillation with 60 to 80 QRS complexes per minute A 52-yr-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute A 42-yr-old woman with first-degree AV block and sinus bradycardia at a rate of 56 beats/min

A 52-yr-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute Rationale: Frequent premature ventricular contractions (PVCs) (>1 every 10 beats) may reduce the cardiac output and precipitate angina and heart failure, depending on their frequency. Because PVCs in CAD or acute myocardial infarction indicate ventricular irritability, the patient's physiologic response to PVCs must be monitored. Frequent PVCs may be treated with oxygen therapy, electrolyte replacement, or antidysrhythmic agents.

The nurse is assisting in the care of several patients in the critical care unit. Which patient is most at risk for developing multiple organ dysfunction syndrome (MODS)? A 22-yr-old patient with systemic lupus erythematosus admitted with a pelvic fracture A 48-yr-old patient with lung cancer admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia A 65-yr-old patient with coronary artery disease, dyslipidemia, and primary hypertension admitted for unstable angina A 82-yr-old patient with type 2 diabetes and chronic kidney disease admitted for peritonitis from a peritoneal dialysis catheter infection

A 82-yr-old patient with type 2 diabetes and chronic kidney disease admitted for peritonitis from a peritoneal dialysis catheter infection Rationale: A patient with peritonitis is at high risk for developing sepsis. In addition, a patient with diabetes is at high risk for infections and impaired healing. Sepsis and septic shock are the most common causes of MODS. Those at greatest risk for developing MODS are older adults and persons with significant tissue injury or preexisting disease. MODS can be initiated by any severe injury or disease process that activates a massive systemic inflammatory response.

Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin? a. Explain the association between dysrhythmias and syncope. b. Instruct the patient to call for assistance before getting out of bed. c. Teach the patient about the need to avoid caffeine and other stimulants. d. Tell the patient about the benefits of implantable cardioverter-defibrillators

B A patient with fainting episodes is at risk for falls. The nurse will plan to minimize the risk by having assistance whenever the patient is up. The other actions may be needed if dysrhythmias are found to be the cause of the patient's syncope but are not appropriate for syncope of unknown origin.

Which action by a new registered nurse (RN) who is orienting to the telemetry unit indicates a good understanding of the treatment of heart dysrhythmias? a. Prepares defibrillator settings at 360 joules for a patient whose monitor shows asystole. b. Injects IV adenosine (Adenocard) over 2 seconds for a patient with supraventricular tachycardia. c. Turns the synchronizer switch to the "on" position before defibrillating a patient with ventricular fibrillation. d. Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second-degree AV block

B Adenosine must be given over 1 to 2 seconds to be effective. The other actions indicate a need for more teaching about treatment of heart dysrhythmias. The RN should hold the diltiazem until discussing it with the health care provider. The treatment for asystole is immediate CPR. The synchronizer switch should be "off" when defibrillating.

Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which data indicate that the nurse should consult with the health care provider before starting the norepinephrine? a. The patient is receiving low dose dopamine. b. The patient's central venous pressure is 3 mm Hg. c. The patient is in sinus tachycardia at 120 beats/min. d. The patient has had no urine output since admission.

B Adequate fluid administration is essential before giving vasopressors to patients with hypovolemic shock. The patient's low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration

A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104° F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. Acetaminophen (Tylenol) 650 mg rectally. b. Administer normal saline IV at 500 mL/hr. c. Start norepinephrine to keep blood pressure above 90 mm Hg. d. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL.

B Because of the decreased preload associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate and should be initiated quickly as well.

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Check temperature every 2 hours. b. Monitor breath sounds frequently. c. Maintain patient in supine position. d. Assess skin for flushing and itching

B Because pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.

The following interventions are prescribed by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first? a. Give diphenhydramine b. Administer epinephrine. c. Start continuous ECG monitoring. d. Draw blood for complete blood count.

B Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions are also appropriate but would not be the first ones completed.

A nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of 92/54 mm Hg, a pulse of 64 beats/min, and a high pulmonary artery wedge pressure (PAWP). Which intervention prescribed by the health care provider should the nurse question? a. Elevate head of bed to 30 degrees. b. Infuse normal saline at 250 mL/hr. c. Hold nitroprusside if systolic BP is less than 90 mm Hg. d. Titrate dobutamine to keep systolic BP is greater than 90 mm Hg.

B The patient's elevated PAWP indicates volume excess in relation to cardiac pumping ability, consistent with cardiogenic shock. A saline infusion at 250 mL/hr will worsen the volume excess. The other actions will help to improve cardiac output, which should lower the PAWP and may raise the BP.

A patient is apneic and has no palpable pulses. The heart monitor shows sinus tachycardia, rate 132. What action should the nurse take next? a. Perform synchronized cardioversion. b. Start cardiopulmonary resuscitation (CPR). c. Give atropine per agency dysrhythmia protocol. d. Apply supplemental O2 via non-rebreather mask.

B The patient's manifestations indicate pulseless electrical activity, and the nurse should immediately start CPR. The other actions would not be of benefit to this patient

Which nursing action can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) working as telemetry technicians on the cardiac care unit? a. Decide whether a patient's heart rate of 116 requires urgent treatment. b. Observe heart rhythms for multiple patients who have telemetry monitoring. c. Monitor a patient's level of consciousness during synchronized cardioversion. d. Select the best lead for monitoring a patient admitted with acute coronary syndrome

B UAP serving as telemetry technicians can monitor heart rhythms for individuals or groups of patients. Nursing actions such as assessment and choice of the most appropriate lead based on ST segment elevation location require RN-level education and scope of practice

A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective? a. No heart murmur b. Skin is warm and pink c. Decreased troponin level d. Blood pressure of 92/40 mm Hg

B Warm, pink, and dry skin indicates that perfusion to tissues is improved. Because nitroprusside is a vasodilator, the blood pressure may be low even if the drug is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock

Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to contact the health care provider? a. The patient's urine output is 18 mL/hr. b. The patient's heart rate is 110 beats/min. c. The patient's peripheral pulses are weak. d. The patient reports diffuse chest pressure.

D Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion and cause chest pain or pressure. Low urine output, weal pulses, and tachycardia are consistent with the patient's diagnosis. They and should be reported to the health care provider but do not require an immediate need for a change in therapy.

An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate? a. Increase the rate for the dopamine infusion. b. Decrease the rate for the nitroglycerin infusion. c. Increase the rate for the sodium nitroprusside infusion. d. Decrease the rate for the 5% dextrose in normal saline infusion

C Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5/.9 NS and nitroglycerin infusions will not directly decrease SVR. Increasing the dopamine will tend to increase SVR.

When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients with shock, which action by the new RN indicates a need for more education? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Maintaining a cool room temperature for a patient with neurogenic shock d. Increasing the nitroprusside for a patient with cardiogenic shock and a high SVR

C Patients with neurogenic shock have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.

To evaluate the effectiveness of the pantoprazole (Protonix) given to a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? a. Auscultate bowel sounds. b. Ask the patient about nausea. c. Check stools for occult blood. d. Palpate for abdominal tenderness

C Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments will also be done, but these will not help in determining the effectiveness of the pantoprazole administration

A patient reports dizziness and shortness of breath for several days. During heart monitoring in the emergency department (ED), the nurse obtains the following electrocardiographic (ECG) tracing. How does the nurse interpret this heart rhythm? a. Junctional escape rhythm b. Accelerated idioventricular rhythm c. Third-degree atrioventricular (AV) block d. Sinus rhythm with premature atrial contractions

C The inconsistency between the atrial and ventricular rates and the variable PR interval indicate that the rhythm is third-degree AV block. Sinus rhythm with PACs will have a normal rate and consistent PR intervals with occasional PACs. An accelerated idioventricular rhythm will not have visible P waves

A patient is admitted to the emergency department (ED) in shock of unknown etiology. What should be the nurse's first action? a. Obtain the blood pressure. b. Check the level of orientation. c. Administer supplemental oxygen. d. Obtain a 12-lead electrocardiogram.

C The initial actions of the nurse are focused on the ABCs—airway, breathing, and circulation—and administration of O2 should be done first. The other actions should be done as rapidly as possible after providing O2.

After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the health care provider? Physical Assessment: petechiae noted on chest and legs, crackles heard bilaterally in lung bases, no redness or swelling at central line IV site Lab data: BUN 34, Hct 30%, PLT 50,000 VS: T 100, HR 102, RR 26, BP 110/60, O2 93% on 2L NC a. Temperature and IV site appearance b. Oxygen saturation and breath sounds c. Platelet count and presence of petechiae d. Blood pressure, pulse rate, respiratory rate

C The low platelet count and presence of petechiae suggest that the patient may have disseminated intravascular coagulation and that multiple organ dysfunction syndrome is developing. The other information will be discussed with the health care provider but does not show that the patient's condition is deteriorating or that a change in therapy is needed immediately.

A patient's heart monitor shows sinus rhythm, rate 64. The PR interval is 0.18 seconds at 1:00 AM, 0.22 seconds at 2:30 PM, and 0.28 seconds at 4:00 PM. Which action should the nurse take first? a. Place the transcutaneous pacemaker pads on the patient. b. Give atropine sulfate 1 mg IV per agency dysrhythmia protocol. c. Hold the scheduled metoprolol (Lopressor) and call the health care provider. d. Document the patient's rhythm and PR measurements in the medical record.

C The patient has progressive first-degree atrioventricular (AV) block, and the -blocker should be held until discussing the drug with the health care provider. Documentation is appropriate later. The patient with first-degree AV block usually is asymptomatic; if the patient became symptomatic, a pacemaker or atropine may be used.

Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider? a. Blood glucose of 243 mg/dL b. Serum chloride of 92 mEq/L c. Serum sodium of 134 mEq/L d. Serum potassium of 2.9 mEq/L

D Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation. The health care provider will need to prescribe a potassium infusion to correct this abnormality. Although the other laboratory values are also abnormal, they are not likely to be the cause of the patient's PVCs and do not require immediate correction.

What should the nurse measure to determine whether there is a delay in impulse conduction through the patient's ventricles? a. P wave b. Q wave c. PR interval d. QRS complex

D The QRS complex represents ventricular depolarization. The P wave represents the depolarization of the atria. The PR interval represents depolarization of the atria, atrioventricular node, bundle of His, bundle branches, and the Purkinje fibers. The Q wave is the first negative deflection following the P wave and should be narrow and short

The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, QRS complex wide and distorted, and QRS duration of 0.18 second. How should the nurse interpret this cardiac rhythm? a. Atrial flutter b. Sinus tachycardia c. Ventricular fibrillation d. Ventricular tachycardia

D The absence of P waves, wide QRS, rate greater than 150 beats/min, and the regularity of the rhythm indicate ventricular tachycardia. Atrial flutter is usually regular, has a narrow QRS configuration, and has flutter waves present representing atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration

A patient who was admitted with a myocardial infarction has a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/min. Which action should the nurse take next? a. Immediately notify the health care provider. b. Document the rhythm and continue to monitor the patient. c. Prepare for synchronized cardioversion per agency protocol. d. Prepare to give IV amiodarone per agency dysrhythmia protocol

D The burst of sustained ventricular tachycardia indicates that the patient has significant ventricular irritability, and antidysrhythmic medication administration is needed to prevent further episodes. The nurse should notify the health care provider after the medication is started. Cardioversion is not indicated given that the patient has returned to a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation.