Chapter 34 AQ
Which condition is a result of a hypereffective heart in a well-conditioned athlete?
bradycardia A hypereffective heart has a strong heart muscle that provides an adequate stroke volume and a low heart rate to achieve a normal cardiac output. Bradycardia occurs due to a hypereffective heart in a well-conditioned athlete. An arrhythmia is an irregular rate. Tachypnea is a key feature of sustained tachydysrythmias. A cardiac arrest is a temporary cessation of the heart.
When caring for a patient with premature ventricular contractions (PVCs), which electrolyte imbalances will contribute to this dysrhythmia and should therefore be monitored? Select all that apply.
hypokalemia hypomagnesemia Low serum levels of potassium and magnesium predispose the patient to PVCs. The other electrolyte imbalances may cause ECG changes but do not increase the risk for PVCs.
What is the greatest priority once a crash cart has been brought to a room when responding to a patient in ventricular fibrillation?
perform defibrillation In cases of ventricular fibrillation, the earlier that defibrillation (asynchronous countershock) is performed, the greater the chance of survival. Defibrillation depolarizes a critical mass of myocardium simultaneously with the goal of restoring spontaneous circulation. Cardiac compressions, rescue breathing, and the administration of epinephrine follow defibrillation.
A 78-year-old patient has recently been prescribed a daily dose of diltiazem for atrial fibrillation. Her daughter calls to report that she is experiencing weakness and confusion for the past couple of days. How does the nurse respond to the daughter's concern?
"Has your mother experienced any dizziness during this time?" The nurse should assess for episodes of syncope since diltiazem is a calcium channel blocker that can cause bradycardia and hypotension. With hypotension, perfusion is impaired and weakness, confusion, and dizziness may result. This is of particular concern in the older patient because it causes an increased risk for falls. Confusion should not be dismissed as simply age-related. It is not within the nurse's scope of practice to advise a patient or family member to change the dose or frequency of a medication.
A patient is taking metoprolol for supraventricular tachycardia. Which statement by the patient warrants further investigation by the nurse?
"I got dizzy when walking to the bathroom earlier." Beta-adrenergic blocking drugs decrease blood pressure, heart rate, and cardiac output; dizziness may occur with bradycardia or hypotension. This warrants further investigation because the patient may be taking the metoprolol when the heart rate is too low or may be rising too quickly, in which case the patient may require further education. Constipation and fatigue are possible side effects of metoprolol. The expected outcome when metoprolol is prescribed for atrial fibrillation or supraventricular tachycardia is a heart rate under 100 beats per minute.
The nurse is caring for a patient on a telemetry unit with a regular heart rhythm and rate of 60 beats/min; a P wave precedes each QRS complex, and the PR interval is 0.24 second. Additional vital signs are as follows: blood pressure 118/68, respiratory rate 16, and temperature 98.8° F. All of these medications are available on the medication record. What action does the nurse take?
continue to monitor
A nurse is evaluating the understanding of family members who are caring for an older adult who has just received a permanent pacemaker. Which family member's statement requires nursing intervention?
"I should make sure the patient wears tight clothing over the generator." When caring for an older adult who has a pacemaker, family members should avoid pressure over the generator, which means loose clothing is preferable to tight clothing. The other statements are correct. The pacemaker can set off an airport metal detector, so airport personnel should be informed. The patient should also stay away from antitheft devices and electrical or gasoline engines or motors that can cause pacemaker malfunction.
Which information does the nurse include in the discharge teaching for a patient with a newly placed implantable cardioverter/defibrillator? Select all that apply.
Know how to perform cough cardiopulmonary resuscitation as instructed When using a cell phone, hold at least 6 inches from the generator using the opposite ear Avoid electromagnetic interference such as leaning directly over the alternator of a running car or boat Electromagnetic interference may inhibit tachydysrhythmia detection by inactivating the device. Caution should be used when in close proximity to a running alternator and when using a cell phone because they emit electromagnetic energy. During forceful coughs, increased pressure in the chest may avert a tachydysrhythmia or enhance circulation during a tachydysrhythmia. The surgical incision for the generator is in the left pectoral area. It is usually recommended that the patient seek medical attention immediately following single activation of the defibrillator, not waiting for three successive activations to occur. There are no external electrodes with an implanted cardioverter/defibrillator.
The nurse receives a report that a patient with a pacemaker has experienced loss of capture. Which situation is consistent with this?
Pacemaker spikes are noted, but no P wave or QRS complex follows Loss of capture occurs when the pacing stimulus (spike) is not followed by the appropriate response, either P wave or QRS complex, depending on placement of the pacing electrode. Pacemaker spikes falling on the T wave indicate improper sensing. A heart rate of 42 with no pacemaker spikes seen on the rhythm strip indicates failure to pace or sense properly; demand pacing should cause the pacemaker to intervene with electrical output when the heart rate falls below the set rate. Although the set rate is not given, this heart rate indicates profound bradycardia. Hiccups may indicate stimulation of the chest wall or diaphragm from wire perforation.
The nurse is caring for a patient with atrial fibrillation. In addition to an antidysrhythmic, what medication does the nurse plan to administer?
Rivaroxaban The loss of coordinated atrial contractions in atrial fibrillation can lead to pooling of blood resulting in thrombus formation. The patient is at high risk for pulmonary embolism! Thrombi may form within the right atrium and then move through the right ventricle to the lungs . In addition, the patient is at risk for systemic emboli, particularly an embolic stroke, which may cause severe neurologic impairment or death. Rivaroxaban or other anticoagulants are used to prevent thrombus development in the atrium and the consequence of embolization (i.e., stroke). Atropine is used to treat bradycardia and heart blocks; atrial fibrillation, unless controlled with medication, is typically rapid. Dobutamine is an inotropic agent used to improve cardiac output; it may cause tachycardia, thereby worsening atrial fibrillation. Although electrolyte levels are monitored in patients with dysrhythmia, magnesium sulfate is not used unless depletion is noted.
How does the nurse recognize that atropine has produced a positive outcome for the patient with bradycardia?
The monitor shows an increase in heart rate An expected outcome after the administration of atropine is increased heart rate. By definition, the bradydysrhythmia has resolved when the heart rate is 60 beats/min. Dizziness and weakness indicate symptoms of decreased cerebral perfusion and intolerance to the bradydysrhythmia. Dyspnea indicates intolerance to the bradydysrhythmia. Atropine is used to treat bradycardia; a heart rate of 42 indicates that bradycardia is unresolved.
A patient is brought into the emergency room with chest pain, shortness of breath, diaphoresis, and hypotension. The heart rate of the patient is 56 beats per minute. What is the immediate nursing intervention provided to stabilize the patient?
administering atropine The administration of atropine along with intravenous fluids will increase intravascular volume and help to manage bradycardia. Beta-blockers such as propranolol are not administered to patients with bradycardia. Cardiac glycoside (digoxin) and calcium channel blockers (verapamil) will further decrease the heart rate and worsen the symptoms.
A patient has episodes of ventricular tachycardia. Which medication does the nurse anticipate administering?
amiodarone Amiodarone, a class III antidysrhythmic, is suggested for use in life-threatening ventricular dysrhythmias. Digoxin, a cardiac glycoside, is used for heart failure and atrial fibrillation. Metoprolol, a beta-adrenergic blocker, and diltiazem, a calcium channel blocker, are useful for atrial fibrillation.
A patient with atrial fibrillation with rapid ventricular response has received medication to slow the ventricular rate. The pulse is now 88 beats/min. For which additional therapy does the nurse plan?
anticoagulation Because of the risk for thromboembolism caused by atrial fibrillation, anticoagulation is necessary. The patient has stabilized; cardioversion is not needed at this time. EPS is indicated for recurring, symptomatic dysrhythmia. Ablation therapy is ordered for recurring and symptomatic atrial fibrillation.
A patient is admitted to the intensive care unit with an acute pulmonary embolism. What dysrhythmia would most likely contribute to this condition?
atrial fibrillation Because the atria are not fully contracting in atrial fibrillation, there is stagnation of blood flow resulting in formation of thrombi in the atria. A thrombus can be dislodged from the right atrium and travel to the lung, causing a pulmonary embolus. There is not a risk of thrombus formation with sinus bradycardia, premature atrial contractions, or ventricular tachycardia.
A patient is prescribed adenosine drug therapy to convert supraventricular tachycardia to normal sinus rhythm. Which parameter should the nurse monitor in this patient?
bradycardia Adenosine is mainly used to covert supraventricular tachycardia to a normal sinus rhythm. Adenosine terminates the acute episode and is followed by a normal saline bolus. The major side effect of this drug therapy is significant bradycardia. Rebound tachycardia, ventricular fibrillation, and premature atrial complexes are conditions that are not associated with adenosine drug therapy.
Which side effect is associated with the drug acebutolol hydrochloride?
bronchospasm Acebutolol hydrochloride is a beta 2-blocking agent. It causes sudden constriction of the muscles in the walls of the bronchioles, which in turn causes bronchospasm. Flecainide acetate causes tremors. Propafenone hydrochloride affects the sleep cycle and causes insomnia. Mexiletine hydrochloride affects vision acuity and may cause blurred vision as a side effect.
When caring for a patient with heart disease, which action may lead to serious bradydysrhythmias?
orophayrngeal suctioning Anything that causes the patient to perform the Valsalva maneuver (e.g., bear down, gag, or vomit) leads to vagal stimulation. Unintended vagal stimulation can result in serious bradydysrhythmias and should be avoided. Oropharyngeal suctioning causes the patient to gag and possibly vomit. Insertion of a Foley catheter, hip flexion, and moderate walking on a treadmill do not induce the Valsalva maneuver.
While the health care provider is at the bedside, the patient's heart rate increases from 82 to 176 beats/min and supraventricular tachycardia is noted on the cardiac monitor. The provider decides to do immediate carotid sinus massage. Which action would the nurse take in this situation?
Bring a defibrillator and resuscitative equipment to the bedside. Serious dysrhythmias may occur as a result of carotid sinus massage. These include bradydysrhythmias, asystole, and ventricular fibrillation, which may result in brain injury. Because of this, a defibrillator and resuscitative equipment must be available during the procedure. Given the urgency of the situation, obtaining a blood specimen prior to the procedure is not reasonable. The nurse prepares the patient with instruction to turn the head slightly away from the side to be massaged. Preparation does not include hyperextending the neck or placing the patient in the reverse Trendelenburg position.
Which statement correctly differentiates cardioversion from defibrillation?
Cardioversion delivers a synchronized shock for ventricular tachycardia or supraventricular tachycardia. Cardioversion involves the delivery of a synchronized electric shock to terminate unstable ventricular or supraventricular rhythms. It is not useful in ventricular fibrillation because all electrical activity is disorganized with no ability to synchronize. Defibrillation delivers an asynchronous countershock, depolarizing a critical mass of the myocardium to stop the re-entry circuit in ventricular fibrillation or pulseless ventricular tachycardia, allowing the sinus node to regain control of the heart.
In caring for a patient following an acute myocardial infarction, what is the greatest priority when planning care?
Monitor for increased frequency of premature ventricular contractions Increasing frequency of premature ventricular contractions following an acute myocardial infarction can lead to life-threatening ventricular dysrhythmias. Prophylaxis of venous thromboembolism, cardiac diet, and prevention of skin breakdown are important, but the greatest priority is the risk of life-threatening dysrhythmias.
Which patient is appropriate for the cardiac care unit charge nurse to assign to the float RN from the medical-surgical unit?
The 64-year-old patient admitted for weakness who has a sinus bradycardia with a heart rate of 58 beats/min The 64-year-old has a stable, asymptomatic bradycardia, which usually requires monitoring but no treatment unless the patient develops symptoms and/or the slow heart rate causes a decrease in cardiac output. This patient can be managed by a nurse with less cardiac dysrhythmia training. The 71-year-old is unstable and requires immediate intervention for dyspnea and tachycardia. The 88-year-old is displaying symptoms of myocardial injury (elevated troponin) and unstable blood pressure and needs immediate attention and medications. The 92-year-old is experiencing a dysrhythmia that could deteriorate into ventricular tachycardia and requires immediate intervention by a telemetry nurse.
When caring for a patient who has been admitted with tachydysrhythmia, which assessment finding would the nurse expect?
fainting Patients with tachydysrhythmia may experience syncope (blackout or fainting), palpitations, chest pressure/pain, pallor (not flushing), and restlessness/anxiety. Agitation is a sign of hypoxemia, and a bounding pulse is associated with increased cardiac output or increased intracranial pressure.
The nurse is receiving shift change report on a patient with an implantable cardioverter/defibrillator (ICD). Which test or activity, if ordered by the provider, would prompt the nurse to contact the provider immediately?
magnetic resonance imaging Patients with an ICD should avoid sources of strong electromagnetic fields, such as large electrical generators and radio and television transmitters. Magnetic resonance imaging (MRI) should not be used. Radiation therapy, microwave ovens, and CT scans are safe to use.
The nurse is teaching a patient about self-management to prevent dysrhythmias caused by premature beats and ectopic rhythms. Which statement made by the patient indicates a need for further teaching?
"I have to drink coffee twice daily and other energy drinks to stay active." A patient with premature beats and ectopic rhythms should not have caffeinated beverages and energy drinks because they can worsen dysrhythmias. Quitting smoking helps prevent dysrhythmias. Managing stress can prevent the risk of dysrhythmias. The patient should limit alcohol intake because alcohol may worsen the symptoms.
The nurse is teaching a patient with a new permanent pacemaker. Which statement by the patient indicates a need for further discharge education?
"I no longer need my heart pills" All prescribed medications are still needed after the pacemaker is implanted. Once the wound from the surgery heals, the patient will be able to shower. The patient's pulse will have to be taken and recorded for 1 full minute at the same time each day. The metal in the pacemaker will trigger the alarm in metal detector devices; a card can be shown to authorities to indicate that the patient has a pacemaker.
The registered nurse teaches a student nurse about the post-discharge self-care management of a patient hospitalized with tachycardia. Which instruction given by the student nurse shows ineffective learning?
"Include foods rich in caffeine that stimulate the central nervous system (CNS)." Because the patient is recovering from tachycardia, the nurse should tell the patient to avoid taking substances that will increase the heart rate (such as caffeine). Alcohol should be avoided because it increases the heart rate. Patients are advised to develop strategies for stress management because stress can increase the heart rate. Consulting a mental health professional can help to alleviate anxiety, which will increase the heart rate.
Which teaching is essential for a patient who has had a permanent pacemaker inserted?
Avoid operating electrical appliances over the pacemaker The patient should avoid operating electrical appliances directly over the pacemaker site because this may cause the pacemaker to malfunction. It is not necessary to avoid a telephone or a cell phone; radio transmitter towers, arc welding, and strong electromagnetic fields may pose a hazard. No hazard exists with sexual activity. Bathing and showering are permitted.
What are the causes of atrial irritability? Select all that apply.
stress fatigue infection
The nurse is caring for a patient with a tachydysrhythmia who asks why his chest hurts. The nurse should base the explanation on which information?
The diastole is shortened, and coronary perfusion is decreased. Coronary artery blood flow occurs mostly during diastole when the aortic valve is closed; shortened diastolic time shortens the coronary artery perfusion time, bringing less oxygenated blood to the myocardium. This results in chest pain. With palpitations, the patient perceives that he or she can feel the heart beating. While tachycardia may result in palpitations, the sensation of one's heart beating may occur with chest pain, but it is not the cause. Conduction delays at the AV node are classified as heart blocks, which are by definition bradydysrhythmias.
Which risk factors are known to contribute to atrial fibrillation? Select all that apply.
advancing age high blood pressure excessive alcohol use The incidence of atrial fibrillation (AF) increases with age. Risk factors include hypertension, previous ischemic stroke, transient ischemic attack or other thromboembolic event, coronary heart disease, diabetes mellitus, heart failure and mitral valve disease, obesity, Caucasian race, and excessive alcohol. Beta-adrenergic blocking agents, which reduce heart rate, are used to treat atrial fibrillation. Palpitations are a symptom of atrial fibrillation rather than a risk or a cause.
The nurse is caring for a patient on a telemetry unit with a regular heart rhythm and rate of 60 beats/min; a P wave precedes each QRS complex, and the PR interval is 0.24 second. Additional vital signs are as follows: blood pressure 118/68, respiratory rate 16, and temperature 98.8° F. All of these medications are available on the medication record. What action does the nurse take?
continue to monitor The patient is displaying normal sinus rhythm. Atropine is used in emergency treatment of symptomatic bradycardia. This patient has normal vital signs. Digoxin is used in the treatment of atrial fibrillation, which is, by definition, an irregular rhythm. Clonidine is used in the treatment of hypertension; a side effect is bradycardia.
The nurse is caring for a patient with sinus tachycardia. For which underlying causes does the nurse assess? Select all that apply.
fever anxiety Graves' disease Sinus tachycardia results from sympathetic nervous system stimulation or parasympathetic inhibition, which increases the heart rate to over 100 beats per minute. Causes may include fever, anxiety, pain, stress, hyperthyroidism (Graves' disease), hypoxemia, and pulmonary embolism. Beta-adrenergic blocking drugs inhibit or block the sympathetic nervous system resulting in lower heart rates or bradycardia. Straining during defecation (Valsalva maneuver) may cause vagal stimulation of the heart with resulting bradycardia.
The nurse is caring for a patient with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol. Which monitoring is essential when administering the medication?
heart rate The effects of metoprolol are to decrease heart rate, blood pressure, and myocardial oxygen demand. ST segment elevation is consistent with MI; it does not address monitoring of metoprolol. Elevation in troponin is consistent with a diagnosis of MI but does not address needed monitoring for metoprolol. Elevation in myoglobin is consistent with myocardial injury in ACS but does not address needed monitoring related to metoprolol.
A patient's cardiac monitor shows ventricular fibrillation. While performing basic life support and awaiting the arrival of the Rapid Response Team, in which order of priority are resuscitative actions performed?
initiate cardiac compressions maintain an open airway ventilate with a mouth-to-mask device begin IV normal saline to infuse at a wide-open rate
The nurse is assisting a nurse practitioner with the wellness examination of a high school athlete and notes the cardiac rhythm strip has all the characteristics of normal sinus rhythm, except it is irregular. There is a pattern to the irregularity associated with the patient's breathing. How does the nurse respond to this finding?
nothing, as this is a healthy rhythm This is sinus arrhythmia, which is frequently observed in healthy children and adults. The rate speeds up during inhalation and slows down during exhalation; this is considered a variant of normal sinus rhythm.
Which dysrhythmia is caused by atrial irritability?
premature atrial complexes Premature atrial complexes will develop when the atrial tissue becomes irritated. The ectopic focus generates impulses before the next normal sinus impulse, which causes palpitations and a sense of the heart skipping a beat. Atrial fibrillation, supraventricular tachycardia, and premature ventricular complexes are not caused by atrial irritability.
A college student presents to the campus clinic reporting palpitations. Frequent premature atrial contractions are identified on the electrocardiogram (ECG). What does the nurse include in teaching this patient? Select all that apply.
smoking cessation decreased consumption of caffeinated beverages referral to the counseling center for stress management Stress is a cause of atrial irritability leading to premature atrial contractions. More effective ways of stress management may be explored at the counseling center. Nicotine and caffeine also increase the incidence of premature atrial contractions and should be avoided or reduced. Increasing water intake will not alleviate the problem. Limiting physical exertion is not indicated.
Which cardiac rhythm typically deteriorates into ventricular fibrillation?
ventricular tachycardia Ventricular tachycardia (VT) may occur in patients with ischemic heart disease, myocardial infarction (MI), cardiomyopathy, hypokalemia, hypomagnesemia, valvular heart disease, heart failure, drug toxicity, hypotension, or ventricular aneurysm. In patients who go into cardiac arrest, VT is commonly the initial rhythm before deteriorating into ventricular fibrillation (VF) as the terminal rhythm. Atrial fibrillation and flutter are not life-threatening rhythms. Third-degree heart block is related to ischemia or scarring in the atrioventricular node, which slows the rate, rather than making the heart irritable as in VT and fibrillation.
What teaching does the nurse include for a patient with atrial fibrillation who has a new prescription for warfarin?
"Report nosebleeds to your provider immediately." Warfarin causes decreased ability to clot; a nosebleed could be indicative of excessive dosing. Green leafy vegetables are high in vitamin K, which may antagonize the effects of warfarin; they should be eaten in moderate amounts and the amounts should be the same each day. Aspirin and nonsteroidal anti-inflammatory agents may prolong the prothrombin time (PT) and the International Normalized Ratio (INR), causing predisposition to bleeding; these should be avoided. It is not necessary to avoid caffeine because this does not affect clotting; however, green tea may interfere with the effects of warfarin.
What instruction should the nurse give a family member caring for the patient who has a permanent pacemaker?
"Take the pulse for one full minute at the same time each day. While educating a patient's family member about management of a permanent pacemaker, the nurse should instruct the caregiver to take the patient's pulse for one full minute at the same time each day and to record it in a pacemaker diary. The family member may take the patient's pulse any time he or she believes there are symptoms of pacemaker failure and report the patient's heart rate and symptoms to the physician. Taking the pulse for two full minutes at the same each day, or at different times of the day, is unnecessary for detecting pacemaker failure. Measuring the pulse for one full minute at a different time each day or recording two full minutes of the pulse reading at different times on the same day does not provide an accurate assessment of the pacemaker's functioning.
When teaching patients at risk for bradydysrhythmias, what information does the nurse include?
"Use a stool softener. Patients at risk for bradydysrhythmias should avoid bearing down or straining during a bowel movement; the Valsalva maneuver can cause bradycardia. Taking a stool softener helps prevent this. Patients with renal failure and hyperkalemia are instructed to avoid potassium-containing foods; if risk for hypokalemia exists, such as with diuretic therapy, the patient is instructed to eat foods high in potassium. Smoking and caffeine increase heart rate; although all people should stop smoking, patients at risk for tachycardia, premature beats, and ectopic rhythms are instructed to stop smoking and avoid caffeine. Nitroglycerin is used to reduce oxygen demand in cardiac ischemia, not for bradycardia.
The nurse is teaching a patient about the synchronous demand pacemaker that has just been implanted for an episode of complete heart block. Which statement indicates the patient understands the teaching?
"When my pulse is less than the set rate, the pacemaker stimulates my heart to beat." Synchronous or demand pacemakers sense the patient's intrinsic or own rhythm. When the patient's heart rate is above the set rate, the pacemaker does not fire. When the heart rate is below the set rate, the pacemaker delivers an electrical impulse which stimulates the heart to beat. While there are antitachycardic pacemakers, they are not considered demand pacemakers. Pacemakers do not deliver shocks to terminate dysrhythmias; cardioverter/defibrillators do that.
The nurse is assisting with resuscitation efforts on a patient in the ICU when the family tearfully comes to the door and requests to be in the room with their loved one. Which response by the nurse is best?
If you feel you need to be present for your loved one, remain to the side and I will answer your questions later." Evidence suggests family presence during resuscitation can promote closure, providing a positive experience; however, limits may need to be set. Asking the family to remain separate from their loved one at a critical time by staying in the waiting area or outside the room may promote distress and the feeling that not everything possible was done.
Which complications are associated with carotid sinus massage therapy? Select all that apply.
bradycardia cerebral damage ventricular fibrillation Supraventricular tachydysrhythmias are treated temporarily by carotid sinus massage therapy. Complications of this therapy include bradycardia, cerebral damage, and ventricular fibrillation. Premature atrial complexes are caused by irritated atrial tissue, which is not associated with carotid sinus massage therapy. Premature ventricular complexes are caused by irritated ventricular tissue, which is also not associated with carotid sinus massage therapy.
The nurse is teaching a patient who has been diagnosed with atrial fibrillation. Which food item does the nurse teach the patient to avoid?
caffeine Atrial fibrillation is a tachydysrhythmia by definition. Caffeine is a stimulant that can increase heart rate and should therefore be avoided. Sodium is restricted in patients with hypertension and heart failure, which does not always occur with atrial fibrillation. Citrus products are often restricted with kidney failure or hyperkalemia, and low-fiber foods are used with diarrhea.
The bedside cardiac monitor alarms, and the patient suddenly becomes limp and unresponsive with no carotid pulse. What should the nurse do first?
call for the RRT The Rapid Response Team should be activated immediately before starting CPR to get expert assistance from other members of the health care team. With the new Basic Cardiac Life Support guidelines, cardiac compressions are initiated, followed by maintaining an airway and ventilating the patient. When help arrives, a firm board is placed under the patient to maximize efficiency of cardiac compressions
To prevent vagal stimulation in a patient with heart disease, what must be avoided? Select all that apply.
constipation oropharyngeal suctioning insertion of a nasogastric tube Anything that causes the patient to perform the Valsalva maneuver (e.g., bear down, gag, or vomit) leads to vagal stimulation. If constipated, the patient may strain or bear down to have a bowel movement. Oropharyngeal suctioning and placement of a nasogastric tube causes the patient to gag and possibly vomit. Hiccups and hip flexion do not stimulate the Valsalva maneuver or cause vagal stimulation.
The nurse is caring for a patient with advanced heart failure who develops asystole. The nurse corrects the graduate nurse when the graduate offers to perform which intervention?
defibrillation Defibrillation interrupts the heart rhythm and allows normal pacemaker cells to take over. In asystole, there is no rhythm to interrupt; therefore, this intervention is not used. If drug therapy fails to restore effective rhythm, CPR is initiated. Epinephrine is used to increase heart rate in asystole. Hypoxia may be a cause of cardiac arrest; the administration of oxygen would be appropriate.
The nurse is caring for a patient who has developed bradycardia. Which possible causes does the nurse investigate? Select all that apply.
diltiazem administered 1 hour ago bearing down for a bowel movement possible inferior wall myocardial infarction (MI) Excessive vagal (parasympathetic) stimulation to the heart causes a decreased rate of sinus node discharge. It may result from carotid sinus massage, vomiting, suctioning, Valsalva maneuvers (e.g., bearing down for a bowel movement or gagging), ocular pressure, or pain. Inferior wall MI is a cause of bradycardia and heart block. Calcium channel blockers such as diltiazem may cause bradycardia. Caffeine intake results in an increased heart rate. Stress, such as an emotional encounter, can result in tachycardia.
Which drugs does the nurse anticipate may be used in the treatment of a patient with atrial fibrillation? Select all that apply.
heparin digoxin warfarin diltiazem amiodarone Antidysrhythmic medications such as diltiazem, digoxin, and amiodarone are used to slow the heart rate and/or restore normal sinus rhythm. Anticoagulants such as heparin or warfarin are used to prevent emboli secondary to the loss of coordinated atrial contraction. Phytonadione is not used in atrial fibrillation because it can reverse the effects of warfarin and has no antidysrhythmic properties.
The nurse is the second responder for a person who collapsed in a school and does not have a pulse. After retrieving the automated external defibrillator (AED), the nurse applies the pads, plugs them in, and starts the machine. The AED indicates the pulseless patient is in ventricular asystole. What is the nurse's priority action?
start compression The American Heart Association Guidelines for Basic Cardiac Life Support are to first provide cardiac compressions, then maintain the airway and begin rescue breathing (CAB). Compressions are the first priority because the desired outcome of resuscitation is the rapid return of a pulse, blood pressure, and consciousness. Ventricular asystole should never be defibrillated. Transcutaneous pacing is ineffective in asystole.
The nurse is teaching a patient with a dysrhythmia to eat potassium-containing foods. Which food does the nurse suggest the patient include in the diet
strawberries Potassium-containing foods include citrus, tomatoes, beans, prunes, avocados, bananas, strawberries, and lettuce. Turnips, grapes, and apples are not foods high in potassium.
The nurse is caring for a patient with unstable angina whose cardiac monitor shows ventricular tachycardia. Which action is appropriate to implement first?
check the patient for a pulse The nurse needs to assess the patient to determine stability before proceeding with further interventions. If the patient has a pulse and is relatively stable, elective cardioversion or antidysrhythmic medications may be prescribed. The drug of choice for stable ventricular tachycardia with a pulse is amiodarone. If the patient is pulseless or nonresponsive, the patient is unstable and defibrillation is used.
The nurse is placing a telemetry monitor on a patient being admitted for surgery who has a history of coronary artery disease. The monitor shows sinus tachycardia with a rate of 144 beats/min. How does the nurse respond to this finding? Select all that apply.
assess for jugular venous distention assess blood pressure and skin temperature Ask the patient if he or she is experiencing any chest pain or pressure A heart rate of 144 beats/min is a major concern in patients with coronary artery disease because it increases the workload of the heart, increasing myocardial oxygen demand. A heart rate of 144 beats/min may decrease ventricular filling time, stroke volume, and cardiac output, which decrease blood pressure and coronary perfusion pressure. These factors combined are likely to exacerbate ischemia, causing chest pain or pressure. Associated symptoms are pallor and cool skin temperature. Tachycardia may also lead to heart failure, manifested by distention of the jugular veins. The patient should be advised to limit activities to reduce cardiac workload. Muscle cramps are not associated with tachycardia or coronary artery disease.
The nurse notes ventricular fibrillation on a patient's cardiac monitor. What is the priority intervention at this time?
initiate high-quality CPR In ventricular fibrillation, cardiac output, pulse, and respirations cease, resulting in the absence of systemic tissue perfusion; immediate defibrillation or high-quality CPR with defibrillation as soon as possible is indicated. The health care provider should be notified immediately after CPR is started. Determining the respiratory rate is not necessary because there is no rate to determine. Administration of oxygen is part of the resuscitation effort, but providing oxygen by mask will be ineffective because there is no respiration.
Which precaution should the nurse follow when providing cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) to a patient?
standard precautions Standard Precautions and personal protective equipment must be used when there is risk of contact with blood and body fluids. Protective isolation is designed to protect the patient from pathogens in the environment. Surgical asepsis involves ridding an item of all pathogens, such as in the operating room, with sterilization procedures. A defibrillator is a "clean," not sterile, item. Respiratory isolation is used to prevent transmission of organisms by droplets, such as chickenpox or meningitis. The nurse may choose to use protective eyewear or a face shield during intubation or suctioning of the airway to protect from spraying blood and body fluids.
