EXAM 2 PRACTICE Q's

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Check all that apply. A. The PR intervals are relatively consistent B. One P wave precedes each QRS complex C. Four to eight complexes occur in a 6 second strip D. The ST segment is higher than the PR interval E. The QRS complex ranges from 0.12 to 0.20 seconds

1. A, B. The consistency of the RR interval indicates regular rhythm. A normal P wave before each complex indicates the impulse originated in the SA node. The number of complexes in a 6 second strip is multiplied by 10 to approximate the heart rate; normal sinus rhythm is 60 to 100. Elevation of the ST segment is a sign of cardiac ischemia and is unrelated to the rhythm. The QRS duration should be less than 0.12 second; the PR interval should be 0.12 to 0.20 second.

A client with rapid rate atrial fibrillation asks a nurse why the physician is going to perform carotid massage. The nurse responds that this procedure may stimulate the: A. Vagus nerve to slow the heart rate B. Vagus nerve to increase heart rate; overdriving the rhythm C. Diaphragmatic nerve to slow the heart rate D. Diaphragmatic nerve to overdrive the rhythm

1. A. Carotid sinus massage is one of the maneuvers used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The others include inducing the gag reflex and asking the client to strain or bear down. Medication therapy often is needed as an adjunct to keep the rate down or maintain the normal rhythm.

A client is having frequent premature ventricular contractions. A nurse would place priority on assessment of which of the following items? A. Blood pressure and peripheral perfusion B. Sense of palpitations C. Causative factors such as caffeine D. Precipitating factors such as infection

1. A. Premature ventricular contractions can cause hemodynamic compromise. The shortened ventricular filling time with the ectopic beats leads to decreased stroke volume and, if frequent enough, to decreased cardiac output. The client may be asymptomatic or may feel palpitations. PVCs can be caused by cardiac disorders or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by the intake of caffeine, alcohol, or nicotine.

While caring for a client who has sustained an MI, the nurse notes eight PVCs in one minute on the cardiac monitor. The client is receiving an IV infusion of D5W and oxygen at 2 L/minute. The nurse's first course of action should be to: A. Increase IV infusion rate B. Notify HCP promptly C. Increase oxygen concentration D. Administer a prescribed analgesic

1. B. PVCs are often a precursor of life-threatening dysrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than 5 or 6 per minute in the post MI client, the physician should be notified immediately. More than 6 PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability.

A nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves or definable QRS complexes. Instead there are coarse wavy lines of varying amplitude. The nurse assesses this rhythm to be: A. Ventricular tachycardia B. Ventricular fibrillation C. Atrial fibrillation D. Asystole

1. B. Ventricular fibrillation is characterized by irregular, chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles.

A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but over 100. The nurse determines that the client is experiencing: A. Premature ventricular contractions B. Ventricular tachycardia C. Ventricular fibrillation D. Sinus tachycardia

1. B. Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (usually greater than 0.14 second), and a rate between 100 and 250 impulses per minute. The rhythm is usually regular.

A nurse is viewing the cardiac monitor in a client's room and notes that the client has just gone into ventricular tachycardia. The client is awake and alert and has good skin color. The nurse would prepare to do which of the following? A) Immediately defibrillate B) Prepare for pacemaker insertion C) Administer amiodarone IV D) Administer epinephrine IV

1. C. First-line treatment of ventricular tachycardia in a client who is hemodynamically stable is the use of anti-dysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm (cardioversion is recommended for stable ventricular tachycardia). Defibrillation is used with pulseless ventricular tachycardia. Epinephrine would stimulate and already excitable ventricle and is contraindicated.

A client with a bundle branch block is on a cardiac monitor. The nurse should expect to observe: A. Sagging ST segments B. Absence of P wave configurations C. Inverted T waves following each QRS complex D. Widening of QRS complexes to 0.12 seconds or greater

1. D. Bundle branch block interferes with the conduction of impulses from the AV node to the ventricle supplied by the affected bundle. Conduction through the ventricles is delayed, as evidenced by a widened QRS complex.

The adaptations of a client with complete heart block would most likely include: A. Nausea and vertigo B. Flushing and slurred speech C. Cephalalgia and blurred vision D. Syncope and slow ventricular rate

1. D. In complete atrioventricular block, the ventricles take over the pacemaker function in the heart but at a much slower rate than that of the SA node. As a result there is decreased cerebral circulation, causing syncope.

1.) Which clients should the nurse monitor closely for manifestations of multiple order dysfunction syndrome (MODS)? Select all that apply. 1. Client with sepsis 2. Client with a gastrointestinal bleed 3. Client with acute respiratory failure 4. Client with DKA 5. Client with basilar skull injury

1.) 1,2,3. Infection (such as sepsis) is the most common cause of MODS. Hemorrhage and respiratory failure are other causes. Primary MODS is believed to be the result of inadequate oxygen delivery to cells and a failure of the microcirculation to remove metabolic end products as seen with hypoxemia or hemorrhage. Head trauma and DKA do not place a client at risk for MODS.

1.) The nurse suspects that the client is in cardiogenic shock based on which clinical findings? 1. Decreased of muffled heart sounds 2. Cardiac index greater than 3.2L/min/m2 3. Bounding pulses 4. Cardiac output 5 L/min

1.) 1. Cardiogenic shock is caused by a decrease in pumping ability of the myocardium. The decrease can be caused by a weakened myocardium or restriction of the myocardium by fluid or blood. Decreased or muffled heart sounds would be indicative of a fluid restriction in the pericardial space, causing restriction of the heart's ability to pump effectively. Decreased pumping ability would cause a decrease in the cardiac index (normal 2.5-4.0 L/min/m2); thread, weak pulse; and decreased cardiac output (normal 4-8 liters/minute).

1.) The nurse is caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a state of shock. The nurse knows that which intervention is the priority for this client? 1. Administration of digoxin 2. Administration of whole blood 3. Administration of intravenous fluids 4. Administration of packed red blood cells

1.) 1. The client in this question is likely experiencing cardiogenic shock secondary to heart failure exacerbation. It is important to note that if the shock state is cardiogenic in nature, the infusion of volume-expanding fluids may result in pulmonary edema; therefore, restoration of cardiac function is the priority for this type of shock. Cardiotonic medications such as digoxin, dopamine, or norepinephrine may be administered to increase cardiac contractility and induce vasoconstriction. Whole blood, intravenous fluids, and packed RBCs are volume-expanding fluids and may further complicate the client's clinical status; therefore, they should be avoided.

10. The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), presents to the ED complaining o abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect? 1. Cardiogenic shock. 2. Hypovolemic shock 3. Neurogenic shock 4. Septic shock

1.) 2 Hypovolemic shock. These client's signs/symptoms make the nurse suspect the client is closing blood, which leads to hypovolemic shock, which is the most common type of shock and is characterized by decreased intravascular volume. The client's taking of NSAID medications puts her at risk for hemorrhage because NSAIDs inhibit prostaglandin production in the stomach, which increases the risk of developing ulcers, which can erode the stomach lining and lead to hemorrhaging.

1.) The nurse is caring for a client with an implantable cardioverter defibrillator (ICD). The client goes into ventricular tachycardia and is pulseless. The ICD has fired twice. What action should the nurse take? 1. Administer epinephrine 1 mg IV push 2. Deactivate the ICD with a magnet 3. Initiate chest compressions 4. Take no action and let the ICD work

1.) 3 Correct: The client with an ICD that is firing is receiving electrical shocks from the internal defibrillator to interrupt the dysrhythmia. It is still imperative that the client receive chest compressions in the form of CPR to provide circulation of blood to vital organs.

1.) The nurse is watching the cardiac monitor and notices that a client's rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats per minute. The nurse determines that the client is experiencing which dysrhythmia? 1. Sinus tachycardia 2. Ventricular fibrillation 3. Ventricular tachycardia 4. Premature ventricular contractions

1.) 3. Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 seconds, and typically a rate between 140 and 180 impulses per minute. The rhythm is regular.

1.) A client in shock develops a central venous pressure (CVP) of 2 mm Hg and mean arterial pressure (MAP) of 60 mm Hg. Which prescribed intervention should the nurse implement first? 1. Increase the rate of O2 flow 2. Obtain atrial blood gas results 3. Insert an indwelling urinary catheter 4. Increase the rate of intravenous (IV) fluids

1.) 4 The MAP and CVP are both low for this client, indicating a shock state. Shock is the result of inadequate tissue perfusion. Fluid volume should be immediately restored first to provide adequate perfusion for the client in a shock state. Although increasing the rate of O2 flow may be a necessary intervention, perfusion is the first priority. Obtaining arterial blood gas results and inserting an indwelling urinary catheter may be necessary interventions to monitor the client's response to prescribed therapy, but these are not the priority.

1.) A client in sinus bradycardia, with a heart rate of 45 beats per minute and blood pressure of 82/60 mm Hg, reports dizziness. Which intervention should the nurse anticipate will be prescribed? 1. Administer digoxin 2. Defibrillate the client 3. Continue to monitor the client 4. Prepare for transcutaneous pacing.

1.) 4. Sinus bradycardia is noted with a heart rate less than 60 beats per minute. This rhythm becomes a concern when the client becomes symptomatic. Hypotension and dizziness are signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the symptomatic client. Defibrillation is used for treatment of pulseless ventricular tachycardia and ventricular fibrillation. Digoxin will further decrease the client's heart rate. Continuing to monitor the client delays necessary intervention.

10. The client has developed atrial fibrillation, with a ventricular rate of 150 beats per minute. The nurse should assess the client for which associated signs and/or symptoms? Select all that apply. 1. Syncope 2. Dizziness 3. Palpitations 4. Hypertension 5. Flat neck veins

1.) Correct: 1, 2, 3. The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 bpm is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, SOB, and distended neck veins. Hypertension and flat neck veins are not associated with the loss of cardiac output.

1.) The nurse is caring for a client with a diagnosis of acute myocardial infarction. The client's cardiac alarm sounds and the nurse assesses the client, who is unresponsive, pulseless, and not breathing. Which rhythm is the client likely to be in when placed on a monitor? Select all that apply. 1. Supraventricular tachycardia 2. Atrial flutter 3. Ventricular fibrillation 4. Asystole 5. Pulseless electrical activity

3,4,5. In ventricular fibrillation, asystole, or pulseless electrical activity there is no effective electrical activity in either the atria or ventricles. As a result, the client is unresponsibe, pulseless, and not breathing

1.) The child is diagnosed with early hypovolemic shock following surgical intervention for a ruptured appendix. Which nursing assessment findings best support early hypovolemic shock? 1. Irritability and anxiousness, capillary refill > 2 seconds, and absent distal pulses 2. Bradycardia, hypotension, mottled skin coloring, cyanosis, and weak distal pulses 3. Tachycardia, capillary refill > 2 seconds, cold extremities. And weak distal pulses 4. Lethargy, increased respiratory rate and urine output, and BP low for the child's age

3. Early hypovolemic shock is supported by these signs and symptoms due to blood or fluid loss: tachycardia, CRT > 2 seconds, cold extremities, and weak distal pulses. Other findings are increased respiratory rate, pallor or mottled skin color, and decreased urine output. Usually the BP is normal for the child's age.

A client has developed atrial fibrillation, which a ventricular rate of 150 beats per minute. A nurse assesses the client for: A. Hypotension and dizziness B. Nausea and vomiting C. Hypertension and headache D. Flat neck veins

A. The client with uncontrolled atrial fibrillation with a ventricular rate more than 150 beats a minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.

A nurse is assessing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats per minute. The nurse A. Normal sinus rhythm B. Sinus bradycardia C. Sick sinus syndrome D. First-degree heart block

A. measurements are normal, measuring 0.12 to 0.20 second and 0.4 to 0.10 second, respectively.

A nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead there are wavy lines. The QRS complexes measure 0.08 second, but they are irregular, with a rate of 120 beats a minute. The nurse interprets this rhythm as: A. Sinus tachycardia B. Atrial fibrillation C. Ventricular tachycardia D. Ventricular fibrillation

B. Atrial fibrillation is characterized by a loss of P waves; an undulating, wavy baseline; QRS duration that is often within normal limits; and an irregular ventricular rate, which can range from 60 to 100 beats per minute (when controlled with medications) to 100 to 160 beats per minute (when uncontrolled).

A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs the client to do which of the following, if prescribed, during an episode of ventricular tachycardia? A. Breathe deeply, regularly, and easily B. Inhale deeply and cough forcibly every 1 to 3 seconds C. Lie down flat in bed D. Remove any metal jewelry

B. Cough cardiopulmonary resuscitation (CPR) sometimes is used in the client with unstable ventricular tachycardia. The nurse tells the client to use cough CPR, if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds. Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented.

A nurse notices frequent artifact on the ECG monitor for a client whose leads are connected by cable to a console at the bedside. The nurse examines the client to determine the cause. Which of the following items is unlikely to be responsible for the artifact? A. Frequent movement by the client B. Tightly secured cable connectors C. Leads applied over hairy areas D. Leads applied to the limbs

B. Motion artifact, or "noise," can be caused by frequent client movement, electrode placement on limbs, and insufficient adhesion to the skin, such as placing electrodes over hairy areas of the skin. Electrode placement over bony prominences also should be avoided. Signal interference can also occur with electrode removal and cable disconnection.

When ventricular fibrillation occurs in a CCU, the first person reaching the client should: A. Administer oxygen B. Defibrillate the client C. Initiate CPR D. Administer sodium bicarbonate IV

B. Ventricular fibrillation is a death-producing dysrhythmia and, once identified, must be terminated immediately by precordial shock (defibrillation). This is usually a standing physician's order in a CCU.

When auscultating the apical pulse of a client who has atrial fibrillation, the nurse would expect to hear a rhythm that is characterized by: A. The presence of occasional coupled beats B. Long pauses in an otherwise regular rhythm C. A continuous and totally unpredictable irregularity D. Slow but strong and regular beats

C. In atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions.

10. The client is diagnosed with neurogenic shock. Which signs/symptoms should the nurse assess in this client? 1. Cool, moist, skin 2. Bradycardia 3. Wheezing 4. Decreased bowel sounds

Correct 2. The client will have bradycardia instead of tachycardia, which is seen in other forms of shock.

10. The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first? 1. Administer amiodarone, an antidysrhythmic, IVP 2. Prepare to defibrillate the client. 3. Assess the client's apical pulse and blood pressure. 4. Start basic cardiopulmonary resuscitation.

Correct 3. The nurse must assess the apical pulse and blood pressure to determine if the client is in cardiac arrest and then treat as ventricular fibrillation. If the client's heart is beating, the nurse would then administer lidocaine.

10. The client shows ventricular fibrillation on the telemetry at the nurse's station. Which action should the telemetry nurse implement first? 1. Administer epinephrine IVP 2. Prepare to defibrillate the client. 3. Call a STAT code 4. Start cardiopulmonary resuscitation (CPR)

Correct 3. The nurse must call a code that activated the crash cart being brough to the room and a team of health-care providers that will care for the client according to an established protocol.

10. The client who is one day postoperative coronary artery bypass surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement? 1. Assess the apical heart rate for one full minute. 2. Notify the client's cardiac surgeon 3. Prepare the client for synchronized cardioversion 4. Determine if the client is having pain.

Correct 4. Sinus tachycardia means the sinoatrial node is the pacemaker, but the rate is greater than 100 because of pain, anxiety, or fever. The nurse must determine the cause and treat appropriately. There is no specific medication for sinus tachycardia.