Exam II Review Questions:

The nurse employed in a cardiac unit determines that which client is the least likely to have an implanted cardioverter-defibrillator (ICD) inserted? 1A client with syncopal episodes related to ventricular tachycardia 2A client with ventricular dysrhythmias despite medication therapy 3A client with an episode of cardiac arrest related to myocardial infarction 4A client with 3 episodes of cardiac arrest unrelated to myocardial infarction

3A client with an episode of cardiac arrest related to myocardial infarction Rationale:An ICD detects and delivers an electrical shock to terminate life-threatening episodes of ventricular tachycardia and ventricular fibrillation. This device is implanted in clients who are considered high risk, including those who have syncopal episodes related to ventricular tachycardia, those who are refractive to medication therapy, and those who have survived sudden cardiac death unrelated to myocardial infarction.

A client has developed uncontrolled atrial fibrillation with a ventricular rate of 150 beats/min. What manifestation would the nurse observe for when performing the client's focused assessment? 1Flat neck veins 2Nausea and vomiting 3Hypotension and dizziness 4Clubbed fingertips and headache

3Hypotension and dizziness Rationale:The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/min is at risk for low cardiac output due to 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 client is attached to a cardiac monitor, and the nurse notes the presence of this cardiac rhythm on the monitor. The nurse quickly assesses the client, knowing that this rhythm is indicative of which of the following? Atrial fibrillation 2Ventricular fibrillation (VF) 3Ventricular tachycardia (VT) 4Premature ventricular complexes

3Ventricular tachycardia (VT) Rationale:In VT, it usually is not possible to determine the atrial rhythm. The ventricular rhythm usually is regular or nearly regular. The P waves usually are not visible and are obscured in the QRS complexes. VT occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more.

A child with rheumatic fever will be arriving at the nursing unit for admission. On admission assessment, the nurse would ask the parents which question to elicit assessment information specific to the development of rheumatic fever? "1"Has the child complained of back pain? "2"Has the child complained of headaches? "3"Has the child had any nausea or vomiting? "4"Did the child have a sore throat or fever within the last 2 months?"

"4"Did the child have a sore throat or fever within the last 2 months?" Rationale:Rheumatic fever is an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, skin (subcutaneous tissues), blood vessels, and central nervous system. Rheumatic fever characteristically manifests 2 to 6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child had a sore throat or an unexplained fever within the past 2 months. Options 1, 2, and 3 are unrelated to rheumatic fever.

The nurse is assisting in the care of a client scheduled for cardioversion. The nurse plans to set the defibrillator to which starting energy range level, depending on the specific emergency physician prescription? "1" 120 joules "2" 200 joules "3" 250 joules "4" 350 joules

"1" 120 joules Rationale:For cardioversion procedures, the defibrillator is charged to the energy level prescribed by the emergency physician. Countershock usually is started at 120 to 200 joules. The number of joules in the remaining options are incorrect.

The registered nurse (RN) is orienting a new RN assigned to the care of a client with a dysrhythmia and is told that the client has an alteration in cardiac output. After educating the new RN about cardiac output, which statement made by the new RN indicates the need for further instruction? "1"A cardiac output of 2 L/min is normal. "2"A cardiac output of 4 L/min is normal. "3"A cardiac output of 6 L/min is normal. "4"A cardiac output of 7 L/min is normal."

"1"A cardiac output of 2 L/min is normal. Rationale:The cardiac cycle consists of contraction and relaxation of the heart muscle. In adults, the cardiac output ranges from 4 to 8 L/min. Therefore, option 1 identifies a low cardiac output.

A client with rapid-rate atrial fibrillation asks the nurse why the cardiologist is going to perform carotid sinus massage. The nurse educates the client about the vagus and diaphragmatic nerves and about the treatment. Which statement by the client indicates that the teaching has been effective? "1"The vagus nerve slows the heart rate. "2"The diaphragmatic nerve slows the heart rate. "3"The diaphragmatic nerve overdrives the rhythm. "4"The vagus nerve increases the heart rate, overdriving the rhythm."

"1"The vagus nerve slows the heart rate. Rationale:Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. Others include inducing the gag reflex and asking the client to strain or bear down. Medication therapy is often needed as an adjunct to keep the rate down or maintain the normal rhythm. The remaining options are incorrect descriptions of this procedure.

The nurse is participating in a class on rhythm strip interpretation. Which statement by the nurse indicates an understanding of a PR interval of 0.20? "1"This is a normal finding. "2"This is indicative of atrial flutter. "3"This is indicative of atrial fibrillation. "4"This is indicative of impending reinfarction."

"1"This is a normal finding. Rationale:The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The normal range for the PR interval is 0.12 to 0.20 seconds. The remaining options are incorrect and indicate that further education is needed.

The nurse has provided self-care activity instructions to a client after insertion of an implanted cardioverter-defibrillator (ICD). The nurse determines that further instruction is needed if the client makes which statement? "I need to avoid doing anything that could involve rough contact with the ICD insertion site. "2"I can perform activities such as swimming, driving, or operating heavy equipment as I need to. "3"I need to try to avoid doing strenuous things that would make my heart rate go up to or above the rate cutoff on the ICD. "4"I need to keep away from electromagnetic sources such as transformers, large electrical generators, and metal detectors, and I shouldn't lean over running motors."

"2"I can perform activities such as swimming, driving, or operating heavy equipment as I need to. Rationale:Postdischarge instructions typically include avoiding tight clothing or belts over the ICD insertion site; rough contact with the ICD insertion site; and electromagnetic fields such as with electrical transformers, radio/TV/radar transmitters, metal detectors, and running motors of cars or boats. Clients also must alert primary health care providers (PHCPs) or dentists to the presence of the device because certain procedures such as diathermy, electrocautery, and magnetic resonance imaging may need to be avoided to prevent device malfunction. Clients would follow the specific advice of a PHCP regarding activities that are potentially hazardous to self or others, such as swimming, driving, or operating heavy equipment.

The nurse is caring for a client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. Which activity will assist with preventing dislodgment of the pacing catheter? "1"Limiting both movement and abduction of the left arm "2"Limiting both movement and abduction of the right arm "3"Assisting the client to get out of bed and ambulate with a walker "4"Having the physical therapist do active range-of-motion exercises to the right arm

"2"Limiting both movement and abduction of the right arm Rationale:In the first several hours after insertion of a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgment. The nurse helps prevent this complication by limiting the client's activities of the arm on the side of the insertion site. Therefore, the remaining options are incorrect.

he nurse determines that a client requires further teaching after permanent pacemaker insertion if which statement is made? "I'll need to call my cardiologist if I feel tired or dizzy. "2"My pulse rate should be less than what my pacemaker is set at. "3"I'll have to avoid carrying the grocery bags into the house for the next 6 weeks. "4"It's safe to use my microwave as long it is properly grounded and well shielded."

"2"My pulse rate should be less than what my pacemaker is set at. Rationale:The client should call the cardiologist if the pulse rate is less than what the pacemaker is set at because this could be a sign of pacemaker or battery failure. Option 2 indicates the client needs further teaching, whereas the remaining options are correct statements.

The new registered nurse (RN) is reviewing cardiac rhythms with a mentor. Which statement by the new RN indicates that teaching about ventricular fibrillation has been effective? "1"Ventricular fibrillation appears as irregular beats within a rhythm. "2"Ventricular fibrillation does not have P waves or QRS complexes. "3"Ventricular fibrillation is a regular pattern of wide QRS complexes. "4"Ventricular fibrillation has recognizable P waves, QRS complexes, and T waves."

"2"Ventricular fibrillation does not have P waves or QRS complexes. Rationale:Ventricular fibrillation is characterized by the absence of P waves and QRS complexes. The rhythm is instantly recognizable by the presence of coarse or fine fibrillatory waves on the cardiac monitoring screen. Premature ventricular contractions (PVCs) appear as irregular beats within a rhythm. Ventricular tachycardia is a regular pattern of wide QRS complexes. Sinus tachycardia has a recognizable P wave, QRS complex, and T wave. Each of the incorrect options has a recognizable complex that appears on the monitoring screen.

The clinic nurse reviews the record of a child just seen by the pediatrician and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? "1"Pallor "2"Hyperactivity "3"Activity intolerance "4"Gastrointestinal disturbances

"3"Activity intolerance Rationale:Aortic stenosis is a narrowing or stricture of the aortic valve, causing resistance to blood flow in the left ventricle, decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion. A child with aortic stenosis shows signs of activity intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted, but it is not specific to this type of disorder alone. Options 2 and 4 are not related to this disorder.

The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis? "1"Immunoglobulin "2"Red blood cell count "3"White blood cell count "4"Anti-streptolysin O titer

"4"Anti-streptolysin O titer Rationale:Rheumatic fever is an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, skin (subcutaneous tissues), blood vessels, and central nervous system. A diagnosis of rheumatic fever is confirmed by the presence of two major manifestations or one major and two minor manifestations from the Jones criteria. In addition, evidence of a recent streptococcal infection is confirmed by a positive anti-streptolysin O titer, Streptozyme assay, or anti-DNase B assay. Options 1, 2, and 3 would not help confirm the diagnosis of rheumatic fever.

The home health nurse makes a home visit to a client who has an implanted cardioverter-defibrillator (ICD) and reviews the instructions concerning pacemakers and dysrhythmias with the client. Which client statement indicates that further teaching is necessary? "1"If I feel an internal defibrillator shock, I should sit down. "2"I won't be able to have a magnetic resonance imaging test (MRI). "3"My spouse knows how to call the emergency medical services (EMS) if I need it. "4"I can stop taking my antidysrhythmic medicine now because I have a pacemaker."

"4"I can stop taking my antidysrhythmic medicine now because I have a pacemaker." Rationale:Clients with an ICD usually continue to receive antidysrhythmic medications after discharge from the hospital. The nurse would stress the importance of continuing to take these medications as prescribed. The nurse would provide clear instructions about the purposes of the medications, dosage schedule, and side effects or adverse effects to report. Clients need to sit down if they feel an internal defibrillator shock. They cannot have an MRI because of the possible magnetic properties of the device. Also, knowledge of how to reach EMS is important.

A client is at risk for vasovagal attacks that cause bradydysrhythmias. The nurse would tell the client to avoid which actions to prevent this occurrence? Select all that apply. 1Applying pressure on the eyes 2Raising the arms above the head 3Taking stool softeners on a daily basis 4Bearing down during a bowel movement 5Simulating a gag reflex when brushing the teeth

1Applying pressure on the eyes 2Raising the arms above the head 4Bearing down during a bowel movement 5Simulating a gag reflex when brushing the teeth Rationale:Vasovagal attacks or syncope occurs when the client faints because the body overreacts to certain triggers. The vasovagal syncope trigger causes the heart rate and blood pressure to drop suddenly. That leads to reduced blood flow to the brain, causing the client to briefly lose consciousness. The client at risk would be taught to avoid actions that stimulate the vagus nerve. Actions to avoid include raising the arms above the head, applying pressure over the carotid artery, applying pressure over the eyes, stimulating a gag reflex when brushing the teeth or putting objects into the mouth, and bearing down or straining during a bowel movement. Taking stool softeners is an important measure to prevent the bearing down and straining during a bowel movement.

The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of 150 beats/minute. The nurse would next assess the client for which finding? 1Hypotension 2Flat neck veins 3Complaints of nausea 4Complaints of headache

1Hypotension Rationale:The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/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.

The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. Which assessment is the nursing priority? 1Anxiety level of the client and family 2Activation status and settings of the device 3Presence of a MedicAlert card for the client to carry 4Knowledge of restrictions on postdischarge physical activity

2Activation status and settings of the device Rationale:The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess device settings, similar to care after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether the device is activated, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver. The remaining options are also nursing interventions but are not the priority.

A client's electrocardiogram shows that the ventricular rhythm is irregular and there are no discernible P waves. The nurse recognizes that this pattern is associated with which condition? 1Atrial flutter 2Atrial fibrillation 3First-degree AV block 4Third-degree atrioventricular (AV) block

2Atrial fibrillation Rationale:With atrial fibrillation, the ventricular rhythm is irregular and there are usually no discernible P waves. Therefore, an atrial rhythm cannot be determined. In atrial flutter, the QRS complexes may be either regular or irregular, and the P waves occur as flutter waves. A client in third-degree AV block (also known as complete heart block) has regular atrial and ventricular rhythms, but there is no connection between the P waves and the QRS complexes. In other words, the PR interval is variable and the QRS complexes are normal or widened, with no relationship with the P waves. With first-degree AV block, the PR interval is longer than normal, and there is a connection between the occurrence of P waves and that of QRS complexes.

A client is admitted to the hospital with a diagnosis of pericarditis. The nurse would assess the client for which manifestation that differentiates pericarditis from other cardiopulmonary problems? 1Anterior chest pain 2Pericardial friction rub 3Weakness and irritability 4Chest pain that worsens on inspiration

2Pericardial friction rub Rationale:A pericardial friction rub is heard when inflammation of the pericardial sac is present during the inflammatory phase of pericarditis. Anterior chest pain may be experienced with angina pectoris and myocardial infarction. Weakness and irritability are nonspecific complaints and could accompany a variety of disorders. Chest pain that worsens on inspiration is characteristic of both pericarditis and pleurisy.

The nurse is assessing a client hospitalized with acute pericarditis. The nurse monitors the client for cardiac tamponade, knowing that which signs are associated with this complication of pericarditis? Select all that apply. 1Bradycardia 2Pulsus paradoxus 3Distant heart sounds 4Falling blood pressure (BP) 5Distended jugular veins

2Pulsus paradoxus 3Distant heart sounds 4Falling blood pressure (BP) 5Distended jugular veins Rationale:Assessment findings with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling BP, accompanied by pulsus paradoxus (a drop in inspiratory BP by more than 10 mm Hg).

The nurse notes that a client's cardiac rhythm shows absent P waves, no PR interval, and an irregular rhythm. How would the nurse interpret this rhythm? 1Bradycardia 2Tachycardia 3Atrial fibrillation 4Normal sinus rhythm (NSR)

3Atrial fibrillation Rationale:In atrial fibrillation, the P waves are absent and replaced by fibrillatory waves. There is no PR interval, and the QRS duration usually is normal and constant and the rhythm is irregular. Bradycardia is a slowed heart rate, and tachycardia is a fast heart rate. In NSR, a P wave precedes each QRS complex, the rhythm is essentially regular, the PR interval is 0.12 to 0.20 second, and the QRS interval is 0.06 to 0.10 second.

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats per minute. Which action would the nurse take? 1Check vital signs. 2Check laboratory test results. 3Monitor for any rhythm change. 4Notify the primary health care provider.

3Monitor for any rhythm change. Rationale:Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats per minute. The PR and QRS measurements are normal, measuring between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There are no irregularities in this rhythm currently, so there is no immediate need to check vital signs or laboratory results, or to notify the primary health care provider. Therefore, the nurse would continue to monitor the client for any rhythm change.

The nurse is evaluating a client's cardiac rhythm strip to determine whether there is proper function of the VVI mode pacemaker. Which denotes proper functioning? 1Spikes precede all P waves and QRS complexes. 2There are consistent spikes before each P wave. 3Spikes occur before QRS complexes when intrinsic ventricular beats do not occur. 4Spikes occur before all QRS complexes regardless of intrinsic ventricular activity.

3Spikes occur before QRS complexes when intrinsic ventricular beats do not occur. Rationale:When a pacemaker is operating in the VVI mode, pacemaker spikes will be observed before the QRS complex if there is no intrinsic beat; therefore, options 1, 2, and 4 are incorrect.

The nurse is assessing the client's condition after cardioversion. Which observation would be of highest priority to the nurse? 1Heart rate 2Skin color 3Status of airway 4Peripheral pulse strength

3Status of airway Rationale:Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway, however, is always the highest priority,

The nurse identifies that a client is having occasional premature ventricular contractions (PVCs) on the cardiac monitor. The nurse reviews the client's laboratory results and determines that which result would be consistent with the observation? 1Serum chloride level of 98 mEq/L (98 mmol/L) 2Serum sodium level of 145 mEq/L (145 mmol/L) 3Serum calcium level of 10.5 mg/dL (2.75 mmol/L) 4Serum potassium level of 2.8 mEq/L (2.8 mmol/L)

4Serum potassium level of 2.8 mEq/L (2.8 mmol/L) Rationale:The nurse would check the client's serum laboratory study results for hypokalemia. The client may experience PVCs in the presence of hypokalemia because this electrolyte imbalance increases the electrical instability of the heart. The values noted in the remaining options are normal.

A client with a complete heart block has had a permanent demand ventricular pacemaker inserted. The nurse assesses for proper pacemaker function by examining the electrocardiogram (ECG) strip for the presence of pacemaker spikes at what point? 1Before each P wave 2Just after each P wave 3Just after each T wave 4Before each QRS complex

4Before each QRS complex Rationale:If a ventricular pacemaker is functioning properly, there will be a pacer spike followed by a QRS complex. An atrial pacemaker spike precedes a P wave if an atrial pacemaker is implanted.

The nurse is assessing a client with a history of cardiac valve problems. Where would the nurse place the stethoscope to hear the first heart sound (S1) the loudest? 1Over the second intercostal space at the left sternal border 2Over the fourth intercostal space at the right sternal border 3Over the second intercostal space at the right sternal border 4Over the fifth intercostal space in the left midclavicular line

4Over the fifth intercostal space in the left midclavicular line Rationale:The first heart sound (S1) is heard loudest at the lower left sternal border or the apex of the heart. The apex is located at the fifth intercostal space in the left midclavicular line. Therefore, the locations in the remaining options are incorrect.

A client has received antidysrhythmic therapy for the treatment of premature ventricular contractions (PVCs). The nurse evaluates this therapy as most effective if which finding is noted with regard to the PVCs? 1They occur in pairs. 2They appear to be multifocal. 3They fall on the second half of the T wave. 4They decrease to a frequency of less than 6 per minute.

4They decrease to a frequency of less than 6 per minute. Rationale:PVCs are considered dangerous when they are frequent (more than 6 per minute), occur in pairs or couplets, are multifocal (multiform), or fall on the T wave. In each of these instances, the client's cardiac rhythm is likely to degenerate into ventricular tachycardia or ventricular fibrillation, both of which are potentially deadly dysrhythmias.