Med surg III Exam 1
A nurse is providing teaching to a client who is scheduled to receive one unit of packed RBCs. Which of the following information should the nurse include in the teaching?
"I will remain with you for the first 15 minutes of the transfusion process."
Calculate the heart rate by using these methods: (1) Six-second strip method: (2) Large block method: (3) Small block method:
(1) 12x10 = 120 BPM (2) 300/2.5 = 120 BPM (3) 1500/12 = 125 BPM
A nurse is preparing to administer 0.45% sodium Chloride 600 ml IV to infuse over 8 hr. The drop factor of manual IV tubing is 15 gtt/ml. The nurse should set the manual IV infusion to deliver how many gtt/min?
19 drop/m
The cardiac rhythm strip reveals 5 large blocks between R waves. What is the heart rate?
60 bpm
A nurse is preparing to administer epinephrine (Adrenalin) 5 mcg/min by continuous IV infusion. Available is epinephrine 1 mg in 250 ml dextrose 5% in water (DSW). The nurse should set the IV pump to deliver how many ml/hr? (Round the answer to the nearest whole number.)
75 ml/hr
A patient with CHF is receiving a prescribed IV diuretic. Which assessment finding indicates the drug was effective?
A right atrial pressure of 6 mmHg
A client is undergoing AP monitoring, and the bedside physiologic monitor alarm sounds. The nurse shouldn't
Add IV solution through the arterial pressure monitoring system.
PAWP is 16 mmHg. The neck veins are distended & the lungs have crackles. Which intervention would the nurse anticipate?
Administer a diuretic and a vasodilator as prescribed.
During CVC insertion, the nurse notes bright red blood flashing back. Physician removes it immediately. Priority action?
Apply direct pressure to the insertion site.
What is the rhythm in this ECG strip?
Asystole
What is the rhythm in this ECG strip?
Atrial Flutter
The PR interval is the time between the
Beginning of the P wave and beginning of the QRS complex.
An ICU patient is on arterial pressure monitoring. The nurse noticed the physiologic monitor alarm sounds. Which of the following indicates correct nursing actions? Select all that apply
Check to see whether the catheter is kinked. Make sure that there is sufficient pressure in the pressure bag. Check the potency of the catheter. Check to see whether the stopcocks are turned the wrong way.
The nurse is assessing a patient's arterial waveform and notes a notch on the descending portion of the waveform. The nurse associates this notch with which physiological events?
Closure of the aortic valve
The nurse notes a notch on the descending portion of the arterial waveform. The nurse associates this notch with?
Closure of the aortic valve
What is the rhythm in this ECG strip?
Coarse VF
A pt is admitted to ED after fainting. Bp 86/60, HR 160 bpm, and RR 20. Skin is cool to touch. Which NDX is priority?
Decreased Cardiac Output
The initial steps of evaluating the strip occur in which order?
Determine A&V HR, examine the rhythm regularity, examine P waves.
The critical care nurse is caring for a client with sinus bradycardia. Which of the following findings requires the nurse to intervene? (Select all that apply.)
Dizziness Hypotension Angina
The phlebostatic axis is best described as the bisection of the fourth intercostal space and the midaxillary line.
False
What is the rhythm in this ECG strip?
Fine VF
A nurse is preparing to administer one unit of packed RBCs to a client who has anemia. Which of the following actions should the nurse take?
Have a second nurse assist with comparing the client's identification information
A nurse is caring for a client who is receiving a unit of packed RBCs. The client reports experiencing flank pain and feeling their heart racing. The nurse should identify that the client is experiencing which of the following types of transfusion reactions?
Hemolytic
SVR has risen to 1,800 dynes/sec/cm 5, whereas the pt CO remains at 6.0 L/m. What'd the nurse expect the pt's BP to be?
Increased
A patient with a radial artery catheter complains of numbness and tingling in the fingers. What is the nurse's priority?
Is there a palpable pulse?
The nurse is performing an assessment on a patient whose CVP 12 mmHg. Which findings would the nurse anticipate?
Jugular vein distention
A client's QRS complex measures 0.16 second. This interval is
Long
Which nursing actions are necessary to collect information needed to figure out the patient's cardiac index?
Measure the patient's height.
What is the rhythm in this ECG strip?
Normal Sinus Rhythm
Critical care nursing is interpreting the patient's ECG. The nurse noted the following: HR 80 bpm, R-R intervals are regular, each P wave looks the same, the PR interval is 0.12 seconds, each P wave is followed by a QRS, the QRS complex is 0.11 seconds, and the QT interval is half the R-R interval. How should the nurse interpret this rhythm?
Normal sinus rhythm
Match the terms with their explanations.
P wave ->> Atrial depolarization PR interval ->> Time from SA node stimulation to ventricular depolarization QRS complex ->> Ventricular depolarization T wave ->> Ventricular re-polarization QT interval ->> Total time for ventricular depolarization and re-polarization
What is the rhythm in this ECG strip?
PAC
Which of the following if observed on the cardiac monitor, requires an intervention? (Select all that apply.)
PR interval is 0.30 seconds. QRS interval is 0.20 seconds.
What is the rhythm in this ECG strip?
PVC
A patient requires the insertion of an arterial catheter. Which nursing action is indicated?
Prime the pressure monitoring system.
Which of the following is the normal cardiac electrical conduction pathway?
SA node - AV node - the bundle of His - bundle branches - Purkinje fibers.
The rhythm is showing the following ECG features: QRS complexes: Present, all shaped the same Regularity: Regular rhythm, HR: 47 bpm P waves: Upright, matching, 1 per QRS, P-P interval regular PR interval: 0.16 seconds, QRS interval: 0.06-0.08 seconds, QT interval: 0.40 seconds Which of the following rhythms is displayed in the ECG strip?
Sinus Bradycardia
What is the rhythm in this ECG strip?
Sinus Bradycardia
Which of the following could cause bradycardia?
Sinus Dysrhythmias
The rhythm is showing the following ECG features: QRS complexes: Present, all shaped the same Regularity: Regular rhythm, HR: 120 bpm P waves: Upright, matching, 1 per QRS, P-P interval regular PR interval: 0.12 seconds, QRS interval: 0.10 seconds, QT interval: not measurable (no measurable T wave in this lead) Which of the following rhythms is displayed in the above ECG strip?
Sinus Tachycardia
The rhythm is showing the following ECG features: QRS complexes: Present, all shaped the same Regularity: Regular rhythm, HR: 120 bpm P waves: Upright, matching, 1 per QRS, P-P interval regular PR interval: 0.14 seconds, QRS interval: 0.08 seconds; QT interval: 0.32 seconds Which of the following rhythms is displayed in the above ECG strip?
Sinus Tachycardia
The above rhythm is showing the following ECG features: QRS complexes: Present, all shaped the same Regularity: Underlying regular rhythm with one premature beat, HR: 115; 6th QRS complex occurred earlier than expected. P waves: Underlying rhythm - upright, matching, 1 per QRS; P-P interval regular in underlying rhythm; 5th P wave occured earlier than expected and appearance does not match PR interval: 0.18 sec. QRS interval: 0.08 sec. QT interval:0.30 sec. Which of the following rhythms is displayed in the above ECG strip?
Sinus tachycardia with one premature atrial contraction (PAC)
The QRS interval is equal to 4 small boxes
Slowed ventricular depolarization
The nurse is caring for a patient being monitored with a PA catheter. Which change requires immediate intervention?
Spontaneous development of a pulmonary artery wedge pressure waveform
Ventricular Depolarization
The electrical activation of the ventricles
Ventricular Contraction
The mechanical contraction of the ventricles
What is the difference between ventricular depolarization and ventricular contraction?
The ventricles contract rapidly increases due to the ventricular depolarization and the pressure inside the ventricles.
What is the rhythm in this ECG strip?
Type II 2nd degree AV
A nurse is preparing to administer platelets to a client who has thrombocytopenia. Which of the following actions should the nurse take?
Use a transfusion set that has a short tubing and a small filter.
Which nursing interventions are indicated when measuring pulmonary artery wedge pressure (PAWP)?
Use a volume of no more than 1.5 mL to inflate the balloon.
Which of the following is a cardiac arrest rhythm?
VF
What is the rhythm in this ECG strip?
VT
The postoperative patient's CVP has dropped from 6 to 2 mmHg. The nurse would assess for findings of which conditions?
Vasodilation from drugs administered during surgery
A patient who was stabbed multiple times in the chest and abdomen has just returned from emergency surgery. Hemodynamic monitoring was initiated during surgery and now reveals that the patient's central venous pressure has dropped to 2 mmHg. The nurse would assess for findings of which conditions? Select all that apply.
Vasodilation from drugs administered during surgery Left heart failure Internal hemorrhage
What is the rhythm in this ECG strip?
Ventricular Tachycardia
A nurse is preparing to administer 2 units of packed RBCs to an older adult client. Which of the following actions should the nurse take?
Wait 2 hours between infusing the two units of packed RBC's.
The nurse is preparing to use a patient's PA catheter to obtain hemodynamic measurements. Which action is indicated?
Zero the transducer at the phlebostatic axis.
