SG-CHAPTER 31: Concepts of Care for Patients with Dysrhythmias

A nurse is assessing a client who is taking oral amiodarone to treat atrial fibrillation. Which of the following findings should the nurse identify as an adverse effect of oral amiodarone? A. Ataxia B. Dysuria C. Hypokalemia D. Hypertension

✔ Correct Answer: A. Ataxia The nurse should identify that ataxia, involuntary movements, peripheral neuropathy, and tremor are all neurological adverse effects of oral amiodarone. Incorrect Answers: B) Dysuria is not an adverse effect of oral amiodarone. Genitourinary adverse effects include decreased libido and epididymitis in male clients. C) Hypokalemia is not an adverse effect of oral amiodarone. However, the nurse should monitor the client for hypokalemia because it can decrease the effectiveness of the medication and contribute to the development of arrhythmias. D) Hypertension is not an adverse effect of oral amiodarone. Adverse effects of oral amiodarone include bradycardia, hypotension, and congestive heart failure. Vital Concept: Amiodarone is a class III potassium channel blocker, a medication that delays repolarization of the heart rhythm. Amiodarone is indicated for the treatment and management of recurrent ventricular fibrillation and recurrent unstable ventricular tachycardia and is used to treat clients where other medications have failed to correct the dysrhythmias such as atrial fibrillation. Client/Family Teaching • Take amiodarone as directed and do not double doses. • Avoid drinking grapefruit juice. • Monitor pulse daily and report abnormal results to the provider. • Wear sunblock and protective clothing to prevent discoloration of the skin. • Notify a health care provider if visual disturbances occur.

Medication For Afib

⬤Antidysrhythmic drugs -to slow the ventricular conduction or to convert the AF to normal sinus rhythm (NSR). ▪Calcium channel blockers: • Diltiazem •Amiodarone(Cordarone)or Dronedarone (Multaq) Slows speed of conduction; vasodilators, Can cause bradycardia, hypotension, prolonged QT ▪Dronedarone -Better tolerated. For maintenance of sinus rhythm after cardioversion. SHOULD NOT be used in patients with Heart Failure ‹#› ▪Beta blockers: Metoprolol (Toprol, Betaloc ) & Esmolol (Brevibloc). Used to slow ventricular response. ▪Digoxin(Lanoxin,Toloxin ) for Heart failure and AF •Control the rate of ventricular response. •Does not convert AF to sinus rhythm , monitor the pulse rate Rhythm Control: Flecainide, Dofetilide, Propafenone, ibutilide- Can develop prolonged QT interval. ⬤If none of these medications work, then the next option is Cardioversion. ‹#› Anticoagulation: Atrial Fib ⬤ASA: little effectiveness ⮚Slightly greater effectiveness if combined with Plavix (clopidogrel) ⬤Warfarin (Coumadin) ⬤Dabigatran (Pradaxa) ⬤Rivaroxaban (Xarelto) ⬤Apixaban ( Eliquis) Book Iggy - 653

SVT - Intervention

⬤Vagal Maneuvers : ⮚Include Carotid sinus massage & Valsalva maneuvers.→ This is often temporary & may cause "rebound" Tachycardia or Severe Bradycardia. ⬤Carotid Sinus Massage • HCP massages over one carotid artery for a few seconds, observing for a change in cardiac rhythm. -This intervention causes slowing SA & AV nodal conduction. -Instruct to turn the head slightly away from the side to be massaged & observe the cardiac monitor for a change in rhythm. -After the procedure: assess vital signs and the level of consciousness. ‹#› Interventions For SVT ⬤"Always begin with Nonpharmacological intervention, then if symptomatic → Pharmacological." ⬤If SVT occurs in a healthy person and stops on its own: ⮚ No intervention may be needed other than eliminating identified causes. ⮚ If SVT continues: Patient should be studied in the electrophysiology study (EPS) laboratory. ⮚The preferred treatment for recurrent SVT: Radiofrequency catheter ablation. ⮚(Ablation also in treatment of atrial fibrillation.) ‹#› SVT - Intervention ⬤If Symptoms of poor perfusion are Severe & Persistent Synchronized Cardioversion to immediately terminate the SVT. ⬤For long-term treatment, patients are referred to an electrophysiologist for: ⮚ Radiofrequency catheter ablation ‹#› Drug Therapy for SVT ⬤ Adenosine (Adenocard) → Used to terminate the acute episode. ▪ Adenosine is given rapidly (over several seconds) followed by a Normal Saline Bolus. (Flush = Push Normal saline) ▪"Need to push quick, and flush quick! It needs to reach heart in under 5 seconds." ▪ * AV nodal blocking agents → Beta & Calcium channel blockers, also given to treat SVT. ‹#› Antidysrhythmic Medication(Iggy 650) Class I: Sodium Channel Blockers Class II: Beta Blockers ○Propranolol (Inderal, Apo-Propanolol ) ○▪ Acebutolol (Sectral) ○▪ Esmolol (Brevibloc) ○▪ Sotalol (Betapace) Class III: Calcium Channel Blockers ○Sotalol (Betapace) ○Amiodarone (Cordarone) ○Dronedarone (Multaq) ○Ibutilide (Corvert) ○Dofetilide (Tikosyn) ‹#› Antiarrhythmic Medications ⬤▪ Sotalol (Betapace) ⮚ Used for atrial and ventricular dysrhythmias. ⬤▪ Amiodarone (Cordarone) → A-fib or A-Flutter - " ⮚Can cause both Atrial & Ventric. dysrhythmias. ⮚Can be Life threatening." ⮚Used for atrial and ventricular dysrhythmias. ⮚Continually monitor ECG rhythm during infusion; bradycardia and AV block can occur. ⮚This drug can cause serious toxicities (lung damage, visual impairment). As a result, approval is limited to use for life-threatening dysrhythmias. ⮚However, because of efficacy, use remains very common. ⮚Corneal pigmentation occurs in most patients, but it generally does not interfere with vision ‹#› Antiarrhythmic Medications ⬤Dronedarone (Multaq) ⮚Used for AF and atrial flutter.

Sinus Bradycardia —>Interventions

- Take action ⬤Treatment : CLIENTS symptoms of decreased CO, apical rate < 50 beats/minute. ⬤Treat cause and hold conduction SLOWING drugs ⬤If symptomatic -**Atropine IVP (while awaiting pacemaker) 0.5 mg q 3-5 minutes - MAX DOSE 3 mg CONTRAINDICATED WITH GLAUCOMA / URINARY RETENTION Transcutaneous pacing (TCP) Dopamine (medium dose) OR Epinephrine IVP ⬤Administer oxygen, if indicated ⬤IV fluids

2. The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased cardiac output related to inability of the heart to pump effectively" is written. Which short-term goal would be best for the client? 1. The client will be able to ambulate in the hall by date of discharge. 2. The client will have an audible S1 and S2 with no S3 heard by end of shift. 3. The client will turn, cough, and deep breathe every two (2) hours. 4. The client will have a SaO2 reading of 98% by day two (2) of care.

1. Ambulating in the hall by day of discharge would be a more appropriate goal for an activity-intolerance nursing diagnosis. ✅2. Audible S1 and S2 sounds are normal for a heart with adequate output. An audible S3 sound might indicate left ventricular fail- ure, which could be life threatening. This is a nursing intervention, not a short- term goal, for this client. A pulse oximeter reading would be a goal for impaired gas exchange, not for cardiac output. TEST-TAKING HINT: When reading a nursing diagnosis or problem, the test taker must be sure that the answer selected addresses the problem. An answer option may be appropri- ate care for the disease process but may not fit with the problem or etiology. Remember, when given an etiology in a nursing diagnosis, the answer will be doing something about the problem (etiology). In this question the testtaker should look for an answer that addresses the ability of the heart to pump blood. Content - Medical: Integrated Nursing Process - Planning: Client Needs - Safe Effective Care Environment, Management of Care: Cognitive Level - Synthesis: Concept - Perfusion.

83. The nurse is preparing to administer medications to the following clients. Which medication should the nurse question administering? 1. The oral coagulant warfarin (Coumadin) to the client with an INR of 1.9. 2. Regular insulin to a client with a blood glucose level of 218 mg/dL. 3. Hang the heparin bag on a client with a PT/PTT of 12.9/98. 4. A calcium channel blocker to the client with a BP of 112/82.

1. An INR of 2 to 3 is therapeutic; therefore, the nurse would administer this medication. 2. This is an elevated blood glucose level; there- fore, the nurse should administer the insulin. ✅3. A normal PTT is 39 seconds, and for heparin to be therapeutic, it should be 1.5 to 2 times the normal value, or 58 to 78. A PTT of 98 indicates the client is not clotting and the medication should be held. 4. This is a normal blood pressure and the nurse should administer the medication. TEST-TAKING HINT: This question is asking the test taker to select a distracter with assessment data that are unsafe for admin- istering the medication. The test taker must know normal laboratory values to administer medication safely. Content - Medical: Integrated Nursing Process - Implementation: Client Needs - Physiological Integrity, Pharmacological and Parenteral Therapies: Cognitive Level - Application: Concept - Medication

79. The nurse identified the client problem "decreased cardiac output" for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care? 1. Monitor the client's arterial blood gases 2. Assess skin color and temperature. 3. Check the client for signs of bleeding. 4. Keep the client in the Trendelenburg position.

1. Arterial blood gases would be included in the client problem "impaired gas exchange." ✅2. These assessment data monitor tissue perfusion, which evaluates for decreased cardiac output. 3. This would be appropriate for the client problem "high risk for bleeding." 4. The client should not be put in a position with the head lower than the legs because this would increase difficulty breathing. TEST-TAKING HINT: The test taker must think about which answer option addresses the problem of the heart's inability to pump blood. Decreased blood to the extremities results in cyanosis and cold extremities. Content - Medical: Integrated Nursing Process - Diagnosis: Client Needs - Safe Effective Care Environ- ment, Management of Care: Cognitive Level - Analysis: Concept - Oxygenation.

76. The client diagnosed with a pulmonary embolus is in the intensive care department. Which assessment data warrant immediate intervention from the nurse? 1. The client's ABGs are pH 7.36, Pao2 95, Paco2 38, Hco3 24. 2. The client's telemetry exhibits occasional premature ventricular contractions (PVCs). 3. The client's pulse oximeter reading is 90%. 4. The client's urinary output for the 12-hour shift is 800 mL.

1. The ABGs are within normal limits and would not warrant immediate intervention. 2. Occasional premature ventricular contractions are not unusual for any client and would not warrant immediate intervention. ✅3. The normal pulse oximeter reading is 93% to 100%. A reading of 90% indicates the client has an arterial oxygen level of around 60. 4. A urinary output of 800 mL over 12 hours in- dicates an output of greater than 30 mL/hour and would not warrant immediate interven- tion by the nurse. TEST-TAKING HINT: This question is asking the test taker to select abnormal, unex- pected, or life-threatening assessment data in relationship to the client's disease process. A pulse oximeter reading of less than 93% indicates severe hypoxia and requires imme- diate intervention. Content - Medical: Integrated Nursing Process - Assessment: Client Needs - Safe Effective Care Environ- ment, Management of Care: Cognitive Level - Synthesis: Concept - Oxygenation.

84. The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolism. Which action should the nurse implement first? 1. Administer oxygen 10 L via nasal cannula. 2. Place the client in high Fowler's position. 3. Obtain a STAT pulse oximeter reading. 4. Auscultate the client's lung sounds.

1. The client needs oxygen, but the nurse can intervene to help the client before applying oxygen. ✅2. Placing the client in this position facilitates maximal lung expansion and reduces venous return to the right side of the heart, thus lowering pressures in the pulmonary vascular system. 3. A pulse oximeter reading is needed, but it is not the first intervention. 4. Assessing the client is indicated, but it is not TEST-TAKING HINT: The test taker must select the option that will directly help the client breathe easier. Therefore, assessment is not the first intervention and option "4" can be eliminated as the correct answer. When the client is in distress, do not assess. Content - Medical: Integrated Nursing Process - Implementation: Client Needs - Safe Effective Care Envi- ronment, Management of Care: Cognitive Level - Synthesis: Concept - Oxygenation

81. Which statement by the client diagnosed with a pulmonary embolus indicates the discharge teaching is effective? 1. "I am going to use a regular-bristle toothbrush." 2. "I will take antibiotics prior to having my teeth cleaned." 3. "I can take enteric-coated aspirin for my headache." 4. "I will wear a Medic Alert band at all times."

1. The client should use a soft-bristle tooth- brush to reduce the risk of bleeding, so the teaching is not effective. 2. This is appropriate for a client with a mechanical valve replacement, not a client receiving anticoagulant therapy, so the teaching is not effective 3. Aspirin, enteric-coated or not, is an anti-platelet, which may increase bleeding tendencies and should be avoided, so the teaching is not effective. ✅4. The client should wear a Medic Alert band at all times so that, if any accident or situation occurs, the health-care providers will know the client is receiving antico- agulant therapy. The client understands the teaching. TEST-TAKING HINT: This is a higher level question in which the test taker must know clients with a pulmonary embolus are prescribed anticoagulant therapy on discharge from the hospital. If the test taker had no idea of the answer, the option stating "wear a Medic Alert band" is a good choice because many disease processes require the client to take long-term medication and a health-care provider should be aware of this. Content - Medical: Integrated Nursing Process - Evaluation: Client Needs - Physiological Integrity, Physi- ological Adaptation: Cognitive Level - Synthesis: Concept - Oxygenatio

78. The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a PT/PTT of 22/39 and an INR of 2.8. What action should the nurse implement? 1. Assess the client for abnormal bleeding. 2. Prepare to administer vitamin K (AquaMephyton). 3. Administer the medication as ordered. 4. Notify the HCP to obtain an order to increase the dose.

1. The client would not be experiencing abnornal bleeding with this INR 2. This is the antidote for an overdose of antico- agulant and the INR does not indicate this. ✅3. A therapeutic INR is 2 to 3; therefore, the nurse should administer the medication. 4. There is no need to increase the dose; this result is within the therapeutic range TEST-TAKING HINT: The test taker must know normal laboratory values; this is the only way the test taker will be able to answer this question. The test taker should make a list of laboratory values that must be memorized for successful test taking. Content - Medical: Integrated Nursing Process - Implementation: Client Needs - Physiological Integrity, Pharmacological and Parenteral Therapies: Cognitive Level - Application: Concept - Medication.

49. The telemetry nurse is unable to read the telemetry monitor at the nurse's station. Which intervention should the telemetry nurse implement first? 1. Go to the client's room to check the client. 2. Instruct the primary nurse to assess the client. 3. Contact the client on the client call system. 4. Request the nursing assistant to take the crash cart to the client's room.

1. The telemetry nurse should not leave the monitors unattended at any time. 2. The telemetry nurse must have someone go assess the client, but this is not the first intervention. ✅ 3. If the client answers the call light and is not experiencing chest pain, then there is probably a monitor artifact, which is not a life-threatening emergency. After talking with the client, send a nurse to the room to check the monitor. 4.The crash cart should be taken to a room when the client is coding TEST-TAKING HINT: When the test taker sees the word "first," the test taker must realize that more than one answer option may be a pos- sible intervention but that only one should be implemented first. The test taker should try to determine which intervention directly affects the client.

77. The client is admitted to the medical unit diagnosed with a pulmonary embolus. Which intervention should the nurse implement? 1. Administer oral anticoagulants. 2. Assess the client's bowel sounds. 3. Prepare the client for a thoracentesis. 4. Institute and maintain bedrest.

1.The intravenous anticoagulant heparin will be administered immediately after diagnosis of a PE, not oral anticoagulants. 2. The client's respiratory system will be assessed, not the gastrointestinal system. 3. A thoracentesis is used to aspirate fluid from the pleural space; it is not a treatment for a PE. ✅4. Bedrest reduces the risk of another clot becoming an embolus leading to a pulmonary embolus. Bedrest reduces metabolic demands and tissue needs for oxygen in the lungs. TEST-TAKING HINT: The test taker must be aware of adjectives such as "oral" in option "1," which makes this option incorrect. The test taker should apply the body system of the disease process to eliminate option "2" as a correct answer. Content - Medical: Integrated Nursing Process - Implementation: Client Needs - Physiological Integrity, Physiological Adaptation: Cognitive Level - Application: Concept - Oxygenation..

50. 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).

1.There are many interventions that should be implemented prior to administering medication. 2. The treatment of choice for ventricular fibril- lation is defibrillation, but it is not the first action. ✅3 The nurse must call a code that activates the crash cart being brought to the room and a team of health-care providers that will care for the client according to an es- tablished protocol. 4. The first person at the bedside should start cardiopulmonary resuscitation (CPR), but the telemetry nurse should call a code so that all necessary equipment and personnel are at the bedside.

75. Which nursing assessment data support that the client has experienced a pulmonary embolism? 1. Calf pain with dorsiflexion of the foot. 2. Sudden onset of chest pain and dyspnea. 3. Left-sided chest pain and diaphoresis. 4. Bilateral crackles and low-grade fever.

1.This is a sign of a deep vein thrombosis, which is a precursor to a pulmonary embolism, but it is not a sign of a pulmonary embolism. ✅2. The most common signs of a pulmonary embolism are sudden onset of chest pain when taking a deep breath and shortness of breath. 3. These are signs of a myocardial infarction. 4. These could be signs of pneumonia or other pulmonary complications but not specifically a pulmonary embolism. TEST-TAKING HINT: The key to selecting option "2" as the correct answer is sudden onset. The test taker would need to note "left-sided" in option "3" to eliminate this as a possible correct answer, and option "4" is nonspecific for a pulmonary embolism. Content - Medical: Integrated Nursing Process - Assessment: Client Needs - Physiological Integrity, Reduc- tion of Risk Potential: Cognitive Level - Analysis: Concept - Oxygenatio

50. Interpret the following Ventricular tachycardia RATE__________ RHYTHM__________ P WAVES___________ PR INTERVAL____________ QRS DURATION _____________

50. RATE About 200 beats/min; RHYTHM Regular with wide QRS complexes; P WAVES none; PR INTERVAL None; QRS DURATION wide 0.28 second; INTERPRETATION Ventricular tachycardia

A nurse is caring for a client who experienced defibrillation. Which of the following should be included in the documentation of this procedure? (Select all that apply.) A. Follow‐up ECG B. Energy settings used C. IV fluid intake D. Urinary output E. Skin condition under electrodes

A. ✔CORRECT: The client's ECG rhythm is documented following the procedure. B. ✔CORRECT: Energy settings used during the procedure are documented. C. IV fluid intake is not documented during defibrillation. D. Urinary output is not documented during defibrillation. E. ✔CORRECT: The condition of the client's skin where electrodes were placed is documented.

54. The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client? 1. Instruct the client to use a soft-bristle toothbrush. 2. Discuss the importance of getting a monthly partial thromboplastin time (PTT). 3. Teach the client about signs of pacemaker malfunction. 4. Explain to the client the procedure for synchronized cardioversion.

ANS 1 1.A client with chronic atrial fibrillation will be taking an anticoagulant to help prevent clot formation. Therefore, the client is at risk for bleeding and should be instructed to use a soft-bristle toothbrush. 2. The client will need a regularly scheduled INR to determine the therapeutic level for the anticoagulant warfarin (Coumadin); PTT levels are monitored for heparin. 3. A client with symptomatic sinus bradycardia, not a client with atrial fibrillation, may need a pacemaker. 4. Synchronized cardioversion may be pre- scribed for new-onset atrial fibrillation but not for chronic atrial fibrillation. TEST TAKING HINT: In order to choose the correct answer for this question the test taker must recognize the disease process, then know what complications are possible, and finally the test-taker must know how the client can possibly be treated so that the complication does not occur. Content - Medical: Integrated Nursing Process - Planning: Client Needs - Physiological Integrity, Physiological Adapta- tion: Cognitive Level - Synthesis: Concept - Nursing R

57. The client is in ventricular fibrillation. Which interventions should the nurse implement? Select all that apply. 1. Start cardiopulmonary resuscitation. 2. Prepare to administer the antidysrhythmic adenosine IVP. 3. Prepare to defibrillate the client. 4. Bring the crash cart to the bedside. 5. Prepare to administer the antidysrhythmic amiodarone IVP.

ANS 1. 3,4,5 ✅1. Ventricular fibrillation indicates the client does not have a heartbeat. Therefore, CPR should be instituted. 2. Adenosine, an antidysrhythmic, is the drug of choice for supraventricular tachycardia, not for ventricular fibrillation. ✅3. Defibrillation is the treatment of choice for ventricular fibrillation. ✅4. The crash cart has the defibrillator and is used when performing advanced cardio- pulmonary resuscitation ✅5. Amiodarone is an antidysrhythmic that is used in ventricular dysrhythmias. TEST-TAKING HINT: This is an alternate-type question that requires the test taker to pos- sibly select more than one option. To receive credit, the test taker must select all correct options; partial credit is not given for this type of question. Content - Medical: Integrated Nursing Process - Implementation: Client Needs - Safe Effective Care Environment, Management of Care: Cognitive Level - Analysis: Concept - Perfusion

60. Which client problem has priority for the client with a cardiac dysrhythmia? 1. Alteration in comfort. 2. Decreased cardiac output. 3. Impaired gas exchange. 4. Activity intolerance.

ANS 2 1.Not every cardiac dysrhythmia causes alteration in comfort; angina is caused by decreased oxygen to the myocardium. ✅2. Any abnormal electrical activity of the heart causes decreased cardiac output. 3.Impaired gas exchange is the result of pulmonary complications, not cardiac dysrhythmias 4. Not all clients with cardiac dysrhythmias have activity intolerance. TEST-TAKING HINT: Option "2" has the word "cardiac," which refers to the heart. Therefore, even if the test taker had no idea what the cor- rect answer was, this would be an appropriate option. The test taker should use medical ter- minology to help identify the correct option. Content - Medical: Integrated Nursing Process - Diagnosis: Client Needs - Physiological Integrity, Physiological Adaptation: Cognitive Level - Analysis: Concept - Perfusion.

56. The client is in complete heart block. Which intervention should the nurse implement first? 1. Prepare to insert a pacemaker. 2. Administer atropine, an antidysrhythmic. 3. Obtain a STAT electrocardiogram (ECG). 4. Notify the health-care provider.

ANS 2 1. A pacemaker will have to be inserted, but it is not the first intervention. ✅2. Atropine will decrease vagal stimulation and increase the heart rate. Therefore, it is the first intervention. A STAT ECG may be done, but the telem- etry reading shows complete heart block, which is a life-threatening dysrhythmia and must be treated. 4. TheHCPwill need to be notified but not prior to administering a medication. The test taker must assume the nurse has the order to administer medication. Many telemetry departments have standing protocols TEST-TAKING HINT: The test taker must select the intervention that should be implemented first and will directly affect the dysrhythmia. Medication is the first intervention, andthen pacemaker insertion. The test taker should not eliminate an option because the test taker thinks there is not an order by a health-care provider. Content - Medical: Integrated Nursing Process - Implementation: Client Needs - Safe Effective Care Environment, Management of Care: Cognitive Level - Synthesis: Concept - Perfusion.

3. The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply. 1. Notify the health-care provider of a weight gain of more than one (1) pound in a week. 2. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct the client to remove the saltshaker from the dinner table. 4. Encourage the client to monitor urine output for change in color to become dark. 5. Discuss the importance of taking the loop diuretic furosemide at bedtime.

ANS 2,3 TEST-TAKING HINT: This is an alternative-type question—in this case, "Select all that apply." If the test taker missed this statement, it is pos- sible to jump at the first correct answer. This is one reason that it is imperative to read all op- tions before deciding on the correct one(s). This could be a clue to reread the question for clarity. Another hint that this is an alternative question is the number of options. The other questions have four potential answers; this one has five. Numbers in an answer option are always im- portant. Is one (1) pound enough to indicate a problem that should be brought to the attention of the health-care provider? Content - Medical: Integrated Nursing Process - Planning: Client Needs - Physiological Integrity, Physiological Adaptation: Cognitive Level - Synthesis: Concept - Nursing Roles.

55. 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

ANS 3 1.Amiodarone is the drug of choice for ven- tricular tachycardia, but it is not the first intervention. 2.Defibrillation may be needed, but it is not the first intervention. 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. 4. CPR is only performed on a client who is not breathing and does not have a pulse. The nurse must establish if this is occurring first prior to taking any other action

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

ANS 4 1. The telemetry reading is accurate, and there is no need f 2. There is no reason to notify the surgeon for a client exhibiting sinus tachycardia. 3. Synchronized cardioversion is prescribed for clients in acute atrial fibrillation or ventricu- lar fibrillation with a pulse. ✅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 TEST-TAKING HINT: The test taker must use the nursing process to determine the correct option and select an option that addresses as- sessment, the first step of the nursing process. Because both option "1" and option "4" address assessment, the test taker must determine which option is more appropriate. How will taking the apical pulse help treat sinus tachy- cardia? Determining the cause for sinus tachy- cardia is the most appropriate intervention. Content - Surgical: Integrated Nursing Process - Implementation: Client Needs - Safe Effective Care Environment, Management of Care: Cognitive Level - Application: Concept - Perfusion.

53.Which intervention should the nurse implement when defibrillating a client who is in ventricular fibrillation? 1. Defibrillate the client at 50, 100, and 200 joules. 2. Do not remove the oxygen source during defibrillation. 3. Place petroleum jelly on the defibrillator pads. 4. Shout "all clear" prior to defibrillating the client.

ANS _4- 1. The adult client should be defibrillated at 360 joules. 2. The oxygen source should be removed to prevent any type of spark during defibrillation. 3. The nurse should use defibrillator pads or defibrillator gel to prevent any type of skin burns while defibrillating the client. ✅4If any member of the health-care team is touching the client or the bed during defibrillation, that person could possibly be shocked. Therefore, the nurse should shout "all clear." TAKING HINT: The test taker should al- ways consider the safety of the client and the health-care team. Options "2" and "3" put the client at risk for injury during defibrillation. Content - Medical: Integrated Nursing Process - Implementation: Client Needs - Safe Effective Care Environment, Management of Care: Cognitive Level - Application: Concept - Perfusion.

52. The client is exhibiting sinus bradycardia, is complaining of syncope and weakness, and has a BP of 98/60. Which collaborative treatment should the nurse anticipate being implemented? 1. Administer a thrombolytic medication. 2. Assess the client's cardiovascular status. 3. Prepare for insertion of a pacemaker. 4. Obtain a permit for synchronized cardioversion.

ANS-3 a client experiencing a myocardial infarction. 2. Assessment is an independent nursing action, not a collaborative treatment. ✅3. The client is symptomatic and will require a pacemaker. 4. Synchronized cardioversion is used for ventricular tachycardia with a pulse or atrial fibrillation. TEST-TAKING HINT: The key to answering this question is the adjective "collaborative," which means the treatment requires obtain- ing a health-care provider's order or work- ing with another member of the health-care team. This would cause the test taker to elim- inate option "2" as a possible correct answer. Content - Medical: Integrated Nursing Process - Planning: Client Needs - Physiological Integrity, Reduction of Risk Potential: Cognitive Level - Synthesis: Concept - Perfusion.

51. The client is experiencing multifocal premature ventricular contractions. Which antidysrhythmic medication would the nurse expect the health- care provider to order for this client? 1. Amiodarone. 2. Atropine. 3. Digoxin. 4. Adenosine.

ANS_1 ✅1.Amiodarone suppresses ventricular ectopy and is the drug of choice for ventricular dysrhythmias. 2. Atropine decreases vagal stimulation and is the drug of choice for asystole. 3. Digoxin slows heart rate and increases cardiac contractility and is the drug of choice for atrial fibrillation. 4. Adenosine is the drug of choice for supraven- tricular tachycardia. TEST-TAKING HINT: This is a knowledge-based question, and the test taker must know the answer. The nurse must know what medica- tions treat specific dysrhythmias. Content - Medical: Integrated Nursing Process - Planning: Client Needs - Physiological Integrity, Pharmacological and Parenteral Therapies: Cognitive Level - Synthesis: Concept - Medication.

4. How would the nurse best interpret the electrocardiogram (ECG) of a younger athletic client which shows sinus bradycardia with a rate of 54 beats/min? A. It is the body's a

B Well-conditioned athletes with bradycardia have a hypereffective heart in which the strong heart muscle provides an adequate stroke volume and a low heart rate to achieve a normal cardiac output. This is not a common finding in adults of all ages, but an indicator of dysrhythmia in older adults. Decreasing heart rate in most adults results in decreased cardiac output.

36. Which statements about permanent pacemakers are accurate? Select all that apply. A. Permanent pacemakers are powered by lithium ba

B, C, D, F The average life of lithium ba

1. what priority concept does the nurs focus on when a client is diagnosed with dysrhythmia? A. clotting B. Fluid and imbalance C. Perfusion D. Acid-base balance

C Perfusion is the priority concept for the client with dysrhythmias. It occurs when there is adequate arterial blood flow through the peripheral tissues (peripheral perfusion) and blood that is pumped by the heart to oxygenate major body organs (central perfusion). Perfusion is a normal physiologic process of the body; without adequate perfusion, cell death can occur. When a client has a dysrhythmia, often perfusion is inadequate. Acid-base imbalance result in inadequate perfusion

Class I: Sodium Channel Blockers

Class IA antiarrhythmics are used to treat a wide variety of atrial and ventricular arrhythmias. Class IA antiarrhythmics include: • quinidine (sulfate, gluconate) • disopyramide phosphate • procainamide hydrochloride Actions • Causes direct and indirect effects on cardiac tissue • Decreases automaticity, conduction velocity, and mem- brane responsiveness • Prolongs effective refractory period Indications (when other medications have failed) • Atrial fibrillation, flutter, and tachycardia • Premature atrial and ventricular contractions • Paroxysmal supraventricular tachycardia Nursing considerations • Monitor for adverse effects, such as vertigo, headache, arrhythmias, electrocardiogram changes (specifically, a widening QRS complex and prolonged QT interval), hypotension, heart failure, tinnitus, diarrhea, nausea, vomiting, hematologic disorders, hepatotoxicity, respiratory arrest, angioedema, fever, and temporary hearing loss. • Frequently monitor pulse and blood pressure. • Keep in mind that anticoagulation may be performed before treatment

A nurse is caring for a client with hypomagnesemia who asks the nurse to recommend foods rich in magnesium. Which of the following foods will the nurse recommend? (Select all that apply.) A. Apples B. Almonds C. Quinoa D. Cornflakes E. Olives

Correct Answers: B. Almonds C. Quinoa Hypomagnesemia is a condition where the serum level of magnesium falls below 1.5 mg/dL. Symptoms of hypomagnesemia include weakness, tetany, paresthesia, seizures, dysphagia, dysrhythmia, vomiting, and personality changes. Hypomagnesemia may be caused by chronic alcohol use disorder, diarrhea, impaired absorption, or renal disease. Treatment is supplementation with oral or intravenous magnesium. The client should increase dietary intake of magnesium-rich foods if magnesium supplementation is not possible or when the condition is mild. Foods that are rich in magnesium include almonds, quinoa, garbanzo beans, and buckwheat. Spinach, bananas, and milk are also rich sources of magnesium. Apples and olives are not good sources of magnesium. Vital Concept: Magnesium is essential for protein synthesis, nucleic acid synthesis, muscle contraction, use of ATP (adenosine triphosphate), nerve conduction, and blood clotting. Chronic alcohol use disorder is a common cause of magnesium deficiency. Dietary sources of magnesium include dark chocolate, nuts, whole grains, avocados, legumes, leafy green vegetables, bananas, and tofu.

• disopyramide phosphate • procainamide hydrochloride

Nursing process These nursing process steps are appropriate for patients undergoing treatment with class IA antiarrhythmics. Assessment • Assess the patient's arrhythmia before therapy and regularly thereafter. • Monitor the ECG continuously when therapy starts and when the dosage is adjusted. Specifically, monitor for ventricular arrhythmias and ECG changes (widening QRS complexes and a prolonged Q-T interval). • Monitor the patient's vital signs frequently, and assess for signs of toxicity. • Measure apical pulse rate and blood pressure before giving the drug. • Monitor serum drug levels as indicated. • Monitor blood studies, such as liver function tests, as indicated. • Be alert for adverse reactions and drug interactions ⭕️Monitor for adverse effects, such as vertigo, headache, arrhythmias, electrocardiogram changes (specifically, a widening QRS complex and prolonged QT interval), hypotension, heart failure, tinnitus, diarrhea, nausea, vomiting, hematologic disorders, hepatotoxicity, respiratory arrest, angioedema, fever, and temporary hearing loss. • Evaluate the patient's and family's knowledge of drug therapy. • Monitor the patient's intake and output. • Evaluate the patient's serum electrolyte levels. Key nursing diagnoses • Decreased cardiac output related to arrhythmias or myocardial depression • Risk for injury related to adverse reactions • Deficient knowledge related to drug therapy Class IA antiarrhythmics can induce arrhythmias as well as treat them. Planning outcome goals • Cardiac output will improve as evidenced by stable blood pressure, cardiac monitoring, and adequate urine output. • Complications from adverse reactions will be diminished. • The patient will verbalize an understanding of drug therapy. Implementation • Don't crush sustained-release tablets. • Notify the prescriber about adverse reactions. • Use IV forms of these drugs to treat acute arrhythmias. Evaluation • Patient maintains adequate cardiac output as evidenced by normal vital signs and adequate tissue perfusion. • Patient has no serious adverse reactions. • Patient and his family demonstrate an understanding of drug therapy. (See Teaching about antiarrhythmics.)

47. Interpret the following interpretation:Sinus tachycardia RATE__________ RHYTHM__________ P WAVES___________ PR INTERVAL____________ QRS DURATION ______________

RATE 150 beats/mmin; RHYTHM Regular; P WAVES one for each QRS; PR INTERVAL 0.12 second; QRS DURATION 0.04 second; INTERPRETATION :Sinus tachycardia

46. Interpret the following interpretation:Sinus bradycardia RATE__________ RHYTHM__________ P WAVES___________ PR INTERVAL____________ QRS DURATION _____________

RATE 50 beats/min; RHYTHM Regular; P WAVES one for each QRS; PR INTERVAL 0.20 second; QRS DURATION 0.08 second;

49. Interpret the Sinus rhythm with one premature atrial contraction (PAC) RATE__________ RHYTHM__________ P WAVES___________ PR INTERVAL____________ QRS DURATION _____________

RATE 60 beats/min; RHYTHM Regular except one premature complex; P WAVES one before each QRS complex; PR INTERVAL 0.20 second; QRS DURATION 0.08 second; INTERPRETATION Sinus rhythm with one premature atrial contraction (PAC)

44. Interpret the following: RATE__________ RHYTHM__________ P WAVES___________ PR INTERVAL____________ QRS DURATION _____________ INTERPRETATION____________________

RATE 80 beats/min; RHYTHM Regular; P WAVES one for each QRS; PR Interval 0.16 second; QRS DURATION 0.10 second; INTERPRETATIO Normal sinus rhythm

48. Interpret the following interpretation :Sinus rhythm with a premature ventricular complex (PVC)_ RATE__________ RHYTHM__________ P WAVES___________ PR INTERVAL____________ QRS DURATION _____________

RATE About 80 beats/min RHYTHM Regular except one premature complex; P WAVES one per QRS except early wide complex; PR INTERVAL 0.20 second; QRS DURATION 0.04 second; INTERPRETATION Sinus rhythm with a premature ventricular complex (PVC)

51. Interpret the following interpretation: Ventricular fibrillation (life threatening) RATE__________ RHYTHM__________ P WAVES___________ PR INTERVAL____________ QRS DURATION _____________ INTERPRETATION_____________

RATE Cannot be determined; RHYTHM Chaotic; P WAVES None; PR INTERVAL None; QRS DURATION None;

52. Interpret the following interpretation Ventricular asystole RATE__________ RHYTHM__________ P WAVES___________ PR INTERVAL____________ QRS DURATION _____________

RATE None; RHYTHM None; P WAVES None; PR INTERVAL None; QRS DURATION None;

45. Interpret the following interpretation: Atrial fibrillation with rapid ventricular respons RATE__________ RHYTHM__________ P WAVES___________ PR INTERVAL____________ QRS DURATION _____________

RATE Variable about 130 beats/min; RHYTHM Irregularly irregular; P WAVES None, fibrillatory waves; PR Interval none; QRS duration 0.08 second; INTERPRETATION : Atrial fibrillation with rapid ventricular response

Premature atrial complexes (PAC's)

Tx - treat cause frequently, lead to more serious atrial tachydysrhythmias ⬤Administration of prescribed anti dysrhythmic drugs may be necessary. ⬤Teach the patient measures to manage stress & substances to avoid, such as Caffeine & Alcohol, that are known to increase atrial irritability Causes:: ▪ Myocardial ischemia ▪ Hypermetabolic states ▪ Electrolyte imbalance ▪ Atrial stretch. •Atrial stretch can result from Congestive heart failure, Valvular disease, & Pulmonary hypertension with Cor Pulmonale Premature Atrial Complexes ⬤Ectopic focus of atrial tissue fires an impulse before next sinus impulse is due. The premature P wave is not always be clearly visible because it can be hidden in the preceding T wave. ⬤ Examine the T wave closely for any change in shape and compare with other T waves. ⬤ A PAC is usually followed by a pause.

Refractory atrial fibrillation

Unresponsive to drug therapy may have ⬤AV nodal ablation performed to totally disconnect the conduction from the atria to the ventricles, which requires implantation of a permanent pacemaker. Complications: cardiac tamponade, pericarditis, complete AV block, ventricular fibrillation, endocarditis, coronary artery occlusion ⬤Nursing Mangement -Similar to Cardiac Catheterization Frequent monitoring - ▪recovery from sedation, ▪S/S stroke, ▪ vascular access site complications, ▪ fluid imbalance ‹#› Atrial Fibrillation Care Coordination and Transition Management ⬤Home Care

12. Which actions are responsibilities of the monitor technician? Select all that apply. A. Report client rhythm and significant changes to the nurse. B. Notify the health care provider of any pertinent changes. C. Print routine ECG strips for each monitored client. D. Apply ba

the client's rhythm and significant changes to the nurse. The nurse would be responsible for notifying the cardiac health care provider (HCP) of changes, and the nurse or a qualified AP would apply the leads to a monitored client.

Which of the following is a late sign of hypoxemia? (Select all that apply.) A nurse is admitting a client who is scheduled to undergo cardioversion that same morning. Which of the following data from the client's health record requires that the nurse notify the provider to cancel the procedure? History and Physical Bariatric surgery 10 years ago Dyspnea with exertion began 3 years ago Client reports taking the following medications: Ferrous sulfate 200 mg PO twice daily Diazepam 2mg PO twice daily Isosorbide 2.5 mg PO four times daily before meals and at bedtime Digoxin 0.25 mg PO daily Dabigatran 150 mg PO daily Vital Signs 0800 Temperature 34.2° C (93.56° F) Pulse 88/min and irregular Respiratory rate 20/min Diagnostic Results aPTT: 65 seconds BUN: 17 mg/dL Creatinine: 1.0 mg/dL A. History of bariatric surgery B. Pulse C. Medications taken yesterday D. aPTT

who is to undergo cardioversion should not take digoxin for 48 hr prior to the procedure because of an increased risk for ventricular fibrillation following the cardioversion. Incorrect Answers: A. A client who has undergone bariatric surgery is not ineligible or prevented from having cardioversion for atrial fibrillation. B. A client who has a dysrhythmia likely has an irregular pulse, which can make them a candidate for cardioversion. D. A client who has an aPTT of 65 seconds is within the expected reference range for anticoagulation therapy. The therapeutic range for a client taking an anticoagulant medication is 1.5 to 2.0 times the control value of 30 to 40 seconds. Vital Concept: Elective cardioversion is performed to interrupt and stop dysrhythmia such as atrial fibrillation. A mild shock is applied to the client in timing with the QRS complex to avoid precipitating ventricular fibrillation while restoring sinus rhythm. Unlike with emergency defibrillation, the gel paddles are placed on both the front and back of the client for this procedure. IV sedation, analgesia, and supplemental oxygen are used. The nurse should ensure that the machine's monitor leads are attached to the client in order to set the defibrillator to the synchronized mode. The nurse should be ready to begin CPR if necessary after the shock is administered. When the procedure is completed, the nurse should monitor the client until they have fully recovered from sedation, and should inspect the client's skin under the pads for signs of injury.

Class II: Beta Blockers )

○Propranolol (Inderal, Apo-Propanolol ) ▪ Acebutolol (Sectral) ▪ Esmolol (Brevibloc) ▪ Sotalol (Betapace)

21. Which signs and symptoms would the nurse expect to assess in a client with sinus tachycardia? Select all that apply. A. Fatigue B. Shortness of breath C. Decreased oxygen saturation D. Decreased blood pressure E. Anginal pain F. Widened QRS complexes

✅ . A, B, C, D, E For clients with sinus tachycardia, assess for fatigue, weakness, shortness of breath, orthopnea, decreased oxygen saturation, increased pulse rate, and decreased blood pressure. Also assess for restlessness and anxiety from decreased cerebral perfusion and for decreased urine output from impaired renal perfusion. The client may also have anginal pain and palpitations. The ECG pa

74. The client is suspected of having a pulmonary embolus. Which diagnostic test suggests the presence of a pulmonary embolus and requires further investigation? 1. Plasma D-dimer test. 2. Arterial blood gases. 3. Chest x-ray (CXR). 4. Magnetic resonance imaging (MRI).

✅ 1. The plasma D-dimer test is highly spe- cific for the presence of a thrombus; an elevated D-dimer indicates a thrombus formation and lysis. This result would require a CT or V/Q scan to then confirm the diagnosis. AnABGevaluatesoxygenationlevel,butit does not diagnose a pulmonary embolus (PE). 2. A CXR shows pulmonary infiltration and pleural effusions, but it does not diagnose a PE. 3. An MRI is a noninvasive test that detects a deep vein thrombosis (DVT), but it does not diagnose a pulmonary embolus. 4. A computed tomography (CT) scan or ventilation/ perfusion (V/Q) scan would be used to confirm the diagnosis. TEST-TAKING HINT: The key to answering this question is "confirms the diagnosis." The test taker should eliminate options "2" and "3" based on the fact these are diagnostic tests used for many disease processes and conditions. Content - Medical: Integrated Nursing Process - Diagnosis: Client Needs - Physiological Integrity, Reduction of Risk Potential: Cognitive Level - Analysis: Concept - Oxygenation.

41. What effect does the nurse expect a Class IV drug to have on a client's cardiac conduction system? A. Slow the flow of calcium into the cell during depolarization to depress automaticity B. Stabilize membranes to decrease myocardial contractility C. Decrease heart rate and conduction velocity D. Lengthen the absolute refractory period and prolong repolarization

✅ A Class IV antidysrhythmics slow the flow of calcium into the cell during depolarization, thereby depressing the automaticity of the sinoatrial (SA) and atrioventricular (AV) nodes, decreasing the heart rate, and prolonging the AV nodal refractory period and conduction. Calcium channel blockers, such as verapamil hydrochloride and diltiazem hydrochloride, are Class IV drugs. They are used to treat supraventricular tachycardia (SVT) and atrial fibrillation (AF) to slow the ventricular response.

5. To determine if a client has a pulse deficit, what procedure would the nurse follow? A. Assess the apical and radial pulses for a full minute and calculate the difference. B. Check the client's blood pressure and subtract the diastolic from the systolic pressure. C. Take the client's pulse rate while supine, then in a standing position. D. Assess the radial pulse for a minute, have the client rest, then check the radial pulse again.

✅ A Pulse deficit is the difference between the apical and peripheral (e.g., radial) pulses. If the apical pulse differs from the radial pulse rate, a pulse deficit exists and indicates that the heart is not pumping adequately to achieve optimal perfusion to the body. The difference between systolic and diastolic pressures is the pulse pressure. When a client's blood pressure and pulse are taken first lying down and then sit

35. Which ECG strip pa

✅ A When a pacing stimulus is delivered to the heart, a spike (or pacemaker artifact) is seen on the monitor or ECG strip. When the pacer spike is followed by a QRS complex, this pa

18. Which actions would the nurse take when the monitor technician states that a client's telemetry ECG signal transmission is not very clear? Select all that apply. A. Ensure that the gel on each electrode is moist and fresh. B. Clean the skin and clip hairs if necessary. C. Abrade the skin by rubbing briskly with a rough washcloth. D. Make sure that the skin is free of lotion or any other substance. E. Clean the skin with povidone-iodine before applying electrodes. F. Check to be sure that electrodes are not placed over scar tissue.

✅ A, B, D, F The clarity of continuous ECG monitor recordings is affected by skin preparation and electrode quality. To ensure the best signal transmission and decrease skin impedance, clean the skin and clip hairs if needed. Make sure that the area for electrode placement is dry. The gel on each electrode must be moist and fresh. A

2. Which normal heart rates does the nurse expect to be initiated by the primary pacemaker of the heart (SA Node) in clients when the heart rate is regular? Select all that apply. A. 55 beats/min B. 62 beats/min C. 74 beats/min D. 86 beats/min E. 98 beats/min F. 110 beats/min

✅ B, C, D, E The SA node is the heart's primary pacemaker. It can spontaneously and rhythmically generate electrical impulses at a rate of 60 to 100 beats/min and therefore has the greatest degree of automaticity (pacing function). Heart rates less than 60 beats/min are bradycardias and heart rates greater than 100 beats/min are tachycardias.

27. When a client has been in atrial fibrillation for 3 days and is scheduled for an elective cardioversion, what priority teaching does the nurse provide to the client? A. Consume potassium-rich food sources such as bananas. B. Report muscle tremors or weakness to the health care provider. C. Get up slowly when ge

✅ D When the onset of AF is greater than 48 hours, the client must take anticoagulants for at least 3 weeks (or until the INR is 2 to 3) before the elective cardioversion to prevent clots from moving from the heart to the brain or lungs. Teaching the client to monitor for bleeding and reporting this to the primary health care provider (HCP) are essential when a client is prescribed an anticoagulant drug.

32. After calling for help, when the nurse finds a client in his or her room without a pulse, apneic and unconscious, which action should be taken next? A. Begin cardiac compressions. B. Establish IV access. C. Give supplemental oxygen. D. Defibrillate the client.

✅. A The desired outcomes of collaborative care are to resolve VF promptly and convert it to an organized rhythm. Therefore, the priority is to defibrillate the client immediately according to ACLS protocol. If a defibrillator is not readily available, as would likely be the case in a client's room, high-quality CPR must be initiated and continued until the defibrillator arrives.

35. Which ECG strip pa

✅. A When a pacing stimulus is delivered to the heart, a spike (or pacemaker artifact) is seen on the monitor or ECG strip. When the pacer spike is followed by a QRS complex, this pa

6. Which ECG waveforms and intervals are the normal measurements or positions? Select all that apply. A. PR interval 0.12-0.20 second B. QRS complex 0.06-0.10 second C. PR segment isoelectric line D. QT interval less than half of the R to R interval E. U wave follows T wave if present F. TP segment one block above isoelectric line

✅. A, B, C, D, E All of these statements are correct except F. The TP segment should return to and be located on the isoelectric line.

9. Where will the nurse place the leads on a client for a five-lead continuous monitoring system? Select all that apply. A. Right arm electrode just below the right clavicle B. Left arm electrode just below the left clavicle C. Right leg electrode on the highest palpable rib, on the right midclavicular line D. Left leg electrode on the lowest palpable rib, on the left midclavicular line E. Fifth electrode placed to obtain one of the six chest leads F. Left arm electrode just above the left clavicle

✅. A, B, D, E If the monitoring system provides five electrode cables, place the electrodes as follows: right arm electrode just below the right clavicle; left arm electrode just below the left clavicle; right leg electrode on the lowest palpable rib, on the right midclavicular line; left leg electrode on the lowest palpable rib, on the left midclavicular line; and fifth electrode placed to obtain one of the six chest leads.

23. Which causes would the nurse recognize as leading to increased atrial irritability and premature atrial contractions (PACs) in a client's myocardium? Select all that apply. A. Caffeine intake B. Anxiety C. Syncope D. Stress in life E. Infection F. Pulmonary hypotension

✅. A, B, D, E The causes of atrial irritability that can lead to PACs include: stress; fatigue; anxiety; inflammation; infection; intake of caffeine, nicotine, or alcohol; and drugs such as epinephrine, sympathomimetics, amphetamines, digoxin, or anesthetic agents. PACs may also result from myocardial ischemia, hypermetabolic states, electrolyte imbalance, or atrial stretch.

39. Which safety precaution must be taken before defibrillating a client with ventricular fibrillation (VF)? A. Make sure that the defibrillator is set on the synchronous mode. B. Be sure to hyperventilate the client before the defibrillation. C. Command all health care team members to stand clear of the client's bed. D. Disconnect the monitor leads to prevent electrical shocks to the client.

✅. C Before defibrillation, loudly and clearly command all personnel to clear contact with the client and the bed and check to see they are clear before the shock is delivered. This safety measure prevents health care team members from receiving a shock when the client is defibrillated. Synchronous mode is used for cardioversion. Disconnection of the monitor leads would prevent assessing the effectiveness of the defibrillation shock. Hyperventilation of the client will not keep the health care team safe.

38. Which important teaching points would the nurse discuss with a client who receives a new permanent pacemaker? Select all that apply. A. Report any pulse rate that is lower than the rate set on the pacemaker. B. Avoid sources of strong electromagnetic fields such as magnets. C. If the surgical incision is near the shoulder, be sure to perform daily range of motion. D. Carry a pacemaker identification card and wear a medical alert bracelet. E. Avoid tight clothing to prevent pressure over the pacemaker generator. F. It is safe to go through airport security because the pacemaker will not set off the alarms.

✅. A, B, D, E The client would inform airport personnel of the pacemaker before passing through a metal detector and show them the pacemaker identification card. The metal in your pacemaker will trigger the alarm in the metal detector device. Instruct the client to avoid lifting the arm over the head or lifting more than 10 lb for the next 4 weeks because this could dislodge the pacemaker wire. Teach the client to report any pulse rate lower than that set on the pacemaker. Tell clients to avoid sources of strong electromagnetic fields, such as magnets and telecommunications transmi

28. Which actions are essential nursing care for a client immediately after elective cardioversion? Select all that apply. A. Administer oxygen. B. Assess vital signs and level of consciousness. C. Provide sips of water or ice chips. D. Monitor for dysrhythmias. E. Maintain an open airway. F. Document the results of the cardioversion.

✅. A, B, D, E, F Nursing care after cardioversion includes: maintaining a patent airway; administering oxygen; assessing vital signs and the level of consciousness; administering antidysrhythmic drug therapy, as prescribed; monitoring for dysrhythmias; assessing for chest burns from electrodes; providing emotional support; and documenting the results of cardioversion. Sips of water and ice chips would not be provided until the client's gag reflex returned.

15. Which questions would the nurse use to assess a client's P wave on an ECG rhythm strip? Select all that apply. A. Do all P waves look similar? B. Are P waves present? C. Does one P wave follow each QRS complex? D. Are P waves occurring regularly? E. Are the P waves greater than 0.20 second? F. Are P waves smooth, rounded, and upright?

✅. A, B, D, F Ask these five questions when analyzing P waves: Are P waves present?; Are the P waves occurring regularly?; Is there one P wave for each QRS complex?; Are the P waves smooth, rounded, and upright in appearance; or are they inverted?; and Do all P waves look similar?

37. Which are nursing responsibilities for the care of a client with a newly implanted permanent pacemaker? Select all that apply. A. Assess the implantation site for bleeding, swelling, redness, tenderness, or infection. B. Administer short-acting sedatives as needed and prescribed. C. Monitor the ECG rhythm strip to ensure that the pacemaker is working correctly. D. Observe for overstimulation of the chest wall, which might cause pneumothorax. E. Assess that the implantation site dressing is clean and dry. F. Teach the client about initial activity restrictions.

✅. A, C, E, F After the procedure, monitor the ECG rhythm to check that the pacemaker is working correctly. Assess the implantation site for bleeding, swelling, redness, tenderness, and infection. The dressing over the site should remain clean and dry. The client should be afebrile and have stable vital signs. The electrophysiologist prescribes initial activity restrictions, which are then gradually increased. Observe for muscle contractions over the diaphragm that are synchronous with the heart rate. Pneumothorax is usually not a complication of pacemaker implantation. Sedative drugs are often given to clients receiving transcutaneous pacing but not for permanent pacemaker insertion.

14. What is the first step when the nurse analyzes a client's ECG rhythm strip? A. Analyze the P waves B. Determine the heart rate C. Measure the QRS complex D. Assess for ST-segment elevation

✅. B Analysis of an ECG rhythm strip requires a systematic approach using an eight-step method. The first step is to determine the heart rate. This is commonly accomplished by use of the 6- second strip method. Normal heart rate is 60-100 per minute. Less than 60 is bradycardia and more than 100 is tachycardia. Analyzing P waves is the 3rd step; measuring the QRS duration is 5th; and measuring the PR interval is the 4th step.

17. What is the priority action for the nurse when the monitor technician states that a client's telemetry monitor shows a rhythm that appears as a wandering or fuzzy baseline? A. Check to see if the client has a do-not-resuscitate order. B. Assess the client to differentiate artifact from an actual lethal rhythm. C. Immediately obtain a 12-lead ECG to assess the actual rhythm. D. Ask the assistive personnel (AP) to take a set of vital signs on the client.

✅. B Artifact is interference seen on the monitor or rhythm strip, which may look like a wandering or fuzzy baseline. It can be caused by client movement, loose or defective electrodes, improper grounding, or faulty ECG equipment such as broken wires or cables. Some artifacts can mimic lethal dysrhythmias such as ventricular tachycardia (with toothbrushing) or ventricular fibrillation (with tapping on the electrode). Assess the client to differentiate artifact from actual lethal rhythms! Do not rely only on the ECG monitor.

31. Which procedure would the nurse provide teaching about to a client who has chronic atrial fibrillation and is at increased risk for a stroke, but is not a candidate for anticoagulation? A. Radiofrequency catheter ablation (RCA) B. Left atrial appendage (LAA) occlusion C. Biventricular pacing D. Surgical maze procedure

✅. B For clients who are at high risk for stroke and who are not candidates for anticoagulation, the left atrial appendage (LAA) occlusion device may be an option. The LAA is the most common site of blood clot development leading to the risk of stroke. Inserted percutaneously via the femoral vein, a device to occlude the LAA is delivered via a transseptal puncture. Radiofrequency catheter ablation (RCA) is an invasive procedure that may be used to destroy an irritable focus in atrial or ventricular conduction. Biventricular pacing is used with clients who have heart failure and conduction disorders. The surgical maze procedure is an open-chest surgical technique performed with coronary artery bypass grafting (CABG).

11. Which serum electrolyte would the nurse check after noting tall and peaked T waves on a client's ECG? A. Sodium B. Potassium C. Magnesium D. Chloride

✅. B T waves may become tall and peaked; inverted (negative); or flat as a result of myocardial ischemia, potassium or calcium imbalances, medications, or autonomic nervous system effects.

26. Which risk factors for atrial fibrillation would the nurse monitor for in client? Select all that apply. A. Peripheral vascular disease B. Hypertension C. Chronic obstructive pulmonary disease D. Diabetes mellitus E. Excessive alcohol intake F. Mitral valve disease

✅. B, D, E, F Risk factors for atrial fibrillation include hypertension (HTN), previous ischemic stroke, transient ischemic a

33. Which drug does the nurse prepare to administer to a client diagnosed with the dysrhythmia torsades de pointes? A. Calcium chloride B. Epinephrine C. Magnesium sulfate D. Adenosine

✅. C Magnesium is used to treat the life-threatening ventricular tachycardia called torsades de pointes. Often a client with this dysrhythmia is hypomagnesemic which causes increased ventricular irritability. Adenosine treats PSVT; epinephrine increases atrial irritability and heart rate; and calcium chloride is used in cardiac resuscitation, arrhythmias, hypermagnesemia, calcium channel blocker overdose, and beta-blocker overdose.

8. To best perform a 12-lead ECG on a client, how does the nurse place the leads on the client? A. Four leads are placed on the limbs and four are placed on the chest. B. The negative electrode is placed on the left arm and the positive electrode is placed on the right leg. C. Four leads are placed on the limbs and six are placed on the chest. D. The negative electrode is placed on the right arm and the positive electrode is placed on the left leg.

✅. C The 12-lead ECG provides 12 views of the electrical activity of the heart. There are six unipolar (or V) chest leads, determined by the placement of the chest electrode. The four limb electrodes are placed on the extremities which provide the 12 views. Positioning of the electrodes is crucial in obtaining an accurate ECG. Comparisons of ECGs taken at different times will be valid only when electrode placement is accurate and identical at each test. In many cases, a surgical marker is used to assure consistent placement of the leads.

13. Which would be the best method for the nurse to confirm a report from the monitor technician about a change in a monitored client's heart rate? A. Count QRS complexes in a 6-second strip and multiply by 10. B. Analyze the ECG rhythm strip using an ECG caliper. C. Assess the client's heart rate directly by checking the apical pulse. D. Request that the monitor technician run an ECG strip for a minute.

✅. C The best and most direct method of checking the client for a change in heart rate is to assess the apical pulse for a full minute. All of the other responses are indirect methods and do not include assessing the client which is the most important action in this situation.

20. What does the nurse determine is the client's heart rate when assessing a 6-second telemetry ECG strip with five QRS complexes? A. 30 beats/min, bradycardia B. 40 beats/min, bradycardia C. 50 beats/min, bradycardia D. 60 beats/min, normal

✅. C The most common method is to count the number of QRS complexes in 6 seconds and multiply that number by 10 to calculate the rate for a full minute. This client has five QRS complexes in a 6-second strip. So, 5 times 10 equals 50 beats/min, which is a bradycardia.

10. Which condition is indicated when the nurse notes ST segment elevation or one to two small blocks on a client's ECG? A. Ventricular irritability B. Subarachnoid hemorrhage C. Myocardial injury or ischemia D. Malfunction of the SA node

✅. C The normal ST segment begins at the isoelectric line. ST elevation or depression is significant if displacement is 1 mm (one small box) or more above or below the line and is seen in two or more leads. ST elevation may indicate problems such as myocardial infarction, pericarditis, and hyperkalemia. ST depression is associated with hypokalemia, myocardial infarction, or ventricular hypertrophy

40. For which cardiac dysrhythmia(s) would an automatic external defibrillator (AED) instruct the nurse to immediately defibrillate an unconscious client at an outpatient clinic? Select all that apply. A. Paroxysmal supraventricular tachycardia B. Pulseless electrical activity C. Ventricular fibrillation D. Pulseless ventricular tachycardia E. Nonsustained ventricular tachycardia F. Atrial fibrillation with rapid ventricular response

✅. C, D Defibrillation shocks are recommended by AEDs only for ventricular fibrillation and pulseless ventricular tachycardia

25. Which nursing actions have priority when a client with acute supraventricular tachycardia (SVT) is to be administered adenosine by the health care provider? Select all that apply. A. Have injectable beta-blocker drugs at the bedside. B. Give the drug slowly over 1-2 minutes. C. Ensure that emergency equipment is at the bedside. D. Follow the drug injection with a normal saline bolus. E. Monitor the client for bradycardia, nausea, and vomiting. F. Prepare for synchronized cardioversion after giving the adenosine.

✅. C, D, E Adenosine is used to terminate the acute episode and is given rapidly (over several seconds) followed by a normal saline bolus. Side effects of adenosine include significant bradycardia with pauses, nausea, and vomiting. Beta blockers would not be given because they would cause increased bradycardia. The purpose of the drug is to terminate the dysrhythmia so cardioversion is not necessary.

16. Which criteria support the nurse's assessment that a client's ECG rhythm strip shows a normal sinus rhythm (NSR)? A. PR interval is 0.24 second. B. Atrial and ventricular rates are 58 beats/min. C. Atrial and ventricular rates are regular. D. P waves are present before every QRS complex. E. QRS duration is consistent at 0.08 second. F. Atrial and ventricular rates are 82 beats/min.

✅. C, D, E, F Normal sinus rhythm (NSR) is the rhythm originating from the sinoatrial (SA) node (dominant pacemaker) that meets these ECG criteria: Rate: atrial and ventricular rates of 60 to 100 beats/min; Rhythm: atrial and ventricular rhythms regular; P waves: present, consistent configuration, one P wave before each QRS complex; PR interval: 0.12 to 0.20 second and constant; and QRS duration: 0.06 to 0.10 second and constant.

34. When would the telemetry unit nurse use temporary transcutaneous pacing for a client? Select all that apply. A. Only when a client's ECG shows a bradydysrhythmia and the client is asymptomatic B. When a client's ECG strip shows atrial fibrillation with a rapid ventricular response C. Only as a temporary emergency measure until invasive pacing method can be started D. When a client is experiencing syncope, dizziness and fainting E. Only until the client's heart rhythm returns to normal F. When invasive pacing is not immediately available

✅. C, E, F Transcutaneous pacing is used as an emergency measure to provide demand ventricular pacing in a profoundly bradycardic or asystolic client until invasive pacing can be used or the client's heart rate returns to normal. This method of pacing is painful and may require administration of pain and sedative medications for the client to tolerate the therapy. Transcutaneous pacing is used only as a temporary measure to maintain heart rate and perfusion until a more permanent method of pacing is used.

29. Which client assessment takes priority when the nurse begins his or her shift? A. Client with chronic atrial fibrillation and ventricular rate of 72 beats/min B. Client with sinus tachycardia and occasional premature atrial contractions (PACs) C. Client with paroxysmal supraventricular tachycardia (PSVT) that terminated D. Client with atrial fibrillation and sustained rapid ventricular response

✅. D The nurse would want to assess all four clients. However, the client with atrial fibrillation with sustained rapid ventricular response is at highest risk for decreased cardiac output and development of symptoms. Therefore this client would need to be assessed first.

24. Which dysrhythmia does the nurse consider life threatening because it causes the ventricles to quiver and results in the absence of cardiac output for a client? A. Asystole B. Ventricular tachycardia C. Atrial fibrillation D. Ventricular fibrillation

✅. D Ventricular fibrillation (VF) is a cardiac dysrhythmia that results from electrical chaos in the ventricles; impulses from many irritable foci fire in a totally disorganized manner so that ventricular contraction cannot occur; there is no cardiac output or pulse and therefore no cerebral, myocardial, or systemic perfusion. This rhythm is rapidly fatal if not successfully terminated within 3 to 5 minutes. Ventricular tachycardia and asystole are also life-threatening dysrhythmias. With atrial fibrillation there is loss of the atrial contribution to cardiac output, but the ventricles are usually still pu

24. Which dysrhythmia does the nurse consider life threatening because it causes the ventricles to quiver and results in the absence of cardiac output for a client? A. Asystole B. Ventricular tachycardia C. Atrial fibrillation D. Ventricular fibrillation

✅. D Ventricular fibrillation (VF) is a cardiac dysrhythmia that results from electrical chaos in the ventricles; impulses from many irritable foci fire in a totally disorganized manner so that ventricular contraction cannot occur; there is no cardiac output or pulse and therefore no cerebral, myocardial, or systemic perfusion. This rhythm is rapidly fatal if not successfully terminated within 3 to 5 minutes. Ventricular tachycardia and asystole are also life-threatening dysrhythmias. With atrial fibrillation there is loss of the atrial contribution to cardiac output, but the ventricles are usually still pu

82. The client diagnosed with a pulmonary embolus is being discharged. Which intervention should the nurse discuss with the client? 1. Increase fluid intake to two (2) to three (3) L/day. 2. Eat a low-cholesterol, low-fat diet. 3. Avoid being around large crowds. 4. Receive pneumonia and flu vaccines.

✅1. Increasing fluids will help increase fluid volume, which will, in turn, help prevent the development of deep vein thrombosis, the most common cause of PE. 2.Pulmonary emboli are not caused by athero- sclerosis; this is not an appropriate discharge instruction for a client with a pulmonary embolus. 3. Infection does not cause a PE; this is not an appropriate teaching instruction. 4. Pneumonia and flu do not cause pulmonary embolism TEST-TAKING HINT: The test taker must know deep vein thrombosis is the most common cause of pulmonary embolus and preventing dehydration is an important in- tervention. The test taker can attempt to eliminate answers by trying to determine which disease process is appropriate for the intervention. Content - Medical: Integrated Nursing Process - Planning: Client Needs - Physiological Integrity, Physi- ological Adaptation: Cognitive Level - Synthesis: Concept - Oxygenation.

1. The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and 4+ pitting edema of feet. 2. Thick white sputum and crackles that clear with cough. 3. The client sleeping with no pillow and eupnea. 4. Radial pulse rate of 90 and CRT less than three (3) seconds.

✅1. The client with CHF would exhibit tachy- cardia (apical pulse rate of 110), dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status. 2. The client with CHF usually has pink frothy sputum and crackles that do not clear with coughing The client with CHF would report sleeping on at least two pillows, if not sleeping in an upright position, and labored breathing, not eupnea, which means normal breathing. In a client diagnosed with heart failure, the apical pulse, not the radial pulse, is the best place to assess the cardiac status. TEST-TAKING HINT: In option "3," the word "no" is an absolute term and, usually, ab- solutes, such as "no," "never," "always," and "only," are incorrect because there is no room for any other possible answer. If the test taker is looking for abnormal data, then the test taker should exclude the options that have normal values in them, such as eupnea, pulse rate of 90, and capillary refill time (CRT) less than three (3) seconds. Content - Medical: Integrated Nursing Process - Assessment: Client Needs - Physiological Integrity, Physiological Adaptation: Cognitive Level - Analysis: Concept - Perfusion.

30. How does the nurse interpret a client's telemetry ECG strip that shows four successive premature ventricular contractions (PVCs)? A. The monitor is showing two PVC couplets in a row. B. This rhythm is ventricular asystole as seen in a dying heart. C. The client had an episode of nonsustained ventricular tachycardia (NSVT). D. The nurse must check the client for loose leads and artifact.

✅30. C Three or more successive PVCs in a row are usually called nonsustained ventricular tachycardia (NSVT). Two PVCs in a row make a couplet. Artifact appears as a fuzzy or wandering baseline. Ventricular asystole is generally described as a flat line although P waves may still be seen

73. The client is diagnosed with a pulmonary embolus (PE) and is receiving a heparin drip. The bag hanging is 20,000 units/500 mL of D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour? ________

✅880 units. If there are 20,000 units of heparin in 500 mL of D5W, there are 40 units in each mL: 20,000 ÷ 500 = 40 units If 22 mL are infused per hour, then 880 units of heparin are infused each hour: 40 × 22 = 880 TEST-TAKING HINT: The test taker must know how to calculate heparin drips from two as- pects: the question may give the mL/hr and the test taker has to determine units/hr, or the question may give units/hr and the test taker has to determine mL/hr. Remember to learn how to use the drop-down calculator on the computer. During the NCLEX-RN, the test taker can request an erase slate. Content - Medical: Integrated Nursing Process - Implementation: Client Needs - Physiological Integrity, Pharmacological and Parenteral Therapies: Cognitive Level - Application: Concept - Medication.

3. Which waveform does the nurse recognize as atrial depolarization when a client is placed on a cardiac monitor? A. P wave B. PR segment C. QRS complex D. T wave

✅A Impulses from the sinus node move directly through atrial muscle and lead to atrial depolarization, which is reflected in a P wave on the electrocardiogram (ECG). Atrial muscle contraction should follow. The PR segment reflects impulses slowing down or being delayed in the AV node before proceeding to the ventricles. QRS complexes reflect ventricular depolarization and T waves reflect ventricular repolarization.

43. Which beta-blocker drug approved for treating dysrhythmias is also a Class III antidysrhythmic drug? A. Sotalol B. Esmolol C. Propranolol D. Acebutolol

✅A Sotalol hydrochloride is an antidysrhythmic agent with both noncardioselective beta-adrenergic blocking effects (Class II) and action potential duration prolongation properties (Class III). It is an oral agent that may be used for the treatment of documented ventricular dysrhythmias such as VT that are life threatening

12. Which actions are responsibilities of the monitor technician? Select all that apply. A. Report client rhythm and significant changes to the nurse. B. Notify the health care provider of any pertinent changes. C. Print routine ECG strips for each monitored client. D. Apply ba

✅A, C, E, F Most acute care facilities have monitor technicians who are specially educated in ECG monitoring and rhythm interpretation. Their responsibilities include: watching a bank of monitors on a unit; printing ECG rhythm strips routinely and as needed; interpreting rhythms; and reporting the client's rhythm and significant changes to the nurse. The nurse would be responsible for notifying the cardiac health care provider (HCP) of changes, and the nurse or a qualified AP would apply the leads to a monitored client.

19. Which conditions would the nurse suspect when a client's telemetry ECG rhythm strip shows ST elevation of 1.5 mm (1.5 small blocks)? Select all that apply. A. Pericarditis B. Hypokalemia C. Myocardial infarction D. Ventricular hypertrophy E. Endocarditis F. Hyperkalemia

✅A, C, F ST elevation may indicate problems such as myocardial infarction, pericarditis, and hyperkalemia. ST depression is associated with hypokalemia, myocardial infarction, or ventricular hypertrophy. Endocarditis is an infection of the endocardium and usually affects the heart valves.

59. The client's telemetry reading shows a P wave before each QRS complex and the rate is 78. Which action should the nurse implement? 1. Document this as normal sinus rhythm. 2. Request a 12-lead electrocardiogram. 3. Prepare to administer the cardiotonic digoxin PO. 4. Assess the client's cardiac enzymes.

✅ANS 1 The P wave represents atrial contraction, and the QRS complex represents ven- tricular contraction— a normal telemetry reading. A rate between 60 and 100 indicates normal sinus rhythm. Therefore, the nurse should document this as normal sinus rhythm and not take any action. 2. A 12-lead ECG should be requested for chest pain or abnormal dysrhythmias. 3. Digoxin is used to treat atrial fibrillation. 4. Cardiac enzymes are monitored to determine if the client has had a myocardial infarction. Nothing in the stem indicates the client has had an MI. TEST-TAKING HINT: The test taker must know normal sinus rhythm, and there are no test- taking hints to help eliminate incorrect op- tions. The test taker should not automatically select assessment as the correct answer, but if the test taker had no idea of the answer, re- member assessment of laboratory data is not the same as assessing the client. Content - Medical: Integrated Nursing Process - Implementation: Client Needs - Safe Effective Care Environment, Management of Care: Cognitive Level - Application: Concept - Perfusion

4. How would the nurse best interpret the electrocardiogram (ECG) of a younger athletic client which shows sinus bradycardia with a rate of 54 beats/min? A. It is the body's a

✅B Well-conditioned athletes with bradycardia have a hypereffective heart in which the strong heart muscle provides an adequate stroke volume and a low heart rate to achieve a normal cardiac output. This is not a common finding in adults of all ages, but an indicator of dysrhythmia in older adults. Decreasing heart rate in most adults results in decreased cardiac output.

36. Which statements about permanent pacemakers are accurate? Select all that apply. A. Permanent pacemakers are powered by lithium ba

✅B, C, D, F The average life of lithium ba

26. Which risk factors for atrial fibrillation would the nurse monitor for in client? Select all that apply. A. Peripheral vascular disease B. Hypertension C. Chronic obstructive pulmonary disease D. Diabetes mellitus E. Excessive alcohol intake F. Mitral valve disease

✅B, D, E, F Risk factors for atrial fibrillation include hypertension (HTN), previous ischemic stroke, transient ischemic a

42. Which descriptions are characteristics of Class III antidysrhythmic drugs? Select all that apply. A. Increase force of contraction B. Lengthen absolute refractory period C. Include hypertension as a side effect for some drugs D. Include bradycardia as a side effect for some drugs E. Prolong QT interval F. Prolong repolarization

✅B, D, F Class III antidysrhythmics lengthen the absolute refractory period and prolong repolarization and the action potential duration of ischemic cells. Class III drugs include amiodarone and ibutilide and are used to treat or prevent ventricular premature beats, VT, and VF. Bradycardia is a side effect with sotalol and amiodarone. Hypertension is not a side effect of these drugs

A nurse in an emergency department is admitting a client who is lethargic and unable to complete sentences. The client has 'a heart rate of 34 beats per minute and a blood pressure of 83/48 mm Hg. The nurse applies electrodes to the client's chest and limbs and the electrocardiogram (ECG) monitor shows complete heart block. Which of the following actions should the nurse take first? A. Transport the client to the cardiovascular laboratory. B. Prepare the client for insertion of a transvenous pacemaker. C. Activate the emergency response system and be prepared to perform CPR. D. Apply transcutaneous pacemaker pads.

✅Correct Answer: D. Apply transcutaneous pacemaker pads. The greatest risk to this client is injury or death from inadequate cardiac output and 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 temporary transvenous or permanent implanted pacemaker can be placed. Transcutaneous pacing is appropriate for emergency use, but it is intended only for short periods of time because it causes the client significant discomfort. Incorrect Answers: A. The nurse should plalan to transport the client to the cardiovascular laboratory for placement of a temporary pacemaker under fluoroscopy to stimulate the client's heart until it is determined whether permanent pacemaker control is necessary. However, there is another action the nurse should take first. B. The nurse should plan to prepare the client for the possible insertion of a transvenous pacemaker by cleansing the skin in the likely insertion areas (femoral, subclavian, jugular) and obtaining the appropriate equipment. However, there is another action the nurse should take first. C. Although the client still has a palpable pulse and is breathing, the client is at risk for imminent cardiac arrest because of the complete heart block. The nurse should activate the emergency response system and should be prepared to initiate CPR. However, there is another action the nurse should take first.' Vital Concept: Cardiac dysrhythmias and their effects on the client range from mild to critical. The nurse must assess the client for signs and symptoms, their contributing factors, frequency, severity, manifestations of diminishing cardiac output, and changes in the client's level of consciousness. In the hospital setting, emergency equipment and personnel are readily available, but the nurse must recognize when and how they should be used. Emergency procedures can be performed without written consent if the client is not coherent and no designated client advocate is available

22. What does the nurse suspect when assessing a client's telemetry ECG strip and noting a wide distorted QRS complex of 0.14 second followed by a P wave? A. Delayed time of the impulse through the ventricles B. Problem with speed set on the ECG telemetry monitor C. Wide but normal complex with no cause for concern D. Premature ventricular complex followed by atrial contraction

✅D Premature ventricular complexes (PVCs), also called premature ventricular contractions, result from increased irritability of ventricular cells and are seen as early ventricular complexes followed by a pause. They appear as widened QRS complexes and sometimes the P waves follow the QRS complexes. They may be all the same shape (unifocal) or different shapes (multifocal). PVCs are common and increase with age.

7. Which definition best describes the electrophysiologic property called automaticity of myocardial pacemaker cells? A. The ability of atrial and ventricular muscle cells to shorten their fiber length in response to electrical stimulation, causing sufficient pressure to push blood forward through the heart B. The ability to send an electrical stimulus from cell membrane to cell membrane C. The ability of nonpacemaker heart cells to respond to an electrical impulse that begins in pacemaker cells D. The ability of cardiac cells to generate an electrical impulse spontaneously and repetitively

✅D The electrophysiologic properties of specialized myocardial cells regulate heart rate and rhythm and possess unique properties: automaticity, excitability, conductivity, and contractility. Automaticity (pacing function) is the ability of cardiac cells to generate an electrical impulse spontaneously and repetitively. Excitability is the ability of nonpacemaker heart cells to respond to an electrical impulse that begins in pacemaker cells. Conductivity is the ability to send an electrical stimulus from cell membrane to cell membrane. Contractility is the ability of atrial and ventricular muscle cells to shorten their fiber length in response to electrical stimulation, causing sufficient pressure to push blood forward through the heart.

27. When a client has been in atrial fibrillation for 3 days and is scheduled for an elective cardioversion, what priority teaching does the nurse provide to the client? A. Consume potassium-rich food sources such as bananas. B. Report muscle tremors or weakness to the health care provider. C. Get up slowly when ge

✅D When the onset of AF is greater than 48 hours, the client must take anticoagulants for at least 3 weeks (or until the INR is 2 to 3) before the elective cardioversion to prevent clots from moving from the heart to the brain or lungs. Teaching the client to monitor for bleeding and reporting this to the primary health care provider (HCP) are essential when a client is prescribed an anticoagulant drug.

80. Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? Select all that apply. 1. Keep protamine sulfate readily available. 2. Avoid applying pressure to venipuncture sites. 3. Assess for overt and covert signs of bleeding. 4. Avoid invasive procedures and injections. 5. Administer stool softeners as ordered.

✅Heparin is administered during throm- bolytic therapy, and the antidote is prot- amine sulfate and should be available to reverse the effects of the anticoagulant. 2. Firm pressure reduces the risk for bleeding into the tissues. ✅3. Obvious (overt) as well as hidden (covert) signs of bleeding should be assessed for. ✅4. Invasive procedures increase the risk of tissue trauma and bleeding. ✅5. Stool softeners help prevent constipation and straining, which may precipitate bleeding from hemorrhoids. TEST-TAKING HINT: Thrombolytic therapy is ordered to help dissolve the clot resulting in the PE. Therefore, all nursing interventions should address bleeding tendencies. The test taker must select all interventions applicable in these alternative questions. Content - Medical: Integrated Nursing Process - Implementation: Client Needs - Safe Effective Care Envi- ronment, Management of Care: Cognitive Level - Application: Concept - Oxygenation.

Atrial Flutter - Treatment

⬤Primary goal: Slow ventricular response by increasing AV block . Calcium channel blockers, β-adrenergic blockers , digitalis ⬤Anti dysrhythmia drugs (e.g., amiodarone, ) to convert atrial flutter to sinus rhythm or to maintain sinus rhythm ⬤Radiofrequency catheter ablation can be curative therapy for atrial flutter. ⬤ Vagal Maneuvers or admin Adenosine (Adenocard). Adenosine- Rapid IV , 20 ml saline flush, elevation of the arm with the IV line ⬤More than 48 hours and if no clot confirmed with TEE, electrical cardioversion may be used to convert the atrial flutter to sinus rhythm emergently and electively ‹#› Complications ⬤Bradydysrhythmias, Asystole, Ventricular fibrillation (VF), & Cerebral damage. ⬤Because of these risks, carotid massage is NOT commonly performed. ⬤ A Defibrillator & Resuscitative equipment must be immediately available during the procedure. ⬤" When Dr. is performing this, you should HAVE CRASH CART with you".