VITAL SIGN: Pulse

Which solution would the nurse consider for a patient with bradycardia? Suggest activities to increase the heart rate. Administer medications to slow the heart rate. Encourage measures to stabilize heart rhythm. Document patient's pulse rate alteration will resolve.

Suggest activities to increase the heart rate. Suggesting activities to increase the heart rate is a solution for a patient who has bradycardia (slowed pulse rate). WRONG: Administer medications to slow the heart rate. Administering medications to slow the heart rate would make the situation worse because the patient already has bradycardia (slowed pulse rate). Encourage measures to stabilize heart rhythm. Encouraging measures to stabilize heart rhythm is a solution for irregular heartbeat, not bradycardia (slowed pulse rate). Document patient's pulse rate alteration will resolve. Documenting patient's pulse rate alteration will resolve is a goal, not a solution.

Which explanation would the nurse make when discussing a patient's cardiac output? The number of heartbeats in 1 minute The amount of blood the heart pumps per minute The amount of time it takes for one cardiac cycle The number of pulse sites that are palpable

The amount of blood the heart pumps per minute The amount of blood the heart pumps in 1 minute is the cardiac output, which can cause problems if the heart rate is too fast or too slow. WRONG: The number of heartbeats in 1 minute The number of heartbeats in 1 minute is the pulse and is recorded as beats per minute (beats/min). The amount of time it takes for one cardiac cycle The amount of time it takes for one cardiac cycle is the conduction cycle, not the cardiac output. The number of pulse sites that are palpable Although the cardiac output can affect the number of pulse sites that are palpable, this is not the explanation for cardiac output.

Place the patients in the order in which the nurse would prioritize their care from highest priority to lowest priority. Adult patient with heart rate of 180 Older adult patient with chronic heart disease Middle-aged patient with a heart rate of 65 Older adult patient with no respirations

The nurse would assess the patient with no respirations first because it is life-threatening and follows the ABCs (breathing before circulation). Next is the adult patient with a heart rate of 180 because this is an acute condition and can be life-threatening. This is followed by the older adult patient with chronic heart disease because it is a chronic disease (chronic follows acute). Finally, the middle-aged patient with a heart rate of 65 is assessed last because the heart rate is expected for this patient's age.

Which information would the nurse share about a Holter monitor with a patient who is suffering from arrhythmias and has fainting spells? This test will monitor your heart rate and rhythm just during sleep. This test utilizes a portable device attached to the chest by electrodes. It is an implantable device that is surgically inserted under the skin to continuously monitor the heart's activity. It is a device intended to convert life-threatening arrhythmias of the heart to normal sinus rhythm. NOT SURE

This test utilizes a portable device attached to the chest by electrodes. A Holter monitor utilizes a portable device attached to the chest by electrodes. It measures and records the heart's electrical activity continually. WRONG: This test will monitor your heart rate and rhythm just during sleep. The Holter monitor will record the patient's heart rate and rhythm for a continuous period while the patient is awake and asleep. It is an implantable device that is surgically inserted under the skin to continuously monitor the heart's activity. A Holter monitor is external to the body, not internal. It is a device intended to convert life-threatening arrhythmias of the heart to normal sinus rhythm. A Holter monitor does not convert arrhythmias; it only records the heart's electrical activity to identify arrhythmias.

Match the pulse site to when each site is assessed by the nurse. To check pulse during cardiopulmonary resuscitation (CPR) or cardiac arrest To measure blood pressure To determine discrepancies with radial pulse To assess circulation to the foot Brachial Dorsalis pedis Carotid Apical

To check pulse during cardio pulmonary resuscitation (CPR) or cardiac arrest Carotid To measure blood pressure Brachial To determine discrepancies with radial pulse Apical To assess circulation to the foot Dorsalis pedis

Which patient pulse rates would the nurse report as unexpected (abnormal)? 150 for a newborn 52 for an older adult 90 for a 6-year-old 180 for a 1-year-old 110 for a 15-year-old

52 for an older adult 52 is unexpected for an older adult; expected is 60 to 100. 110 for a 15-year-old 110 for a 15-year-old is unexpected; expected is 50 to 90. 180 for a 1-year-old 180 for a 1-year-old is unexpected regardless of whether the 1-year-old is awake (80 to 150) or asleep (70 to 120). WRONG: 150 for a newborn 150 for a newborn is expected whether the newborn is awake (100 to 180) or asleep (80 to 160). 90 for a 6-year-old 90 for a 6-year-old is expected (75 to 110).

In which patient instances would the nurse use a Doppler unit to assess pulse? 56-year-old morbidly obese patient with hardening of the arteries 62-year-old patient with obstructed blood vessels in the feet 34-year-old patient with an irregular heart rhythm 45-year-old patient with intestinal problems 26-year-old patient with poor circulation in the lower extremities

56-year-old morbidly obese patient with hardening of the arteries The nurse would use a Doppler unit to assess peripheral circulation to amplify sound on a patient with hardening of the arteries because palpation may be an issue. 62-year-old patient with obstructed blood vessels in the feet A Doppler is often used to assess pulses in patients who have an obstruction because palpation would not be a reliable assessment. 26-year-old patient with poor circulation in the lower extremities A Doppler unit is used to assess pulses that are difficult to palpate from poor circulation because it can amplify sound. WRONG: 34-year-old patient with an irregular heart rhythm A stethoscope rather than a Doppler is used to auscultate the apical pulse when the patient has an irregular heart rhythm. 45-year-old patient with intestinal problems A Doppler would not be used to assess intestinal activity. That is accomplished by using a stethoscope.

Which actions would a nurse take for a patient who has tachycardia from low fluid volume? Select all that apply. Administer prescribed fluid replacement. Administer diuretic medication. Administer prescribed oxygen. Prepare patient for an emergency pacemaker insertion. Prepare patient for an electrocardiogram. NOT SURE

Administer prescribed fluid replacement. The nurse would administer prescribed fluid replacement to replenish lost fluid. Administer prescribed oxygen. The nurse would administer oxygen to increase the oxygen levels. Prepare patient for an electrocardiogram. The nurse would prepare the patient for an electrocardiogram to determine the specific rhythm occurring. WRONG: Administer diuretic medication. Administering diuretic medication would make the situation worse; the patient is already low on fluid volume and giving diuretics makes the body remove even more fluids. Prepare patient for an emergency pacemaker insertion. An emergency pacemaker is for a patient with bradycardia rather than tachycardia.

Which factors would the nurse consider when the patient's pulse rate is decreased? Select all that apply. Age Stress Hypoxia Hypovolemia Hypothyroidism

Age Pulse rate decreases with age. Hypothyroidism Hypothyroidism slows the heart rate. WRONG: Stress Stress would increase (not decrease) the heart rate from stimulation of the sympathetic nervous system. Hypoxia Hypoxia would increase (not decrease) the heart rate to compensate for the lack of oxygen to the tissues. Hypovolemia Hypovolemia would increase (not decrease) the heart rate to compensate for the lack of oxygen to the tissues.

Which conditions would be likely to cause tachycardia? Select all that apply. Beta blocker medication Sleep Anemia Bronchodilator medication Drop in blood pressure

Anemia Anemia, a lack of red blood cells, is a cause of tachycardia. Bronchodilator medication Bronchodilator medication, a respiratory medication, is a cause of tachycardia. Drop in blood pressure A decrease or drop in blood pressure is a cause of tachycardia. WRONG: Beta blocker medication Beta blocker medication is a cause for bradycardia, not tachycardia. Sleep Sleep is a cause for bradycardia, not tachycardia. Athletic fitness level Athletic fitness level is a cause for bradycardia, not tachycardia.

Which pulse site would the nurse use that is the most definitive site to determine a patient's cardiac health? Apical Radial Peripheral Carotid

Apical The apical pulse is a central pulse that can be auscultated over the apex of the heart, the most definitive site used for cardiac health. WRONG: Radial Although the radial is the site most often used for vital signs, it is not the most definitive for cardiac health. Peripheral Although peripheral sites can be used to assess a pulse, they are located in arteries away from the heart. Carotid The carotid is in the neck and is a peripheral pulse, not a definitive site to determine a patient's cardiac health.

Which pulse site would the nurse check when an infant appears lifeless? Carotid Femoral Brachial Popliteal

Brachial The brachial pulse in the arm is the best choice as it is easily accessible on an infant. WRONG: Carotid The carotid pulse in the neck is not appropriate for an infant because it is difficult to access the carotid pulse. Femoral Although the femoral can be used in an adult, it is inappropriate for an infant. Popliteal The popliteal pulse in the leg is checked when assessing perfusion of the extremity but not to assess rhythm or heart rate.

Which hypothesis would the nurse develop for an adult patient who has a pulse rate of 40 and is sluggish and confused? Tachycardia Bradycardia Risk for Bradycardia Heart Rate Within Normal Limits

Bradycardia A Bradycardia hypothesis would be developed for this patient because the heart rate is below 60. WRONG: Tachycardia A Tachycardia hypothesis would be developed for a patient who has a heart rate above 100, not for a heart rate of 40. Risk for Bradycardia A Risk for Bradycardia hypothesis would not be developed for this patient because the condition has occurred; a risk hypothesis is used when the condition has not occurred but is likely. Heart Rate Within Normal Limits Heart Rate Within Normal Limits does not describe an adult's heartbeat of 40.

Which action would the nurse take to obtain a patient's apical pulse? Place a cooled stethoscope on the chest. Turn the patient to the right side. Listen at the angle of Louis. Count "lub-dub" as one beat.

Count "lub-dub" as one beat. "Lub-dub" counts as one beat because one apical heartbeat has two sounds. WRONG: Place a cooled stethoscope on the chest. The stethoscope is warmed, not cooled. Turn the patient to the right side. If needed, the patient is turned to the left side, not the right. Listen at the angle of Louis. The nurse listens at the point of maximal impulse (PMI), not at the angle of Louis; the angle of Louis is located at the sternal notch where the second rib attaches and is a landmark to find the PMI.

Which questions would the nurse ask a patient before performing a pulse assessment? Select all that apply. Do you smoke? What medications do you take? Are your hands or feet swollen? Do you experience shortness of breath? Have you engaged in any type of exercise in the past 90 minutes?

Do you smoke? Smoking can affect heart rate, and the nurse would ask this question. What medications do you take? This is an appropriate question to ask before a pulse assessment. Medication can affect pulse rate. Are your hands or feet swollen? This question is appropriate to ask a patient before a pulse assessment. Swollen hands and feet can indicate an underlying medical condition. Do you experience shortness of breath? Shortness of breath can indicate a hypoxia, which can increase the heart rate or indicate an underlying disease. Therefore this question is appropriate to ask a patient before a pulse assessment. WRONG: Have you engaged in any type of exercise in the past 90 minutes? This question is not appropriate. The nurse asks the patient if exercise has been performed within 30 to 60 minutes rather than 90 minutes.

Which action would the nurse take after obtaining a patient's regular radial pulse rate of 45 in 30 seconds? Document the appropriate heart rate. Take the radial pulse for 1 full minute. Find the point of maximal impulse. Notify the health care provider immediately.

Document the appropriate heart rate.The nurse would document the appropriate heart rate (45 × 2 = 90) because the patient's pulse is regular. WRONG: Take the radial pulse for 1 full minute.The pulse rate is only taken for 1 full minute if the radial pulse is irregular; in this scenario the patient's pulse is regular. Find the point of maximal impulse.The point of maximal impulse is for an apical pulse, not for a radial; in this scenario the patient's pulse is regular, and the apical pulse does not need to be assessed. Notify the health care provider immediately.This is an expected heart rate (45 × 2 = 90) and does not need to be reported immediately to the health care provider.

Either side of the neck Either side of the forehead Inner aspect of the arm Inside the wrist Radial Apical Carotid Pedal Temporal Brachial

Either side of the neck Carotid Either side of the forehead Temporal Inner aspect of the arm Brachial Inside the wrist Radial

Which actions would the nurse take for a patient who has Impaired Cardiac Function caused by overhydration and edema? Select all that apply. Encourage oral fluid intake. Elevate legs when at rest. Check peripheral pulses. Balance periods of rest and exercise. Assess heart sounds.

Elevate legs when at rest. When edema is present, legs are elevated to decrease swelling. Check peripheral pulses. Peripheral pulses are checked to determine perfusion to the extremities. Balance periods of rest and exercise. Balancing periods of rest and exercise enhances activity measures and cardiac output. Assess heart sounds. The nurse assesses heart sounds to determine functioning of the cardiac system. WRONG: Encourage oral fluid intake. The patient has overhydration; therefore oral fluids would be limited.

Which factors can affect a patient's heartbeat? Select all that apply. Fever Hunger Exercise Medications Hypovolemia

Hunger Hunger has no direct effect on heart rate. WRONG: Fever Fever causes the heart rate to be elevated because of an increased metabolic rate. Exercise Exercise may increase the heart rate while someone is actively participating in an activity. Medications Medications may increase or decrease a patient's heart rate. Hypovolemia A low fluid volume status may cause the heart to pump faster because of the lower blood volume and stimulation of the sympathetic nervous system.

Which conditions would prompt the nurse to consider a hypothesis of Bradycardia? Select all that apply. Hypothermia Beta blocker administration Increased intracranial pressure Hyperthyroidism Overexertion

Hypothermia Hypothermia lowers the heart rate; thus the nurse would consider a hypothesis of Bradycardia. Beta blocker administration Beta blocker administration lowers the heart rate; thus the nurse would consider a hypothesis of Bradycardia. Increased intracranial pressure Increased intracranial pressure lowers the heart rate; thus the nurse would consider a hypothesis of Bradycardia. WRONG: Hyperthyroidism Hyperthyroidism increases the heart rate; thus the nurse would consider a hypothesis of Tachycardia, not Bradycardia. Overexertion Overexertion increases the heart rate and cause dysthymias; thus the nurse would consider a hypothesis of Tachycardia or Impaired Cardiac Function, but not Bradycardia.

In which instances would the nurse listen to an apical pulse? Select all that apply. If the patient has a palpable peripheral pulse If the patient has weak heart contractions When the patient's pedal pulse is difficult to palpate When the patient's radial pulse is 86 and irregular When a medication may alter the patient's cardiac function

If the patient has weak heart contractions If the patient has weak heart contractions, the nurse may have difficulty palpating the pulse, and listening to the apical pulse would allow an accurate assessment. When the patient's radial pulse is 86 and irregular In the presence of an irregular rhythm, it may be easier for the nurse to auscultate heart sounds and count the apical pulse. When a medication may alter the patient's cardiac function When a medication regimen may alter cardiac function, it is imperative that the nurse auscultate the apical pulse. WRONG: If the patient has a palpable peripheral pulse If a peripheral pulse is palpable, the nurse does not have to listen to an apical pulse because it is not necessary in this instance. When the patient's pedal pulse is difficult to palpate A pedal pulse is not auscultated with a stethoscope. To assess a pedal pulse that is difficult to palpate, the nurse might use a Doppler to assess the pedal pulse.

Which actions would the nurse perform to obtain patient observation cues for pulse? Select all that apply. Interview the patient Check laboratory results for the patient's calcium level Visually inspect the patient for alterations Review the patient's baseline on the graphic/flow sheet Read the nurse's notes about the patient's pulse

Interview the patient Interviewing the patient is a method to collect patient observation cues. Visually inspect the patient for alterations Visually inspecting the patient for alterations is a method to collect patient observation cues. WRONG: Check laboratory results for the patient's calcium level Checking laboratory results for the patient's calcium level is a medical record cue, not a patient observation cue. Review the patient's baseline on the graphic/flow sheet Reviewing the patient's baseline on the graphic/flow sheet is a medical record cue, not a patient observation cue. Read the nurse's notes about the patient's pulse Reading the nurse's notes about the patient's pulse is a medical record cue, not a patient observation cue.

At which site would the nurse assess the patient's apical pulse? Thumb side of the wrist Left fifth and sixth intercostal space Right midclavicular line Simultaneously on both sides of the neck

Left fifth and sixth intercostal spaceAssessment of the apical pulse requires use of a stethoscope and is best heard between the left fifth and sixth intercostal spaces, over the midclavicular line. WRONG: Thumb side of the wrist The thumb side of the wrist is where the radial, not apical, pulse is taken. Right midclavicular line The apical pulse is heard on the left (not the right) midclavicular line. Simultaneously on both sides of the neck The carotid (not the apical pulse is located on both sides of the neck, but assessment of carotid pulse is never done simultaneously on both sides of the neck because fainting can occur if this technique is used.

Match the expected pulse parameters with the appropriate age group. Newborn (awake or asleep) 6-year-old 15-year-old Adult 75-110 50-90 80-180 60-100

Newborn (awake or asleep)80-180 6-year-old75-110 15-year-old50-90 Adult60-100

Match the numeric value the nurse would document for each pulse description. Normal pulse, able to palpate with normal pressure Bounding pulse, may be able to see pulsation Weak and thready, difficult to palpate Absent pulse 1+ 0 2+ 3+

Normal pulse, able to palpate with normal pressure 2+ Bounding pulse, may be able to see pulsation 3+ Weak and thready, difficult to palpate 1+ Absent pulse 0

Which actions would the nurse take for a patient with tachycardia and atrial fibrillation whose pulse continues to increase? Select all that apply. Notify health care provider. Assist with electrical cardioversion. Transfer to intensive care unit. Prepare to insert an emergency pacemaker. Suggest a consult with a cardiologist. Initiate cardiopulmonary resuscitation (CPR)

Notify health care provider. The nurse would notify the health care provider for new prescriptions. Assist with electrical cardioversion. The nurse may have to assist with electrical cardioversion to facilitate the heart's return to expected rate and rhythm. Transfer to intensive care unit. Because the patient is declining, more intensive care is needed. Suggest a consult with a cardiologist. The nurse would suggest a consult with a cardiologist, a specialized health care provider who assists with heart/cardiac problems. WRONG: Prepare to insert an emergency pacemaker. Bradycardia (not tachycardia) can lead to an emergency pacemaker. Initiate cardiopulmonary resuscitation (CPR). The patient in this situation has a pulse; thus CPR is not needed.

Which actions would the nurse take for a patient who develops tachycardia with dizziness and lightheadedness from hypovolemia? Raise the head of the bed. Slowly ambulate the patient. Offer noncaffeinated beverages. Administer fluid replacement. Monitor potassium and calcium levels.

Offer noncaffeinated beverages. The nurse would offer noncaffeinated beverages to replace lost fluids. Administer fluid replacement. The nurse would administer fluid replacement to correct the hypovolemia. Monitor potassium and calcium levels. The nurse would monitor potassium and calcium levels because these imbalances in electrolytes can cause cardiac irregularities. WRONG: Raise the head of the bed. Raising the head of the bed would make the situation worse by increasing lightheadedness and should be avoided. Slowly ambulate the patient. Slowly ambulating the patient would make the situation worse by increasing tachycardia and should be avoided.

Which actions would the nurse take for a patient who develops tachycardia with dizziness and lightheadedness from hypovolemia? Select all that apply. Raise the head of the bed. Slowly ambulate the patient. Offer noncaffeinated beverages. Administer fluid replacement. Monitor potassium and calcium levels. NOT SURE

Offer noncaffeinated beverages. The nurse would offer noncaffeinated beverages to replace lost fluids. Administer fluid replacement. The nurse would administer fluid replacement to correct the hypovolemia. Monitor potassium and calcium levels. The nurse would monitor potassium and calcium levels because these imbalances in electrolytes can cause cardiac irregularities. WRONG: Raise the head of the bed. Raising the head of the bed would make the situation worse by increasing lightheadedness and should be avoided. Slowly ambulate the patient. Slowly ambulating the patient would make the situation worse by increasing tachycardia and should be avoided

Which adult patient would the nurse assess first? One with heart disease One with tachycardia One with stable breathing One with patent (open) airway

One with tachycardia Tachycardia, if severe, can be life-threatening and is an acute condition that would be assessed first. WRONG: One with heart disease Heart disease is chronic, and there is a patient with an acute condition that would be assessed first. One with stable breathing Even though breathing is addressed first, the breathing is stable, indicating no problems; there is another patient who would be assessed first. One with patent (open) airway Although airway is addressed first, the airway is patent (open), indicating no problems; there is another patient who would be assessed first.

Which factors would the nurse consider for an elevated heart rate in a 78-year-old patient who had surgery 1 day prior and currently has a temperature of 102°F (38.9°C) and the nurse is having a difficult time obtaining a blood pressure? Select all that apply. Pain Older age Fever Exercise A drop in blood pressure

Pain Since the patient is 1 day postsurgery, pain may be increasing the heart rate. Fever The patient has a fever, and fever increases the heart rate because of an increased metabolic rate. A drop in blood pressure A drop in blood pressure as indicated by having a difficult time obtaining a blood pressure can cause the heart to elevate to compensate for the decreased cardiac output. WRONG: Older age As one ages, the heart rate decreases rather than increases. Exercise Although exercise can increase heart rate, it is unlikely that a patient 1 day postsurgery is exercising.

Which short-term outcome would the nurse develop for a patient experiencing a decreased heart rate? Patient will exhibit pulse rate within expected range after 12 hours of beginning prescribed interventions. Patient will maintain capillary refill to fingers/toes, skin color, skin integrity, and skin temperature of extremities at the 2-week follow-up appointment. Patient will maintain adequate fluid volume within 8 hours. Patient will exhibit good tissue perfusion.

Patient will exhibit pulse rate within expected range after 12 hours of beginning prescribed interventions. This is an expected outcome because it is measurable, specific, attainable, and realistic, and has a timeline that is short term. WRONG: Patient will maintain capillary refill to fingers/toes, skin color, skin integrity, and skin temperature of extremities at the 2-week follow-up appointment. Although this does have a timeline, it is a goal, not a short-term outcome. As written, there are too many parameters to evaluate, and "maintain" is too broad for a short-term goal in this scenario. Patient will maintain adequate fluid volume within 8 hours. Although there is a timeline, "adequate" fluid volume cannot be measured and does not specifically relate back to decreased heart rate. Patient will exhibit good tissue perfusion. There is no timeline and "good" cannot be measured, making this an inappropriate short-term outcome.

Which treatment option would the nurse anticipate for a patient with bradycardia whose pulse continues to decrease? Discontinue continuous monitoring. Prepare patient for an emergency pacemaker. Transfer patient to a long-term care facility. Consult a physical therapist.

Prepare patient for an emergency pacemaker. If the patient with bradycardia has a pulse that continues to decrease, the patient is declining and would require an emergency pacemaker. WRONG: Discontinue continuous monitoring. A patient with bradycardia whose pulse continues to decrease is declining and would have continuous monitoring rather than discontinuing the monitoring. Transfer patient to a long-term care facility. The patient with bradycardia whose pulse continues to decrease is declining and is too unstable to transfer to a long-term care facility; the patient may be transferred to an intensive or cardiac care unit. Consult a physical therapist. For a patient with bradycardia whose pulse continues to decrease, the patient is declining and would be transferred to a cardiologist rather than a physical therapist.

Which actions would the nurse take when the nurse finds the following pulse rates on the flow sheet: 86, 94, 100, 105, 110? Select all that apply. Reassess cardiac system. Perform a head-to-toe assessment. Review medications. Notify the health care provider. Monitor heart rate every 4 hours. Review electrolyte levels.

Reassess cardiac system. The patient has an upward trend, indicating the cardiac system must be reassessed. Perform a head-to-toe assessment. The patient has an upward trend, indicating the nurse would perform a head-to-toe assessment. Review medications. The patient has an upward trend, indicating the nurse would review the medications to determine if any side effects cause tachycardia. Notify the health care provider. The patient has an upward trend, indicating the nurse would notify the health care provider. Review electrolyte levels. Electrolyte levels can increase the heart rate, especially if potassium and/or calcium are altered. WRONG: Monitor heart rate every 4 hours. The nurse would monitor the heart rate more frequently than every 4 hours.

Which finding would the nurse observe in an adult patient with Bradycardia who is improving? Pulse rate increases to 110. Pulse rate decreases from 60 to 50. Reflexes increase. Responses decrease.

Reflexes increase. Reflexes increasing indicates the patient is improving because slowed reflexes are a cue for Bradycardia. WRONG: Pulse rate increases to 110. A pulse over 100 indicates tachycardia; this indicates the patient is not improving. Pulse rate decreases from 60 to 50. A pulse rate decreasing from 60 to 50 indicates the patient is declining, not improving. Responses decrease. Responses decreasing indicates the patient is declining because slowed responses are cues for Bradycardia.

What heart rate would the nurse record for a patient's heart rate of 46 beats in 30 seconds? __________beats/min

92Count pulse for 30 seconds and multiply times 2: 46 × 2 = 92.

List the electrical impulse for the conduction cycle in the heart, beginning with the natural pacemaker. Bundle of His Right and left bundle branches Purkinje fibers Sinoatrial node Atrioventricular node Internodal pathway

Sinoatrial node Internodal pathway Atrioventricular node Bundle of His Right and left bundle branches Purkinje fibers The electrical impulse is as follows: sinoatrial (SA) node (natural pacemaker) → internodal pathway → atrioventricular (AV) node → bundle of His → right and left bundle branches→ Purkinje fibers.

Which site is the natural pacemaker of the heart? Sinoatrial node Atrioventricular node Purkinje fibers Internodal pathway

Sinoatrial node The sinoatrial node is the natural pacemaker that starts the electrical impulse that causes a pulse. WRONG: Atrioventricular node The atrioventricular node is located between the atria and the ventricle and is not the natural pacemaker of the heart. Purkinje fibers The Purkinje fibers cause the ventricles to contract; they are not the natural pacemaker of the heart. Internodal pathway The internodal pathway allows the atria to contract; it is not the natural pacemaker of the heart.

Which cues would the nurse assess for in an adult patient with bradycardia? Select all that apply. Pulse rate 125 Sluggish Lethargic Confused Bronchodilator prescription NOT SURE

Sluggish A patient with bradycardia will be sluggish because of a lack of oxygen to the brain. Lethargic A patient with bradycardia will be lethargic because of a lack of oxygen to the tissue. Confused A patient with bradycardia will be confused because of a lack of oxygen to the brain. WRONG: Pulse rate 125 A pulse rate of 125 is tachycardia, not bradycardia. Bronchodilator prescription A patient taking bronchodilators is more likely to have tachycardia than bradycardia.

Teach patient to move extremities periodically Encourage oral intake Assess heart sounds Balance periods of rest and exercise Tissue perfusion Cardiac output Fluid volume Activity

Teach patient to move extremities periodicallyT issue perfusion Encourage oral intake Fluid volume Assess heart sounds Cardiac output Balance periods of rest and exercise Activity