Week 5- Cardiac

The nurse is assessing an electrocardiogram rhythm strip. The P-waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall HR is 64 bpm. The nurse assesses the cardiac rhythm as: A. Normal sinus rhythm B. Sinus bradycardia C. Sinus tachycardia D. Sick sinus syndrome

A. Normal sinus rhythm

17. A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats per minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How would the nurse interpret this rhythm? 1. Sinus tachycardia 2. Sinus bradycardia 3. Sinus dysrhythmia 4. Normal sinus rhythm

1. Sinus tachycardia Rationale: Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats per minute.

12. A client's cardiac rhythm suddenly changes on the monitor. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How would the nurse interpret the rhythm? 1. Atrial fibrillation 2. Sinus tachycardia 3. Ventricular fibrillation 4. Ventricular tachycardia

1. Atrial fibrillation Rationale: Atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each QRS complex. The atria quiver, which can lead to thrombus formation.

Upon entering a client's room, the nurse finds the client unresponsive. In what order will the nurse provide care? 1. Begin chest compressions 2. Check carotid pulse 3. Notify the Rapid Response Team 4. Get the crash cart/AED 5. Provide rescue breaths

3. Notify the Rapid Response Team 4. Get the crash cart/AED 2. Check carotid pulse 1. Begin chest compressions 5. Provide rescue breaths

9. A client has frequent bursts of ventricular tachycardia on the cardiac monitor. Which factor is highest priority with regard to this dysrhythmia? 1. It can develop into ventricular fibrillation at any time. 2. It is almost impossible to convert to a normal rhythm. 3. It is uncomfortable for the client, giving a sense of impending doom. 4. It produces a high cardiac output with cerebral and myocardial ischemia.

1. It can develop into ventricular fibrillation at any time. Rationale: Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. Ventricular tachycardia can deteriorate into ventricular fibrillation with cardiac arrest at any time. Clients frequently experience a feeling of impending doom. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (if the client is awake), or defibrillation (loss of consciousness).

11. The client has developed atrial fibrillation, with a ventricular rate of 150 beats per minute. Which associated findings would the nurse anticipate in the assessment? Select all that apply. 1. Syncope 2. Dizziness 3. Palpitations 4. Hypertension 5. Flat neck veins

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

18. The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable. How would the nurse interpret the client's neurovascular status? 1. The neurovascular status is expected because of increased blood flow through the leg. 2. The neurovascular status is moderately impaired, and the surgeon needs to be called. 3. The neurovascular status is slightly deteriorating and needs to be monitored for another hour. 4. The neurovascular status shows adequate arterial flow, but venous complications are arising.

1. The neurovascular status is expected because of increased blood flow through the leg. Rationale: An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. The remaining options are incorrect interpretations.

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

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

15. The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? 1. Blood pressure 2. Airway patency 3. Oxygen flow rate 4. Level of consciousness

2. Airway patency Rationale: Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection.

4. A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? 1. Stridor 2. Crackles 3. Scattered rhonchi 4. Diminished breath sounds

2. Crackles Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway.

1. A client with a history of type 2 diabetes is admitted to the hospital with chest pain and scheduled for a cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? 1. Glipizide 2. Metformin 3. Repaglinide 4. Regular insulin

2. Metformin Rationale: Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld before and after cardiac catheterization.

5. A client with myocardial infarction is developing cardiogenic shock. Which potential condition would the nurse anticipate and monitor the client for to detect cardiogenic shock? 1. Pulsus paradoxus 2. Ventricular dysrhythmias 3. Rising diastolic blood pressure 4. Falling central venous pressure

2. Ventricular dysrhythmias Rationale: Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium. Classic signs of cardiogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure become apparent. Pulsus paradoxus is a finding associated with cardiac tamponade.

10. A client is having frequent premature ventricular contractions. The nurse would place priority on assessment of which information? 1. Causative factors, such as caffeine 2. Sensation of fluttering or palpitations 3. Blood pressure and oxygen saturation 4. Precipitating factors, such as infection

3. Blood pressure and oxygen saturation Rationale: Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders; states of hypoxemia; any number of physiological stressors, such as infection, illness, surgery, or trauma; and intake of caffeine, nicotine, or alcohol.

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

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

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

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

20. A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? 1. "I need to notify my cardiologist if my feet or legs start to swell." 2. "I am supposed to report to my cardiologist if my pulse rate decreases below 60." 3. "Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast." 4. "My spouse told me that since I have this problem, we are going to stop walking in the mall every morning."

4. "My spouse told me that since I have this problem, we are going to stop walking in the mall every morning." Rationale: Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often at rest. The pain is a result of coronary artery spasm. The treatment of choice is usually a calcium channel blocker, which relaxes and dilates the vascular smooth muscle, thus relieving the coronary artery spasm in variant angina. Adverse effects can include peripheral edema, hypotension, bradycardia, and heart failure. Grapefruit juice interacts with calcium channel blockers and needs to be avoided. If bradycardia occurs, the client needs to contact the primary health care provider or cardiologist. Clients need to also be taught to change positions slowly to prevent orthostatic hypotension. Physical exertion does not cause this type of angina; therefore, the client would be able to continue morning walks with their spouse.

What is the priority intervention for a patient in ventricular fibrillation? A. Defibrillation B. Cardioversion C. Notifying the family D. Continue to monitor

A. Defibrillation Rationale: Think "V-fib = defib." Cardioversion is done when the patient is unstable with a pulse. Action is required for ventricular fibrillation beyond monitoring. Notifying the family is not the priority.

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

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

Which serum lab value can assist in diagnosing heart failure? A. Brain natriuretic peptide (BNP) B. Blood urea nitrogen (BUN) C. Blood pressure D. Cardiac catheterization

A. Brain natriuretic peptide (BNP) Rationale: A BNP level over 100 suggests heart failure. BUN is not specific to heart failure, and blood pressure and cardiac catheterization are not serum lab values.

The nurse is admitting an 84-year-old client with heart failure to the emergency department with confusion, blurry vision, and an upset stomach. Which assessment data are most concerning? A. Digoxin therapy daily B. Daily metoprolol C. Furosemide twice daily D. Currently taking an antacid for upset stomach

A. Digoxin therapy daily

A client has developed atrial fibrillation, with a ventricular rate of 150 bpm. A nurse assesses the client for: A. Hypotension and dizziness B. N/V C. Hypertension and headache D. Flat neck veins

A. Hypotension and dizziness

The nurse is caring for a client with heart failure who is prescribed spironolactone. Which client statement requires further nursing education? A. "I may need to take this drug every other day according to lab values." B. "I need to take potassium supplements with this medication." C. "I will try my best not to use table salt on my food." D. "This medication will cause me to urinate more often."

B. "I need to take potassium supplements with this medication."

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

B. Atrial fibrillation

A client is diagnosed with left-sided heart failure. Which client assessment findings will the nurse anticipate? Select all that apply. A. Peripheral edema B. Crackles in both lungs C. Tachycardia D. Ascites E. Tachypnea F. S3 gallop

B. Crackles in both lungs C. Tachycardia E. Tachypnea F. S3 gallop

Which are causes of bradycardia? Select all that apply. A. Fever B. Sleeping C. Infection D. Vagal nerve stimulation E. Spinal cord injury

B. Sleeping D. Vagal nerve stimulation E. Spinal cord injury Rationale: Causes of bradycardia include sleeping, vagal nerve stimulation, and spinal cord injury. Infection and fever typically cause tachycardia.

While suctioning a client with a tracheostomy, the client becomes diaphoretic and nauseous and the heart rate decreases to 37 beats/min. What is the priority nursing action? A. Continue to clear the airway. B. Stop suctioning the patient. C. Administer atropine. D. Call the health care provider immediately.

B. Stop suctioning the patient.

The primary health care provider prescribes warfarin for a client with atrial fibrillation. Which client statement indicates that additional education is needed? A. "I need to go to the clinic once a week to have my blood level checked." B. "If my stools turn black, I will be sure to call my primary health care provider." C. "I'm glad I don't need to change my diet. Salads are my favorite food." D. "I need to stop taking my herbal supplement."

C. "I'm glad I don't need to change my diet. Salads are my favorite food."

A nurse is administering a beta blocker to a patient who has heart failure. Which statement may be part of the nurse's patient education? A. "This medication will help your heart beat faster." B. "This medication will help your symptoms only." C. "This medication will improve your survival and symptoms of heart failure." D. "This medication helps get rid of the extra fluid in your body."

C. "This medication will improve your survival and symptoms of heart failure." Rationale:Beta blockers improve symptoms of heart failure and extend survival. Beta blockers lower heart rates and help do more than managing symptoms. Diuretics may be used to get rid of extra fluid in the body.

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

C. Administer Amiodarone IV

The nurse is assessing the client's cardiac rhythm and notes the following: HR 64, regular rhythm, PR interval 0.20; QRS 0.10. How will the nurse document this rhythm interpretation in the electronic health record? A. Sinus tachycardia B. Sinus bradycardia C. Normal sinus rhythm D. Sinus arrhythmia

C. Normal sinus rhythm

The nurse is caring for a client with heart failure who is on oxygen at 2 L per nasal cannula with an oxygen saturation of 90%. The client states, "I feel short of breath." Which action will the nurse take first? A. Contact respiratory therapy. B. Increase the oxygen to 4 L. C. Place the client in a high-Fowler position. D. Draw arterial blood for arterial blood gas analysis.

C. Place the client in a high-Fowler position.

A patient has an ejection fraction (EF) of 35%. What does this indicate? A. The patient has an optimally functioning heart. B. The patient is in diastolic heart failure. C. The patient is in systolic heart failure. D. The patient is at risk for developing heart failure.

C. The patient is in systolic heart failure Rationale: An EF less than 40% indicates decreased cardiac output and pump failure, which means they have systolic heart failure. EF is preserved in diastolic heart failure. The heart is not optimally functioning, and the patient has already developed heart failure.

What is the best way to treat sinus tachycardia? A. Administer beta blockers. B. Encourage deep breathing exercises. C. Treat the underlying cause. D. Cardiovert.

C. Treat the underlying cause. Rationale: The best way to treat sinus tachycardia is to treat the underlying cause. Beta blockers may be needed to do this and deep breathing could help, but addressing the underlying cause will solve the problem. Cardioversion is not indicated for sinus tachycardia.

What is the drug of choice to treat SVT? A. Atenolol B. Amlodipine C. Atropine D. Adenosine

D. Adenosine Rationale: The goal for treating SVT is to break or slow down the heart rate; adenosine will accomplish this. Atenolol is a beta blocker, amlodipine is a calcium channel blocker, and atropine is indicated for bradycardia.

A client in the telemetry unit is on a cardiac monitor. The monitor technician alerts the nurse that there are no ECG complexes, and the alarm is sounding. What is the first action by the nurse? A. Suspend the alarm. B. Call the emergency response team. C. Press the record button to get an ECG strip D. Assess the client and check lead placement

D. Assess the client and check lead placement

The nurse is caring for client who is experiencing occasional premature ventricular contractions. What assessment data are most concerning to the nurse? A. Potassium 4.8 mEq/L B. Magnesium 2 mEq/L C. Heart rate 90 D. History of smoking

D. History of smoking

Which is not a common cause of heart failure? A. Coronary artery disease (CAD) B. Myocardial infarction (MI) C. Hypertension D. Hypothyroidism

D. Hypothyroidism Rationale: Hypothyroidism is not a cause of heart failure. CAD, MI, and hypertension can all lead to heart failure.

19. The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous (IV) infusion at a rate of 150 mL/hr, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL is most recent). The client's blood urea nitrogen (BUN) level is 35 mg/dL (12.6 mmol/L), and the serum creatinine level is 1.8 mg/dL (159 mcmol/L), measured this morning. Which nursing action is the priority? 1. Check the serum albumin level. 2. Check the urine specific gravity. 3. Continue to monitor urine output. 4. Call the primary health care provider.

4. Call the primary health care provider. Rationale: Following abdominal aortic aneurysm resection or repair, the nurse monitors the client for signs of acute kidney injury. Acute kidney injury can occur because often much blood is lost during the surgery and, depending on the aneurysm location, the renal arteries may be hypoperfused for a short period during surgery. Normal reference levels are BUN 10 to 20 mg/dL (3.6 to 7.1 mmol/L), and creatinine 0.5 to 1.2 mg/dL (44 to 106 mcmol/L). Continuing to monitor urine output or checking other parameters can wait. Urine output lower than 30 mL/hr is reported to the PHCP for urgent treatment.

A patient has been diagnosed with atrial fibrillation. What class of medications is expected to be prescribed? A. Anticholinergics B. Anticoagulants C. Proton pump inhibitors D. Histamine blockers

B. Anticoagulants Rationale: Anticoagulants are expected to be prescribed for a patient with atrial fibrillation to prevent blood pooling in the ventricles and causing clots, which can lead to pulmonary embolism or stroke. Anticholinergics, proton pump inhibitors and histamine blockers are indicated for GERD

Upon assessment, the nurse notes a patient has crackles and dyspnea. What does this indicate? A. The patient's right side of the heart is affected. B. The patient's left side of the heart is affected. C. The patient has systolic heart failure. D. The patient has diastolic heart failure.

B. The patient's left side of the heart is affected. Rationale: Crackles and dyspnea result from a poorly functioning left side of the heart. If the right side is affected, fluid will back up into the rest of the body leading to an enlarged liver and spleen, ascites, and dependent edema. Crackles and dyspnea do not indicate if heart failure is systolic or diastolic

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

B. Ventricular tachycardia

13. The nurse is assisting to defibrillate a client in ventricular fibrillation. Which intervention is a priority after placing the pads on the client's chest and before discharging the device? 1. Ensure that the client has been intubated. 2. Set the defibrillator to "synchronize" mode. 3. Administer an amiodarone bolus. 4. Confirm the cardiac rhythm.

4. Confirm the cardiac rhythm. Rationale: Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any loose connections. The client does not have to be intubated to be defibrillated. The machine is not set to the synchronous mode because there is no underlying rhythm with which to synchronize. Defibrillation should not be delayed for administration of any drugs, including amiodarone.

3. The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse immediately asks another nurse to contact the primary health care provider and prepares to implement which priority interventions? Select all that apply. 1. Administer oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the client in a low-Fowler's side-lying position

1. Administer oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intravenously Rationale: Extreme dyspnea, tachycardia, and lung crackles in a client with heart failure indicate pulmonary edema, a life-threatening event. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high-Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

7. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? 1. Call a code. 2. Check the client's status. 3. Call the primary health care provider. 4. Document the lack of complexes.

2. Check the client's status. Rationale: Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client is necessary to determine the cause and identify the appropriate intervention. The remaining options are secondary to client assessment.