EAQ Cardiac Med Surg
The nurse is analyzing the client's rhythm when she notes multiple premature ventricular contractions (PVCs). Each PVC occurs in no particular pattern and looks like all other PVCs. This indicates that the PVCs are: 1 Multifocal. 2 Unifocal. 3 Bigeminal. 4 A pair
A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs arising from multiple foci are not identical and are called multifocal PVCs. PVCs may occur in a predictable pattern, such as every other beat (bigeminal), every third beat (trigeminal), or every fourth beat (quadrageminy). PVCs also can occur sequentially. Two PVCs in a row are called a pair, and three or more in a row are called nonsustained ventricular tachycardia.
The primary health care provider has prescribed a stat chest x-ray and electrocardiogram for an 85-year-old client with a history of congestive heart failure. The pulse oximeter has changed from 90% to 86% oxygen saturation. The nurse's immediate actions include which of the following? Select all that apply. Correct 1 Tell a staff member to get the electrocardiogram machine. Correct 2 Notify the x-ray department that a chest x-ray must be done stat. Correct 3 Increase the supplemental oxygen without a prescription from 2 L nasal cannula to 4 L nasal cannula and notify the health care provider. Correct 4 Have a staff member notify the nursing supervisor of the change in client status. 5 Notify the health care provider of the change in the oxygen saturation to ask what to do. 6 Tell the certified nursing assistant to get a prescription from the health care provider to increase the oxygen
A staff member can get the electrocardiogram machine and start the procedure. Ancillary personnel are trained to do electrocardiograms even if they are not able to interpret the results. Anyone can notify the x-ray department that the chest x-ray must be done. It is important to delegate the tasks to a specific person. Increasing the oxygen without a prescription is appropriate in the short term, but the nurse must obtain a prescription when notifying the health care provider. Notifying the health care provider of the change in oxygen saturation is appropriate, but it would be expected that nursing judgment had taken place and the oxygen already was increased from 2 L/min. Telling the certified nursing assistant (CNA) to get a prescription is an inappropriate action as a CNA is not allowed to take medical prescriptions. Taking a medical prescription is a nursing role.
A nurse observes a window washer falling 25 feet to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first? 1 Feel for a pulse. 2 Begin chest compressions. 3 Leave to call for assistance. 4 Perform the abdominal thrust maneuver.
According to the 2010 American Heart Association Guidelines for CPR, the first step is to feel for a pulse. In this case, it has been established the patient has no pulse, therefore, chest compressions are initiated. Do not leave the patient to call for assistance. The abdominal thrust (Heimlich) maneuver is used to relieve airway obstruction and is not appropriate in this instance.
A client receiving 0.9% normal saline (NS) intravenously at keep vein open (KVO) complains of pain at the insertion site. The nurse notes that there is erythema and edema present at the access site. Based on the phlebitis scale, how should the nurse properly document the phlebitis? 1 One (1) 2 Two (2) 3 Three (3) 4 Four (4
According to the phlebitis scale, grade two presents as pain at the access site with erythema or edema. Grade one presents as erythema with or without pain. Grade three presents as pain at access site with erythema or edema, streak formation, and palpable cord. Grade four presents at access site with erythema or edema, streak formation, palpable cord more than one inch long, and purulent drainage.
What clinical finding should the nurse expect when assessing a client who had a splenectomy? 1 Lung crackles 2 Pain on inspiration 3 Shortness of breath 4 Excessive secretions
Because of the location of the spleen, expansion of the thoracic cavity during inspiration causes pain at the operative site. The presence of crackles indicates accumulation of secretions, which is not an expected outcome; nursing care is designed to prevent this complication. Because limited activity decreases oxygen consumption, shortness of breath is not a common complaint. Excessive secretions are not expected; accumulation of secretions can be prevented by coughing and deep breathing.
A nurse provides instruction when the beta blocker atenolol (Tenormin) is prescribed for a client with moderate hypertension. What action identified by the client indicates to the nurse that the client needs further teaching? Incorrect 1 Move slowly when changing positions. Correct 2 Take the medication before going to bed. 3 Expect to feel drowsy when taking this drug. 4 Count the pulse before taking the medication
Beta blockers (BBs) should not be taken at night because the blood pressure usually decreases when sleeping. This medication blocks beta-adrenergic receptors in the heart, which ultimately lowers the blood pressure. Therefore, the drug should be taken early in the morning to maximize its therapeutic effect. Orthostatic hypotension is a side effect of BBs, and the client should change positions slowly to prevent dizziness and falls. Drowsiness is a side effect of BBs, and the client should be taught precautions to prevent injury. The pulse rate should be taken before administration because ventricular dysrhythmias and heart block may occur with BBs.
An 83-year-old client is diagnosed with left-sided congestive heart failure. Which assessment findings should the nurse expect to find on this client? Select all that apply. Correct 1 Dyspnea Correct 2 Crackles 3 Peripheral edema 4 Jugular distention Correct 5 Cool extremities
Left-sided heart failure causes impaired tissue perfusion, pulmonary congestion, and pulmonary edema, which also causes signs and symptoms such as crackles and dyspnea. Decreased cardiac output causes decreased blood flow to major body organs, especially the kidneys. Peripheral edema and jugular distention are signs of right sided congestive heart failure.
The nurse is planning nutritional education for a client with lower extremity arterial disease (LEAD). What diet modifications should the nurse include? 1 Decreasing both fluid and sodium intake 2 Increasing both calcium and potassium intake 3 Increasing both vitamin E and refined grain intake 4 Decreasing both cholesterol and saturated fat intake
Lower extremity arterial disease frequently is accompanied by generalized atherosclerosis; decreasing both cholesterol and saturated fat intake will help decrease lipid buildup on artery walls. Decreasing both fluid and sodium intake are inappropriate dietary modifications; this client does not have edema. Increasing both calcium and potassium is not appropriate for the client's condition because it may alter the client's electrolyte balance. Recent research indicates that supplemental vitamin E can precipitate cardiac problems and only should be taken when prescribed by a health care provider who can monitor the client's ongoing status. Increasing grain intake will add calories and may contribute to unnecessary weight gain.
The nurse is providing teaching to a client with atrial flutter who has received a prescription for an oral anticoagulant. The client asks the nurse to provide a list of foods that are high in vitamin K and that should be avoided. What should the nurse include on the list? Select all that apply. Correct 1 Spinach 2 Oranges Correct 3 Broccoli 4 Chicken breast Incorrect 5 Sweet potatoe
The amount of vitamin K in spinach is 266 mcg/100 g; the recommended daily allowance of vitamin K is 80 mcg/100 g for men and 65 mcg/100 g for women when a person is receiving an oral anticoagulant. The amount of vitamin K in broccoli is 132 mcg/100 g. Fruit, including oranges, contains minimal vitamin K. Chicken breast is high in protein, not vitamin K. Sweet potatoes are high in vitamin A, not vitamin K.
A nurse is a preceptor for a new graduate nurse. The new graduate is providing care for a client that requests pain medication. The new graduate discovers that the prescribed dose is higher than the safe range listed in the hospital formulary and informs the preceptor of this discovery. The preceptor instructs the new graduate to go ahead and give the prescribed dose. What action should the new graduate take? Correct 1 Contact the primary healthcare provider to discuss the dose 2 Contact a hospital pharmacist to verify the dose prescribed 3 Give the medication as prescribed to decrease the client's pain Incorrect 4 Check the dose with another nurse on the unit to see if it is correc
The nurse should discuss the dose with the health care provider who prescribed the medication. Although talking to the pharmacist may elicit additional information, the nurse still has to come to a conclusion about the next course of action. Giving the medication as prescribed may place the client at risk. Although checking the dose with another nurse may elicit additional information, the nurse still has to come to a conclusion about the next course of action.
