2501 exam 1

A client hospitalized with a diagnosis of myocardial infarction calls for the unit nurse because the client is experiencing chest pain. The nurse administers a sublingual nitroglycerin tablet as prescribed. The client, who is receiving oxygen by nasal cannula, reports that her chest pain is unrelieved by the nitroglycerin. Which is the next nursing action for this client? 1. Call the client's family. 2. Increase the flow rate of oxygen. 3. Contact the health care provider (HCP). 4. Administer another nitroglycerin tablet.

4. Administer another nitroglycerin tablet. Rationale: For the hospitalized client, nitroglycerin tablets are administered one tablet every 5 minutes, for a total of three tablets per episode of chest pain, so long as the client maintains a systolic blood pressure of 100 mm Hg or higher. Increasing the flow rate of oxygen may be prescribed by the HCP but would not be the next nursing action. If three nitroglycerin tablets do not relieve the client's chest pain, the HCP needs to be notified. It is premature to call the client's family.

A client in cardiogenic shock has a pulmonary artery catheter (Swan-Ganz type) placed. The nurse would interpret which cardiac output (CO) and pulmonary capillary wedge pressure (PCWP) readings as indicating that the client is most unstable? 1. CO 5 L/min, PCWP low 2. CO 3 L/min, PCWP low 3. CO 4 L/min, PCWP high 4. CO 3 L/min, PCWP high

4. CO 3 L/min, PCWP high Rationale: The normal cardiac output is 4 to 7 L/min. With cardiogenic shock, the CO falls below normal because of failure of the heart as a pump. The PCWP, however, rises because it is a reflection of the left ventricular end-diastolic pressure, which rises with pump failure.

A client has frequent runs of ventricular tachycardia. The health care provider has prescribed an antidysrhythmic, flecainide (Tambocor). What is the best nursing action related to the effects of this medication? 1. Monitor the client's urinary output. 2. Assess the client for neurological changes. 3. Keep the call bell within the client's reach. 4. Monitor the client's vital signs and cardiac rhythm frequently.

4. Monitor the client's vital signs and cardiac rhythm frequently. Rationale: Flecainide is an antidysrhythmic medication that slows conduction and decreases excitability, conduction velocity, and automaticity. The nurse needs to monitor the client's vital signs for changes and cardiac rhythm for the development of a new or a worsening dysrhythmia.

A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse caring for the client uses which item as the best means to monitor respiratory status on an ongoing basis? 1. Apnea monitor 2. Oxygen flowmeter 3. Telemetry cardiac monitor 4. Oxygen saturation monitor

4. Oxygen saturation monitor Rationale: Dyspnea in the cardiac client often is accompanied by hypoxemia. Hypoxemia can be detected by an oxygen saturation monitor, especially if it is used continuously. An apnea monitor detects apnea episodes, such as when the client has stopped breathing briefly. An oxygen flowmeter is part of the setup for delivering oxygen therapy. Cardiac monitors detect dysrhythmias.

A client with myocardial infarction is experiencing new, multiform premature ventricular contractions (PVCs). Knowing that the client is allergic to lidocaine hydrochloride, the nurse plans to have which medication available for immediate use? 1. Procainamide 2. Digoxin (Lanoxin) 3. Verapamil (Calan SR) 4. Metoprolol (Lopressor)

1. Procainamide Rationale: Procainamide is an antidysrhythmic that may be used to treat ventricular dysrhythmias in clients who are allergic to lidocaine. Digoxin is a cardiac glycoside; verapamil is a calcium-channel blocking agent; metoprolol is a β-adrenergic blocking agent

A client with a history of angina pectoris tells the nurse that chest pain usually occurs after going up two flights of stairs or after walking four blocks. What type of angina should the nurse determine that the client is experiencing? 1. Stable 2. Variant 3. Unstable 4. Intractable

1. Stable

Which should the nurse do when setting up an arterial line? 1. Tighten all tubing connections. 2. Use macrodrop intravenous tubing. 3. Level the transducer to the ventricle. 4. Raise the height of the normal saline infusion to prevent backup.

1. Tighten all tubing connections. Rationale: Because the arterial vasculature is a high-pressure system, all tubing connections must be tight to avoid blood loss from loose connections. High-pressure tubing with a transducer is used (not macrodrip tubing). The transducer should be level to the atrium not the ventricle. Raising the height of the infusion is not sufficient to prevent backflow.

A client with angina complains that the anginal pain is prolonged, severe, and occurs at the same time each day, most often in the morning. On further assessment, the nurse notes that the pain occurs in the absence of precipitating factors. How would the nurse best describe this type of anginal pain? 1. Stable angina 2. Variant angina 3. Unstable angina 4. Nonanginal pain

2. Variant angina

A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often at rest in the absence of precipitating factors. How would the nurse best describe this type of anginal pain? 1. Stable angina 2. Variant angina 3. Unstable angina 4. Nonanginal pain

2. Variant angina Rationale: Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often at rest. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction.

A client with angina pectoris is experiencing chest pain that radiates down the left arm. The nurse administers a sublingual nitroglycerin tablet to the client. The client's pain is unrelieved, and the nurse determines that the client needs another nitroglycerin tablet. Which vital sign is the most important for the nurse to check before administering the medication? 1. Temperature 2. Respirations 3. Blood pressure 4. Radial pulse rate

3. Blood pressure

A client has developed uncontrolled atrial fibrillation with a ventricular rate of 150 beats/min. What manifestation should the nurse observe for when performing the client's focused assessment? 1. Flat neck veins 2. Nausea and vomiting 3. Hypotension and dizziness 4. Clubbed fingertips and headache

3. Hypotension and dizziness Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/min is at risk for low cardiac output due to 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.

A client is diagnosed with an ST-segment elevation myocardial infarction (STEMI) and is receiving tissue plasminogen activator, alteplase (Activase, tPA). Which action is a priority nursing intervention? 1. Monitor for kidney failure. 2. Monitor psychosocial status. 3. Monitor for signs of bleeding. 4. Have heparin sodium available.

3. Monitor for signs of bleeding. Rationale: Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication. The client is monitored for bleeding.

The nurse is reviewing 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 heart rate is 64 beats/minute. Which would be a correct interpretation based on these characteristics? 1. Sinus bradycardia 2. Sick sinus syndrome 3. Normal sinus rhythm 4. First-degree heart block

3. Normal sinus rhythm

A client with a first-degree heart block has an electrocardiogram (ECG) taken during an episode of chest pain. The nurse knows that which ECG finding would be an indication of first-degree heart block? 1. Presence of Q waves 2. Tall, peaked T waves 3. Prolonged PR interval 4. Widened QRS complex

3. Prolonged PR interval Rationale: A prolonged PR interval indicates first-degree heart block. An ECG taken during a pain episode is intended to capture ischemic changes, which also include ST-segment elevation or depression.

The home care nurse has taught a client with a problem of inadequate cardiac output about helpful lifestyle adaptations to promote health. Which statement by the client best demonstrates an understanding of the information provided? 1. "I will eat enough daily fiber to prevent straining at stool." 2. "I will try to exercise vigorously to strengthen my heart muscle." 3. "I will drink 3000 to 3500 mL of fluid daily to promote good kidney function." 4. "Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging blood vessels."

1. "I will eat enough daily fiber to prevent straining at stool." Rationale: Standard home care instructions for a client with this problem include, among others, lifestyle changes such as decreased alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen to prevent straining and constipation, and maintaining fluid and electrolyte balance. Consuming 3000 to 3500 mL of fluid and exercising vigorously will increase the cardiac workload

A client is scheduled for elective cardioversion to treat chronic high-rate atrial fibrillation. Which finding indicates that further preparation is needed for the procedure? 1. The client is wearing a nasal cannula delivering oxygen at 2 L/min. 2. The client's digoxin (Lanoxin) has been withheld for the last 48 hours. 3. The defibrillator has the synchronizer turned on and is set at 50 joules (J). 4. The client has received an intravenous dose of a conscious sedation medication.

1. The client is wearing a nasal cannula delivering oxygen at 2 L/min. Rationale: During the procedure, any oxygen is removed temporarily because oxygen supports combustion, and a fire could result from electrical arcing. Digoxin may be withheld for up to 48 hours before cardioversion because it increases ventricular irritability and may cause ventricular dysrhythmias after the countershock. The defibrillator is switched to synchronizer mode to time the delivery of the electrical impulse to coincide with the QRS and avoid the T wave, which could cause ventricular fibrillation. Energy level typically is set at 50 to 100 J. The client typically receives a dose of an intravenous sedative or antianxiety agent.

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 and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status? 1. The neurovascular status is normal because of increased blood flow through the leg. 2. The neurovascular status is moderately impaired, and the surgeon should be called. 3. The neurovascular status is slightly deteriorating and should be monitored for another hour. 4. The neurovascular status is adequate from an arterial approach, but venous complications are arising.

1. The neurovascular status is normal 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.

A client's electrocardiogram (ECG) strip shows atrial and ventricular rates of 70 complexes/min. The PR interval is 0.16 second, the QRS complex measures 0.06 second, and the PP interval is slightly irregular. How should the nurse interpret this rhythm? 1. Sinus tachycardia 2. Sinus dysrhythmia 3. Sinus bradycardia 4. Normal sinus rhythm

2. Sinus dysrhythmia Rationale: Sinus dysrhythmia has all of the characteristics of normal sinus rhythm except for the presence of an irregular PP interval. This irregular rhythm occurs because of phasic changes in the rate of firing of the sinoatrial node, which may occur with vagal tone and with respiration. Cardiac output is not affected.

The nurse notes that a client's cardiac rhythm shows absent P waves and no PR interval. How should the nurse interpret this rhythm? 1. Bradycardia 2. Tachycardia 3. Atrial fibrillation 4. Normal sinus rhythm (NSR)

3. Atrial fibrillation Rationale: In atrial fibrillation, the P waves may be absent. There is no PR interval, and the QRS duration usually is normal and constant. Bradycardia is a slowed heart rate, and tachycardia is a fast heart rate. In NSR a P wave precedes each QRS complex, the rhythm is essentially regular, the PR interval is 0.12 to 0.20 seconds in duration, and the QRS interval is 0.06 to 0.10 seconds in duration.

A client with angina pectoris is experiencing chest pain that radiates down the left arm. The nurse administers a sublingual nitroglycerin tablet to the client. The client's pain is unrelieved, and the nurse determines that the client needs another nitroglycerin tablet. Which vital sign is the most important for the nurse to check before administering the medication? 1. Temperature 2. Respirations 3. Blood pressure 4. Radial pulse rate

3. Blood pressure Rationale: Nitroglycerin acts directly on the smooth muscle of the blood vessels, causing relaxation and dilation. As a result, hypotension can occur. The nurse would check the client's blood pressure before administering the second nitroglycerin tablet

A nurse is reinforcing instructions to a hospitalized client with heart block about the fundamental concepts regarding the cardiac rhythm. The nurse explains to the client that the normal site in the heart responsible for initiating electrical impulses is which site? 1. Bundle of His 2. Purkinje fibers 3. Sinoatrial (SA) node 4. Atrioventricular (AV) node

3. Sinoatrial (SA) node Rationale: The SA node is responsible for initiating electrical impulses that are conducted through the heart. The impulse leaves the SA node and travels down through internodal and interatrial pathways to the AV node. From there, impulses travel through the bundle of His to the right and left bundle branches and then to the Purkinje fibers. This group of specialized cardiac cells is referred to as the cardiac conduction system. The ability of this specialized tissue to generate its own impulses is called automaticity.

The nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization performed through the femoral artery. The nurse checks the health care provider's (HCP's) prescription and plans to allow which client position or activity following the procedure? 1. Bed rest in high Fowler's position 2. Bed rest with bathroom privileges only 3. Bed rest with head elevation at 60 degrees 4. Bed rest with head elevation no greater than 30 degrees

4. Bed rest with head elevation no greater than 30 degrees Rationale: After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for 4 to 6 hours. The client is maintained on bed rest for 4 to 6 hours (time for bed rest may vary depending on the HCP's preference and on whether a vascular closure device was used) and the client may turn from side to side. The head is elevated no more than 30 degrees (although some HCPs prefer the flat position) until hemostasis is adequately achieved.

A client who has begun taking Propanolol (Inderal) demonstrates an effective response to the medication as indicated by which nursing assessment finding? 1. Increase in edema to 3+ 2. Weight gain of 5 pounds 3. Decrease in pulse rate from 74 beats/min to 58 beats/min 4. Decrease in blood pressure from 142/94 mm Hg to 128/82 mm Hg

4. Decrease in blood pressure from 142/94 mm Hg to 128/82 mm Hg Rationale: Betaxolol is a β-adrenergic blocking agent used to lower blood pressure, relieve angina, or decrease the occurrence of dysrhythmias. Side effects include bradycardia and signs and symptoms of heart failure, such as increased edema and weight gain.

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

4. Prepare for transcutaneous pacing. Rationale: 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. Continuing to monitor the client delays necessary intervention. Digoxin will further decrease the client's heart rate.

The nurse working in a long-term care facility is assessing a client who is experiencing chest pain. The nurse should interpret that the pain is most likely caused by myocardial infarction (MI) on the basis of what assessment finding? 1. The client is not experiencing dyspnea. 2. The client is not experiencing nausea or vomiting. 3. The pain has not been relieved by rest and nitroglycerin tablets. 4. The client says the pain began while she was trying to open a stuck dresser drawer.

3. The pain has not been relieved by rest and nitroglycerin tablets.

The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain at home. During the assessment the client complains of chest pain. The nurse should immediately ask the client which question? 1. "Where is the pain located?" 2. "Are you having any nausea?" 3. "Are you allergic to any medications?" 4. "Do you have your nitroglycerin with you?"

1. "Where is the pain located?" Rationale: If a client complains of chest pain, the initial assessment question would be to ask the client about the pain intensity, location, duration, and quality.

The nurse is assisting in the care of a client scheduled for cardioversion. The nurse plans to set the defibrillator to which starting energy range level, depending on the specific health care provider (HCP) prescription? 1. 50 to 100 joules 2. 150 to 300 joules 3. 300 to 350 joules 4. 350 to 400 joules

1. 50 to 100 joules

The nurse determines that a client requires further teaching after permanent pacemaker insertion if which statement is made? 1. "My pulse rate should be less than what my pacemaker is set at." 2. "I'll need to call my health care provider if I feel tired or dizzy." 3. "I'll have to avoid carrying the grocery bags into the house for the next 6 weeks." 4. "It's safe to use my microwave as long it is properly grounded and well shielded."

1. "My pulse rate should be less than what my pacemaker is set at." Rationale: The client should call the health care provider if the pulse rate is less than what the pacemaker is set at because this could be a sign of pacemaker or battery failure.

A new nursing graduate is caring for a client who is attached to a cardiac monitor. While assisting the client with bathing, the nurse observes the sudden development of ventricular tachycardia (VT), but the client remains alert and oriented and has a pulse. Which interventions would the nurse take? Select all that apply. 1. Administer oxygen. 2. Defibrillate the client. 3. Obtain an electrocardiogram (ECG). 4. Contact the health care provider (HCP). 5. Assess circulation, airway, and breathing. 6. Initiate cardiopulmonary resuscitation (CPR).

1. Administer oxygen. 3. Obtain an electrocardiogram (ECG). 4. Contact the health care provider (HCP). 5. Assess circulation, airway, and breathing. Rationale: With VT in a stable client, the nurse assesses circulation, airway, and breathing; administers oxygen; and confirms the rhythm via a 12-lead ECG. The HCP is contacted, and antidysrhythmics may be prescribed. With pulseless VT, the HCP or a specially trained nurse must immediately defibrillate the client or initiate CPR followed by defibrillation as soon as possible.

A client in the hospital emergency department who received nitroglycerin for chest pain has obtained relief but now complains of a headache. The nurse should interpret that this client is most likely experiencing which condition? 1. An expected medication side effect 2. An allergic reaction to nitroglycerin 3. An early sign of tolerance to the medication 4. A warning that the medication should not be used again

1. An expected medication side effect Rationale: Headache is a frequent side effect of nitroglycerin, resulting from its vasodilator action. It often subsides as the client becomes accustomed to the medication and is effectively treated with acetaminophen (Tylenol).

The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client's heart 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.

A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places highest priority on telling the client to report which sensation during the procedure? 1. Chest pain 2. Urge to cough 3. Warm, flushed feeling 4. Pressure at the insertion site

1. Chest pain Rationale: The client is taught to report chest pain or any unusual sensations immediately. The client also is told that he or she may be asked to cough or breathe deeply from time to time during the procedure. The client is informed that a warm, flushed feeling may accompany dye injection and is normal. Because a local anesthetic is used, the client is expected to feel pressure at the insertion site.

The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a ventricular rate of 150 beats/min. The nurse should next assess the client for which finding? 1. Hypotension 2. Flat neck veins 3. Complaints of nausea 4. Complaints of headache

1. Hypotension Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/min is at risk for low cardiac output owing to 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.

A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with 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 that quickly leads to 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. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Clients frequently experience a feeling of impending doom. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (if client is awake), or defibrillation (loss of consciousness). Ventricular tachycardia can deteriorate into ventricular fibrillation at any time.

A nurse who is auscultating a 56-year-old client's apical heart rate before administering digoxin (Lanoxin) notes that the heart rate is 52 beats/min. The nurse should make which interpretation about this information? 1. Normal, because of the client's age 2. Abnormal, requiring further assessment 3. Normal, as a result of the effects of digoxin 4. Normal, because this is the reason the client is receiving digoxin

2. Abnormal, requiring further assessment Rationale: The normal heart rate is 60 to 100 beats/min in an adult. On auscultating a heart rate that is less than 60 beats/min, the nurse would not administer the digoxin and would report the finding to the health care provider. Digoxin increases the strength and contraction of the heart; it is not used to treat low heart rates. If a low heart rate is noted in a client taking digoxin, the medication is withheld and the health care provider is notified.

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

2. 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/minute

The nurse is evaluating a client's response to cardioversion. Which observation would be of highest priority to the nurse? 1. Blood pressure 2. Status of airway 3. Oxygen flow rate 4. Level of consciousness

2. Status of airway 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

The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. No P waves or QRS complexes are seen; instead, the monitor screen shows an irregular wavy line. The nurse interprets that the client is experiencing which rhythm? 1. Sinus tachycardia 2. Ventricular fibrillation 3. Ventricular tachycardia 4. Premature ventricular contractions (PVCs)

2. Ventricular fibrillation Rationale: Ventricular fibrillation is characterized by the absence of P waves and QRS complexes. The rhythm is instantly recognizable by the presence of coarse or fine fibrillatory waves on the cardiac monitoring screen. Sinus tachycardia has a recognizable P wave and QRS. Ventricular tachycardia is a regular pattern of wide QRS complexes. PVCs appear as irregular beats within a rhythm. Each of the incorrect options has a recognizable complex that appears on the monitoring screen.

The nurse should report which assessment finding to the health care provider (HCP) before initiating thrombolytic therapy in a client with pulmonary embolism? 1. Adventitious breath sounds 2. Temperature of 99.4° F orally 3. Blood pressure of 198/110 mm Hg 4. Respiratory rate of 28 breaths/minute

3. Blood pressure of 198/110 mm Hg Rationale: Thrombolytic therapy is contraindicated in a number of preexisting conditions in which there is a risk of uncontrolled bleeding, similar to the case in anticoagulant therapy. Thrombolytic therapy also is contraindicated in severe uncontrolled hypertension because of the risk of cerebral hemorrhage. Therefore the nurse would report the results of the blood pressure to the HCP before initiating therapy.

A chaotic small, irregular, disorganized cardiac pattern suddenly appears on a client's cardiac monitor. Which is the nurse's first action? 1. Check the blood pressure. 2. Call the health care provider. 3. Check the client and the chest leads. 4. Initiate cardiopulmonary resuscitation (CPR).

3. Check the client and the chest leads. Rationale: This type of pattern on the cardiac monitor indicates either ventricular fibrillation or lead displacement. The first action of the nurse is always to check the client and the chest leads. If the client is nonresponsive and the leads are not the problem, then option 4 would be the next choice, along with contacting the health care provider.

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiographic complexes on the screen. Which is the priority action of the nurse? 1. Call a code. 2. Call the health care provider. 3. Check the client's status and lead placement. 4. Press the recorder button on the electrocardiogram console.

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

The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication? 1. Flat neck veins 2. A pulse rate of 60 beats/min 3. Muffled or distant heart sounds 4. Wheezing on auscultation of the lungs

3. Muffled or distant heart sounds Rationale: Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention with clear lung sounds, and a falling blood pressure accompanied by pulsus paradoxus (a drop in inspiratory blood pressure greater than 10 mm Hg). Bradycardia is not a sign of cardiac tamponade.

The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit. The nurse notes that a cardiac troponin T level assay was performed while the client was in the intensive care unit. The nurse determines that this test was performed to assist in diagnosing which condition? 1. Heart failure 2. Atrial fibrillation 3. Myocardial infarction 4. Ventricular tachycardia

3. Myocardial infarction Rationale: Cardiac troponin T or cardiac troponin I has been found to be a protein marker in the detection of myocardial infarction, and assay for this protein is used in some institutions to aid in the diagnosis of a myocardial infarction

A thrombolytic is administered in the hospital emergency department to a client who has had a myocardial infarction. The client's spouse asks the nurse about the purpose of the medication. The nurse bases the response on which fact regarding this medication? 1. Thrombolytics suppress the production of fibrin. 2. Thrombolytics act to prevent thrombus formation. 3. Thrombolytics act to dissolve thrombi that have already formed. 4. Thrombolytics have been proved to reverse all detrimental effects of heart attacks.

3. Thrombolytics act to dissolve thrombi that have already formed. Rationale: Thrombolytics are most effective when started within 4 to 6 hours after symptom onset and act to dissolve or lyse existing thrombi that are causing a blockage.

The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How should the nurse correctly interpret this rhythm? 1. Asystole 2. Atrial fibrillation 3. Ventricular fibrillation 4. Ventricular tachycardia

3. Ventricular fibrillation Rationale: Ventricular fibrillation is characterized by irregular chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles.

The 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 more than 140 beats/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 second), and typically a rate between 140 and 180 impulses/minute. The rhythm is regular.

Which steps should occur first when using an automated external defibrillator (AED)? 1. Place the AED in the analyze mode. 2. Press the shock button if indicated. 3. Check to see that no one is touching the client. 4. Apply defibrillator pads on the client and attach cables to the AED.

4. Apply defibrillator pads on the client and attach cables to the AED. Rationale: Knowing that the device needs to be in contact with the client in order to read the heart rhythm will lead you to select option 4 as the first step. The nurse next checks to see that no one is touching the client. The nurse then places the AED in the analyze mode. Then the shock button is pressed if indicated

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

4. 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, or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by intake of caffeine, nicotine, or alcohol.

A client with angina has a 12-lead electrocardiogram taken during an episode of chest pain. The nurse should examine the tracing for which electrocardiographic (ECG) change caused by myocardial ischemia? 1. Tall, peaked T waves 2. Prolonged PR interval 3. Widened QRS complex 4. ST segment elevation or depression

4. ST segment elevation or depression Rationale: An electrocardiogram taken during a chest pain episode captures ischemic changes, which include ST segment elevation or depression. Tall, peaked T waves may indicate hyperkalemia. A prolonged PR interval indicates first-degree heart block. A widened QRS complex indicates delay in intraventricular conduction, such as a bundle branch block.