CH 36 & 67 DYSRHYTHMIAS & SHOCK

The nurse would recognize which clinical manifestation as suggestive of sepsis? A. Sudden diuresis unrelated to drug therapy B. Hyperglycemia in the absence of diabetes C. Respiratory rate of seven breaths per minute D. Bradycardia with sudden increase in blood pressure

Hyperglycemia in the absence of diabetes Rationale: Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis along with tachypnea and tachycardia.

TOPHAT: A patient reports dizziness and shortness of breath for several days. During cardiac monitoring in the emergency department (ED), the nurse obtains the following electrocardiographic (ECG) tracing. The nurse interprets this rhythm as: A. junctional escape rhythm B. accelerated idioventricular rhythm. C. third-degree atrioventricular (AV) block. D. sinus rhythm with premature atrial contractions (PACs).

third-degree atrioventricular (AV) block.

The nurse is doing discharge teaching with the patient and spouse of the patient who just received an implantable cardioverter-defibrillator (ICD) in the left side. Which statement by the patient indicates to the nurse that the patient needs more teaching? A. "I will call the cardiologist if my ICD fires." B. "I cannot fly because it will damage the ICD." C. "I cannot move my left arm until it is approved." D. "I cannot drive until my cardiologist says it is okay."

"I cannot fly because it will damage the ICD." Rationale: The patient statement that flying will damage the ICD indicates misunderstanding about flying. The patient should be taught that informing TSA about the ICD can be done because it may set off the metal detector and if a hand-held screening wand is used, it should not be placed directly over the ICD. The other options indicate the patient understands the teaching.

The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first? a. NS infusion b. Give epinephrine (Adrenalin) c. Start continuous ECG monitoring d. Give Benadryl

Give epinephrine (Adrenalin) Rationale:

A 78-year old man has confusion and temperature of 104F. He is a diabetic with purulent drainage from his right heel. After an infusion of 3 L of normal saline solution, his assessment findings are BP 84/40, HR 110, RR 42, & shallow; CO 8 L/min; and PAWP 4 mmHg. The patient's SX. are most likely indicative of: A. Sepsis B. Septic Shock C. Multiple organ dysfunction D. SIRS

Septic Shock

A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? A. Acute pain B. Impaired tissue integrity C. Decreased cardiac output D. Ineffective tissue perfusion

Ineffective Tissue Perfusion Rationale: The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. This nursing diagnosis supersedes the other diagnoses.

The nurse is seeing artifact on the telemetry monitor. Which factors could contribute to this artifact? A. Disabled automaticity B. Electrodes in the wrong lead C. Too much hair under the electrodes D. Stimulation of the vagus nerve fibers

Too much hair under the electrodes Rationale: Artifact is caused by muscle activity, electrical interference, or insecure leads and electrodes that could be caused by excessive chest wall hair. Disabled automaticity would cause an atrial dysrhythmia. Electrodes in the wrong lead will measure electricity in a different plane of the heart and may have a different wave form than expected. Stimulation of the vagus nerve fibers causes a decrease in heart rate, not artifact.

The nurse performs discharge teaching for a 74-year-old woman with an implantable cardioverter-defibrillator. Which statement by the patient indicates to the nurse that further teaching is needed? A. "The device may set off the metal detectors in an airport." B. "My family needs to keep up to date on how to perform CPR." C. "I should not stand next to antitheft devices at the exit of stores." D. "I can expect redness and swelling of the incision site for a few days."

"I can expect redness and swelling of the incision site for a few days." Rationale: Patients should be taught to report any signs of infection at incision site (e.g., redness, swelling, drainage) or fever to their primary care provider immediately. Teach the patient to inform airport security of presence of ICD because it may set off the metal detector. If hand-held screening wand is used, it should not be placed directly over the ICD. Teach the patient to avoid standing near antitheft devices in doorways of stores and public buildings, and to walk through them at a normal pace. Caregivers should learn cardiopulmonary resuscitation (CPR).

The nurse is monitoring the ECGs of several patients on a cardiac telemetry unit. The patients are directly visible to the nurse, and all of the patients are observed to be sitting up and talking with visitors. Which patient's rhythm would require the nurse to take immediate action? A. A 62-year-old man with a fever and sinus tachycardia with a rate of 110 beats/minute B. A 72-year-old woman with atrial fibrillation with 60 to 80 QRS complexes per minute C. A 52-year-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute D. A 42-year-old woman with first-degree AV block and sinus bradycardia at a rate of 56 beats/minute

A 52-year-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute Rationale: Frequent premature ventricular contractions (PVCs) (greater than 1 every 10 beats) may reduce the cardiac output and precipitate angina and heart failure, depending on their frequency. Because PVCs in CAD or acute MI indicate ventricular irritability, the patient's physiologic response to PVCs must be monitored. Frequent PVCs most likely must be treated with oxygen therapy, electrolyte replacement, or antidysrhythmic agents.

A 38-year-old teacher who reported dizziness and shortness of breath while supervising recess is admitted with a dysrhythmia. Which medication, if ordered, requires the nurse to carefully monitor the patient for asystole? A. Atropine sulfate B. Digoxin (Lanoxin) C. Metoprolol (Lopressor) D. Adenosine (Adenocard)

Adenosine (Adenocard) Rationale: IV adenosine (Adenocard) is the first drug of choice to convert supraventricular tachycardia to a normal sinus rhythm. Adenosine is administered IV rapidly (over 1 or 2 seconds) followed by a rapid, normal saline flush. The nurse should monitor the patient's ECG continuously because a brief period of asystole after adenosine administration is common and expected. Atropine sulfate increases heart rate, whereas lanoxin and metoprolol slow the heart rate.

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 (Cordarone) intravenously D. Administer epinephrine (Adrenaline) intravenously

Administer amiodarone (Cordarone) IV Rationale: First-line treatment of ventricular tachycardia in a client who is hemodynamically stable is the use of anti-dysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm (cardioversion is recommended for stable ventricular tachycardia). Defibrillation is used with pulseless ventricular tachycardia. Epinephrine would stimulate and already excitable ventricle and is contraindicated

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 second, but they are irregular, with a rate of 120 beats a minute. The nurse interprets this rhythm as: A. Sinus tachycardia B. Atrial fibrillation C. Ventricular tachycardia D. Ventricular fibrillation

Atrial fibrillation Rationale: Atrial fibrillation is characterized by a loss of P waves; an undulating, wavy baseline; QRS duration that is often within normal limits; and an irregular ventricular rate, which can range from 60 to 100 beats per minute (when controlled with medications) to 100 to 160 beats per minute (when uncontrolled).

A client is having frequent premature ventricular contractions. A nurse would place priority on assessment of which of the following items? A. Blood pressure and peripheral perfusion B. Sensation of palpitations C. Causative factors such as caffeine D. Precipitating factors such as infection

BP & Peripheral Perfusion Rationale: Premature ventricular contractions can cause hemodynamic compromise. The shortened ventricular filling time with the ectopic beats leads to decreased stroke volume and, if frequent enough, to decreased cardiac output. The client may be asymptomatic or may feel palpitations. PVCs can be caused by cardiac disorders or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by the intake of caffeine, alcohol, or nicotine.

The nurse is caring for a patient in septic shock. Which hemodynamic change would the nurse expect? A. Increased ejection fraction. B. Increased mean arterial pressure. C. Decreased central venous pressure. D. Decreased systemic vascular resistance.

Decreased systemic vascular resistance.

A patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which action will the nurse anticipate taking? a. Increase the rate for the prescribed dopamine (Intropin) infusion. b. Decrease the rate for the prescribed nitroglycerin (Tridil) infusion. c. Decrease the rate for the prescribed 5% dextrose in water (D5W) infusion. d. Increase the rate for the prescribed sodium nitroprusside (Nipride) infusion.

Increase the rate for the prescribed sodium nitroprusside (Nipride) infusion. Rationale: Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5W and nitroglycerin infusions will not directly increase SVR. Increasing the dopamine will tend to increase SVR.

TEXTBOOK: A patient has a spinal cord injury at T4. Vital signs include falling blood pressure with bradycardia. The nurse recognizes that the patient is experiencing: A. relative hypovolemia B. absolute hypovolemia C. neurogenic shock from low blood flow D. neurogenic shock from massive vasodilation

Neurogenic shock from massive vasodilation

For which dysrhythmia is defibrillation primarily indicated? A. Ventricular fibrillation B. Third-degree AV block C. Uncontrolled atrial fibrillation D. Ventricular tachycardia with a pulse

Ventricular fibrillation Rationale: Defibrillation is always indicated in the treatment of ventricular fibrillation. Drug treatments are normally used in the treatment of uncontrolled atrial fibrillation and for ventricular tachycardia with a pulse (if the patient is stable). Otherwise, synchronized cardioversion is used (as long as the patient has a pulse). Pacemakers are the treatment of choice for third-degree heart block.

A client has developed atrial fibrillation, with a ventricular rate of 150 beats per minute. A nurse assesses the client for: A. Hypotension and dizziness B. Nausea and vomiting C. Hypertension and headache D. Flat neck veins

Hypotension and dizziness Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate more than 150 beats a 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.

The nurse is caring for a critically ill patient. The nurse suspects that the patient has progressed beyond the compensatory stage of shock if what occurs? A. Increased blood glucose levels B. Increased serum sodium levels C. Increased serum calcium levels D. Increased serum potassium levels

Increased blood glucose levels Rationale:

A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs the client to do which of the following, if prescribed, during an episode of ventricular tachycardia? A. Breathe deeply, regularly, and easily. B. Inhale deeply and cough forcefully every 1 to 3 seconds. C. Lie down flat in bed D. Remove any metal jewelry

Inhale deeply and cough forcefully every 1 to 3 seconds Rationale: Cough cardiopulmonary resuscitation (CPR) sometimes is used in the client with unstable ventricular tachycardia. The nurse tells the client to use cough CPR, if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds. Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented.

The nurse is caring for a 29-year-old man who was admitted a week ago with multiple rib fractures, a pulmonary contusion, and a left femur fracture from a motor vehicle crash. After the attending physician tells the family that the patient has developed sepsis, the family members have many questions. Which information should the nurse include in explaining the early stage of sepsis? A. Antibiotics are not useful once an infection has progressed to sepsis. B. Weaning the patient away from the ventilator is the top priority in sepsis. C. Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. D. The patient has recovered from sepsis if he has warm skin and ruddy cheeks.

Large amounts of IV fluid are required in sepsis to fill dilated blood vessels Rationale: Patients with sepsis may be normovolemic but because of acute vasodilation, relative hypovolemia and hypotension occur. Patients in septic shock require large amounts of fluid replacement and may require frequent fluid boluses to maintain circulation. Antibiotics are an important component of therapy for patients with septic shock. They should be started after cultures (e.g., blood, urine) are obtained and within the first hour of septic shock. Oxygenating the tissues is the top priority in sepsis, so efforts to wean septic patients from mechanical ventilation halt until sepsis is resolving. Addititonal respiratory support may be needed during sepsis. Although cool and clammy skin is present in other early shock states, the patient in early septic shock may feel warm and flushed because of a hyperdynamic state.

While caring for a client who has sustained an MI, the nurse notes eight PVCs in one minute on the cardiac monitor. The client is receiving an IV infusion of D5W and oxygen at 2 L/minute. The nurse's first course of action should be to: A. Increase the IV infusion rate B. Notify the physician promptly C. Increase the oxygen concentration D. Administer a prescribed analgesic

Notify the physician promptly Rationale: PVCs are often a precursor of life-threatening dysrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than 5 or 6 per minute in the post MI client, the physician should be notified immediately. More than 6 PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such aslidocaine. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability.

TEXTBOOK: A patient admitted with ACS has continuous ECG monitoring. An examination of the rhythm strip reveals the following characteristics: atrial rate 74 bpm & regular; ventricular rate 64 bpm & irregular; P wave normal shape; PR interval lengthens progressively until a P wave is not conducted; QRS normal shape. The priority nursing intervention would be: A. perform synchronized cardioversion B. administer epinephrine C. observe for symptoms of hypotension or angina D. apply transcutaneous pacemaker pads on the patient.

Observe for Symptoms of hypotension or angina Rationale: The rhythm is a second-degree atrioventricular (AV) block, type I (i.e., Mobitz I or Wenckebach heart block). The rhythm is characterized by a gradual lengthening of the PR interval. Type I AV block is usually a result of myocardial ischemia or infarction and typically is transient and well tolerated. The nurse should assess for bradycardia, hypotension, and angina. If the patient experiences symptoms, atropine or a temporary pacemaker may be needed.

PRETEST: The nurse is caring for a 72-year-old man in cardiogenic shock after an acute myocardial infarction. Which clinical manifestations would be of most concern to the nurse? A. Restlessness, heart rate of 124 beats/minute, and hypoactive bowel sounds B. Mean arterial pressure of 54 mm Hg, increased jaundice, and cold, clammy skin C. PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites D. Agitation, respiratory rate of 32 breaths/minute, and serum creatinine level of 2.6 mg/dL

PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites Rationale: Severe hypoxemia, lactic acidosis, and bleeding are clinical manifestations of the irreversible state of shock. Recovery from this stage is not likely because of multiple organ system failure. Restlessness, tachycardia, and hypoactive bowel sounds are clinical manifestations that occur during the compensatory stage of shock. Decreased mean arterial pressure, jaundice, cold/ clammy skin, agitation, tachypnea, and increased serum creatinine are clinical manifestations of the progressive stage of shock.

Which ECG characteristic is consistent with a diagnosis of ventricular tachycardia (VT)? A. Unmeasurable rate and rhythm B. Rate 150 beats/min; inverted P wave C. Rate 200 beats/min; P wave not visible D. Rate 125 beats/min; normal QRS complex

Rate 200 beats/min; P wave not visible Rationale: VT is associated with a rate of 150 to 250 beats/min; the P wave is not normally visible. Rate and rhythm are not measurable in ventricular fibrillation. P wave inversion and a normal QRS complex are not associated with VT.

Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider? a. Blood glucose 243 mg/dL b. Serum chloride 92 mEq/L c. Serum sodium 134 mEq/L d. Serum potassium 2.9 mEq/L

Serum potassium 2.9 mEq/L Rationale: Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation. The health care provider will need to prescribe a potassium infusion to correct this abnormality. Although the other laboratory values also are abnormal, they are not likely to be the etiology of the patient's PVCs and do not require immediate correction.

The nurse is monitoring the ECG of a patient admitted with ACS. Which ECG characteristics would be most suggestive of MI? A. sinus rhythm with a pathologic Q wave B. sinus rhythm with an elevated ST segment C. sinus rhythm with a depressed ST segment D. Sinus rhythm with premature atrial contractions

Sinus rhythm with a depressed ST segment Rationale: Typical electrocardiographic (ECG) changes that are seen in myocardial ischemia include ST-segment depression and T-wave inversion.

A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic and has no palpable pulses. What is the first action that the nurse should take? a. Perform synchronized cardioversion. b. Start cardiopulmonary resuscitation (CPR). c. Administer atropine per agency dysrhythmia protocol. d. Provide supplemental oxygen via non-rebreather mask.

Start cardiopulmonary resuscitation (CPR). Rationale: The patient's clinical manifestations indicate pulseless electrical activity and the nurse should immediately start CPR. The other actions would not be of benefit to this patient.

The patient has atrial fibrillation with a rapid ventricular response. The nurse knows to prepare for which treatment if an electrical treatment is planned for this patient? A. Defibrillation B. Synchronized cardioversion C. Automatic external defibrillator (AED) D. Implantable cardioverter-defibrillator (ICD

Synchronized cardioversion Rationale: Synchronized cardioversion is planned for a patient with supraventricular tachydysrhythmias (atrial fibrillation with a rapid ventricular response). Defibrillation or AEDs are the treatment of choice to end ventricular fibrillation and pulseless ventricular tachycardia (VT). An ICD is used with patients who have survived sudden cardiac death (SCD), have spontaneous sustained VT, and are at high risk for future life-threatening dysrhythmias.

Cardioversion is attempted for a 64-year-old man with atrial flutter and a rapid ventricular response. After the nurse delivers 50 joules by synchronized cardioversion, the patient develops ventricular fibrillation. Which action should the nurse take immediately? A. Administer 250 mL of 0.9% saline solution IV by rapid bolus. B. Assess the apical pulse, blood pressure, and bilateral neck vein distention. C. Turn the synchronizer switch to the "off" position and recharge the device. D. Tell the patient to report any chest pain or discomfort and administer morphine sulfate.

Turn the synchronizer switch to the "off" position and recharge the device. Rationale: Ventricular fibrillation produces no effective cardiac contractions or cardiac output. If during synchronized cardioversion the patient becomes pulseless or the rhythm deteriorates to ventricular fibrillation, the nurse should turn the synchronizer switch off and initiate defibrillation. Fluids, additional assessment, or treatment of pain alone will not restore an effective heart rhythm.

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

Ventricular tachycardia Rationale: Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (usually greater than 0.14 second), and a rate between 100 and 250 impulses per minute. The rhythm is usually regular.

A patient's localized infection has progressed to the point where septic shock is now suspected. What medication is an appropriate treatment modality for this patient? A. Insulin infusion B. IV administration of epinephrine C. Aggressive IV crystalloid fluid resuscitation D. Administration of nitrates and β-adrenergic blockers

Aggressive IV crystalloid Fluid resuscitation Rationale: Patients in septic shock require large amounts of crystalloid fluid replacement. Nitrates and β-adrenergic blockers are most often used in the treatment of patients in cardiogenic shock. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be)

The nurse is caring for a patient who is 24 hours postpacemaker insertion. Which nursing intervention is most appropriate at this time? A. Reinforcing the pressure dressing as needed B. Encouraging range-of-motion exercises of the involved arm C. Assessing the incision for any redness, swelling, or discharge D. Applying wet-to-dry dressings every 4 hours to the insertion site

Assessing the incision for any redness, swelling, or discharge Rationale: After pacemaker insertion, it is important for the nurse to observe signs of infection by assessing for any redness, swelling, or discharge from the incision site. The nonpressure dressing is kept dry until removed, usually 24 hours postoperatively. It is important for the patient to limit activity of the involved arm to minimize pacemaker lead displacement.

When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)? A. Increased serum albumin B. Decreased respiratory compliance C. Increased gastrointestinal (GI) motility D. Decreased blood urea nitrogen (BUN)/creatinine ratio

Decreased Respiratory Compliance Rationale: Clinical manifestations of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decreased GI motility, acute neurologic changes, myocardial dysfunction, disseminated intravascular coagulation (DIC), and changes in glucose metabolism.

When ventricular fibrillation occurs in a CCU, the first person reaching the client should: A. Administer oxygen B. Defibrillate the client C. Initiate CPR D. Administer sodium bicarbonate intravenously

Defibrillate the client Rationale: Ventricular fibrillation is a death-producing dysrhythmia and, once identified, must be terminated immediately by precordial shock (defibrillation). This is usually a standing physician's order in a CCU.

Appropriate treatment modalities for the management of cardiogenic shock include: (SATA) A. dobutamine to increase myocardial contractility B. vasopressors to increase systemic vascular resistance C. Circulatory assist devices such as an intraaortic balloon pump D. corticosteroids to stabilize the cell wall in the infarcted myocardium E. Trendelenburg positioning to facilitate venous return and increase preload

Dobutamine to increase myocardial contractility Corticosteroids to stabilize the cell wall in the infarcted myocardium Rationale:

A patient in asystole is likely to receive which drug treatment? A. Epinephrine and atropine B. Lidocaine and amiodarone C. Digoxin and procainamide D. β-adrenergic blockers and dopamine

Epinephrine & Atropine Rationale: Normally the patient in asystole cannot be successfully resuscitated. However, administration of epinephrine and atropine may prompt the return of depolarization and ventricular contraction. Lidocaine and amiodarone are used for PVCs. Digoxin and procainamide are used for ventricular rate control. β-adrenergic blockers are used to slow heart rate, and dopamine is used to increase heart rate.

The patient has hypokalemia, and the nurse obtains the following measurements on the rhythm strip: Heart rate of 86 with a regular rhythm; the P wave is 0.06 seconds (sec) and normal shape; the PR interval is 0.24 sec; the QRS is 0.09 sec. How should the nurse document this rhythm? A. First-degree AV block B. Second-degree AV block C. Premature atrial contraction (PAC) D. Premature ventricular contraction (PVC)

First-degree AV block In first-degree AV block there is prolonged duration of AV conduction that lengthens the PR interval above 0.20 sec. In type I second-degree AV block the PR interval continues to increase in duration until a QRS complex is blocked. In Type II the PR interval may be normal or prolonged, the ventricular rhythm may be irregular, and the QRS is usually greater than 0.12 sec. PACs cause an irregular rhythm with a different-shaped P wave than the rest of the beats, and the PR interval may be shorter or longer. PVCs cause an irregular rhythm, and the QRS complex is wide and distorted in shape.

A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104° F, and blood glucose 246 mg/dL. Which of these prescribed interventions will the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Infuse drotrecogin- (Xigris) 24 mcg/kg. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Titrate norepinephrine (Levophed) to keep mean arterial pressure (MAP) at 65 to 70 mm Hg.

Give normal saline IV at 500 mL/hr. Rationale: Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate and should be initiated quickly as well.

What laboratory finding fits with a medical diagnosis of cardiogenic shock? A. Decreased liver enzymes B. Increased white blood cells C. Decreased red blood cells, hemoglobin, & hematocrit D. Increased blood urea nitrogen (BUN) & serum creatinine levels

Increased blood urea nitrogen (BUN) & serum creatinine levels Rationale: The renal hypoperfusion that accompanies cardiogenic shock results in increased BUN and creatinine levels. Impaired perfusion of the liver results in increased liver enzymes, while white blood cell levels do not typically increase in cardiogenic shock. Red blood cell indices are typically normal because of relative hypovolemia.

When caring for a patient in acute septic shock, what should the nurse anticipate? A. Infusing large amounts of IV fluids B. Administering osmotic and/or loop diuretics C. Administering IV diphenhydramine (Benadryl) D. Assisting with insertion of a ventricular assist device (VAD)

Increasing large amounts of IV fluids Rationale: Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. VADs are useful for cardiogenic shock not septic shock. Diphenhydramine (Benadryl) may be used for anaphylactic shock but would not be helpful with septic shock.

The most accurate assessment of parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are: A. BP, Pulse, RR B. breath sounds, BP, Temp C. Pulse pressure, LOC, pupillary responds D. LOC, UO, and Skin color & Temp

LOC, UO, and Skin color & Temp Rationale:

When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR d. Maintaining the room temperature at 66° to 68° F for a patient with neurogenic shock

Maintaining the room temperature at 66° to 68° F for a patient with neurogenic shock Rationale:

The patient is admitted with acute coronary syndrome (ACS). The ECG shows ST-segment depression and T-wave inversion. What should the nurse know that this indicates? A. Myocardia injury B. Myocardial ischemia C. Myocardial infarction D. A pacemaker is present.

Myocardial Ischemia Rationale: The ST depression and T wave inversion on the ECG of a patient diagnosed with ACS indicate myocardial ischemia from inadequate supply of blood and oxygen to the heart. Myocardial injury is identified with ST-segment elevation. Myocardial infarction is identified with ST-segment elevation and a widened and deep Q wave. A pacemaker's presence is evident on the ECG by a spike leading to depolarization and contraction.

NCLEX: A 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 heart rate is 64 beats per minute. The nurse assesses the cardiac rhythm as: A. Normal sinus rhythm B. Sinus bradycardia C. Sick sinus syndrome D. First-degree heart block.

Normal Sinus Rhythm Rationale: Measurements are normal, measuring 0.12 to 0.20 second and 0.4 to 0.10 second, respectively.

A patient has sought care following a syncopal episode of unknown etiology. Which nursing action should the nurse prioritize in the patient's subsequent diagnostic workup? A. Preparing to assist with a head-up tilt-test B. Preparing an IV dose of a β-adrenergic blocker C. Assessing the patient's knowledge of pacemakers D. Teaching the patient about the role of antiplatelet aggregators

Preparing to assist with a head-up tilt-test Rationale: In patients without structural heart disease, the head-up tilt-test is a common component of the diagnostic workup following episodes of syncope. IV β-blockers are not indicated although an IV infusion of low-dose isoproterenol may be started in an attempt to provoke a response if the head-up tilt-test did not have a response. Addressing pacemakers is premature and inappropriate at this stage of diagnosis. Patient teaching surrounding antiplatelet aggregators is not directly relevant to the patient's syncope at this time.

When analyzing the rhythm of a patient's ECG, the nurse will need to investigate further upon finding a(n): a. isoelectric ST segment b. P-R interval of 0-.18 seconds c. Q-T interval of 0.38 seconds d. QRS interval of 0.14 seconds

QRS interval of 0.14 seconds Rationale: Because the normal QRS interval is 0.04 to 0.10 seconds, the patient's QRS interval of 0.14 seconds indicates that the conduction through the ventricular conduction system is prolonged. The P-R interval and Q-T interval are within normal range, and ST segment should be isoelectric (flat).

The nurse obtains a 6-second rhythm strip and charts the following analysis: Tab 1: Atrial Data - Rate: 70, regular, Variable PR interval, Independent beats Tab 2: Ventricular data - Rate: 40, regular, Isolated escape beats Tab 3: Additional data - QRS: 0.04 sec, P wave and QRS complexes unrelated What is the correct interpretation of this rhythm strip? A. Sinus arrhythmias B. Third-degree heart block C. Wenckebach phenomenon D. Premature ventricular contractions

Third Degree Heart Block Rationale: Third-degree heart block represents a loss of communication between the atrium and ventricles from AV node dissociation. This is depicted on the rhythm strip as no relationship between the P waves (representing atrial contraction) and QRS complexes (representing ventricular contraction). The atria are beating totally on their own at 70 beats/min, whereas the ventricles are pacing themselves at 40 beats/min. Sinus dysrhythmia is seen with a slower heart rate with exhalation and an increased heart rate with inhalation. In Wenckebach heart block, there is a gradual lengthening of the PR interval until an atrial impulse is nonconducted and a QRS complex is blocked or missing. Premature ventricular contractions (PVCs) are the early occurrence of a wide, distorted QRS complex.

A nurse notices frequent artifact on the ECG monitor for a client whose leads are connected by cable to a console at the bedside. The nurse examines the client to determine the cause. Which of the following items is unlikely to be responsible for the artifact? A. Frequent movement of the client B. Tightly secured cable connections C. Leads applied over hairy areas D. Leads applied to the limbs

Tightly secured cable connections Rationle: Motion artifact, or "noise," can be caused by frequent client movement, electrode placement on limbs, and insufficient adhesion to the skin, such as placing electrodes over hairy areas of the skin. Electrode placement over bony prominences also should be avoided. Signal interference can also occur with electrode removal and cable disconnection.

The ECG monitor of a patient in the cardiac care unit after an MI indicates ventricular bigeminy with a rate of 50 bpm. The nurse would anticipate? A. performing defibrillation B. treating with IV amiodarone C. inserting a temporary transvenouse pacemaker D. assessing the patient's response to the dysrhythmias

Assessing the patient's response to the dysrhythmias Rationale: A premature ventricular contraction (PVC) is a contraction originating in an ectopic focus in the ventricles. When every other beat is a PVC, the rhythm is called ventricular bigeminy. PVCs are usually a benign finding in patients with a normal heart. In patients with heart disease, PVCs may reduce the cardiac output and precipitate angina and heart failure, depending on the frequency. Because PVCs in coronary artery disease (CAD) or acute myocardial infarction indicate ventricular irritability, the patient's physiologic response to PVCs must be monitored. Assessment of the patient's hemodynamic status is important for determining whether treatment with drug therapy is needed.

Following coronary artery bypass graft surgery a patient has postoperative bleeding that requires returning to surgery to repair the leak. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient assessment is the most important for planning nursing care? A. Cardiac index (CI) 5 L/min/m2 B. Central venous pressure 8 mm Hg C. Mean arterial pressure (MAP) 86 mm Hg D. Pulmonary artery pressure (PAP) 28/14 mm Hg

PAP Rationale: Pulmonary hypertension as indicated by an elevated PAP indicates impaired forward flow of blood because of left ventricular dysfunction or hypoxemia. Both can be due to the MI. The CI, CVP, and MAP readings are normal.

A 50-year-old man who develops third-degree heart block reports feeling chest pressure and shortness of breath. Which instructions should the nurse provide to the patient before initiating emergency transcutaneous pacing? A. "The device will convert your heart rate and rhythm back to normal." B. "The device uses overdrive pacing to slow the heart to a normal rate." C. "The device is inserted through a large vein and threaded into your heart." D. "The device delivers a current through your skin that can be uncomfortable."

The device delivers a current through your skin that can be uncomfortable Rationale: Before initiating transcutaneous pacing (TCP) therapy, it is important to tell the patient what to expect. The nurse should explain that the muscle contractions created by the pacemaker when the current passes through the chest wall are uncomfortable. Pacing for complete heart block will not convert the heart rhythm to normal. Overdrive pacing is used for very fast heart rates. Transcutaneous pacing is delivered through pacing pads adhered to the skin.

Norepinephrine (Levophad) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicates that the nurse should consult with the health care provider? a. The patient's central venous pressure is 3 mm Hg. b. The patient is receiving low dose dopamine (Intropin). c. The patient is in sinus tachycardia at 100 to 110 beats/min. d. The patient has had no urine output since being admitted.

The patient's central venous pressure is 3 mm Hg. Rationale: Adequate fluid administration is essential before administration of vasopressors to patients with hypovolemic shock. The patient's low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.

Important teaching for the patient scheduled for a radiofrequency catheter ablation procedure includes explaining that: A. ventricular bradycardia may be induced and treated during the procedure B. a catheter will be placed in both femoral arteries to allow double catheter use C. The procedure will destroy areas of the conduction system that are causing rapid heart rhythm D. a general anesthetic will be given to prevent the awareness of any "sudden cardiac death" experiences

The procedure will destroy areas of the conduction system that are causing rapid heart rhythm Rationale: Radiofrequency catheter ablation therapy involves the use of electrical energy to "burn" or ablate areas of the conduction system as definitive treatment of tachydysrhythmias.

When computing a heart rate from the ECG tracing, the nurse counts 15 of the small blocks between the R waves of a patient whose rhythm is regular. From these data, the nurse calculates the patient's heart rate to be: A. 60 beats/min. B. 75 beats/min. C. 100 beats/min. D. 150 beats/min.

100 BPM Rationale: Since each small block on the ECG paper represents 0.04 seconds, 1500 of these blocks represents 1 minute. By dividing the number of small blocks (15, in this case) into 1500, the nurse can calculate the heart rate in a patient whose rhythm is regular (in this case, 100).

The nurse prepares a patient for synchronized cardioversion knowing that cardioversion differs from defibrillation in that: A. defibrillation requires a lower dose of electrical energy B. cardioversion is indicated to treat atrial bradydysrhythmias C. defibrillation is synchronized to deliver a shock during the QRS complex D. patients should be sedated if cardioversion is done on a non-emergency basis

Patients should be sedated if cardioversion is done on a non-emergency basis Rationale: Synchronized cardioversion is the therapy of choice for patients with hemodynamically unstable ventricular or supraventricular tachydysrhythmias. A synchronized circuit in the defibrillator delivers a countershock that is programmed to occur on the R wave of the QRS complex of the electrocardiogram. The synchronizer switch must be turned on when cardioversion is planned. The procedure for synchronized cardioversion is the same as for defibrillation with the following exceptions: If synchronized cardioversion is performed on a nonemergency basis, the patient is sedated before the procedure, and the initial energy needed for synchronized cardioversion is less than the energy needed for defibrillation.

A 64-year-old woman is admitted to the emergency department vomiting bright red blood. The patient's vital signs are blood pressure 78/58 mm Hg, pulse 124 beats/minute, respirations 28 breaths/minute, and temperature 97.2° F (36.2° C). Which physician order should the nurse complete first? A. Obtain a 12-lead ECG and arterial blood gases. B. Rapidly administer 1000 mL normal saline solution IV. C. Administer norepinephrine (Levophed) by continuous IV infusion. D. Carefully insert a nasogastric tube and an indwelling bladder catheter.

Rationale: Rapidly administer 1000 mL normal saline solution IV Isotonic crystalloids, such as normal saline solution, should be used in the initial resuscitation of hypovolemic shock. Vasopressor drugs (e.g., norepinephrine) may be considered if the patient does not respond to fluid resuscitation and blood products. Other orders (e.g., insertion of nasogastric tube and indwelling bladder catheter and obtaining the diagnostic studies) can be initiated after fluid resuscitation is initiated.

Which patient teaching points should the nurse include when providing discharge instructions to a patient with a new permanent pacemaker and the caregiver? (SATA) A. avoid or limit air travel B. take and record daily pulse rate C. obtain & wear a Medic Alert ID or bracelet at all times D. avoid lifting arms on the side of the pacemaker above shoulder E. avoid microwave ovens because they interfere with pacemaker function

Take and record daily pulse rate Obtain & wear a Medic Alert ID or bracelet at all times Avoid lifting arms on the side of the pacemaker above shoulder Rationale: Pacemaker discharge teaching should include the following instructions: First, air travel is not restricted. The patient should inform airport security of the presence of a pacemaker because it may set off the metal detector. If a hand-held screening wand is used, it should not be placed directly over the pacemaker. Manufacturer information may vary with regard to the effect of metal detectors on the function of the pacemaker. Second, the patient should monitor the pulse and inform the cardiologist if it drops below a predetermined rate. Third, the patient should obtain and wear a Medic Alert ID or bracelet at all times. Fourth, the patient must avoid lifting the arm on the pacemaker side above the shoulder until this is approved by the cardiologist. Fifth, microwave ovens are safe to use, and they do not interfere with pacemaker function. Table 36-13 provides additional discharge teaching guidelines for a patient with a pacemaker.

Which statement best describes the electrical activity of the heart represented by measuring the PR interval on the ECG? A. The length of time it takes to depolarize the atrium B. The length of time it takes for the atria to depolarize and repolarize C. The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers D. The length of time it takes for the electrical impulse to travel from the SA node to the AV node

The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers Rationale: The electrical impulse in the heart must travel from the SA node through the AV node and into the Purkinje fibers in order for synchronous atrial and ventricular contraction to occur. When measuring the PR interval (the time from the beginning of the P wave to the beginning of the QRS), the nurse is identifying the length of time it takes for the electrical impulse to travel from the SA node to the Purkinje fibers. The P wave represents the length of time it takes for the impulse to travel from the SA node through the atrium causing depolarization of the atria (atrial contraction). Atrial repolarization occurs during ventricular depolarization and is hidden by the QRS complex. The length of time it takes for the electrical impulse to travel from the SA node to the AV node is the flat line between the end of the P wave and the beginning of the Q wave on the ECG and is not usually measured.

The nurse is assisting in the care of several patients in the critical care unit. Which patient is at greatest risk for developing multiple organ dysfunction syndrome (MODS)? A. 22-year-old patient with systemic lupus erythematosus who is admitted with a pelvic fracture after a motor vehicle accident B. 48-year-old patient with lung cancer who is admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia C. 65-year-old patient with coronary artery disease, dyslipidemia, and primary hypertension who is admitted for unstable angina D. 82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection

82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection Rationale: A patient with peritonitis is at high risk for developing sepsis. In addition, a patient with diabetes is at high risk for infections and impaired healing. Sepsis and septic shock are the most common causes of MODS. Individuals at greatest risk for developing MODS are older adults and persons with significant tissue injury or preexisting disease. MODS can be initiated by any severe injury or disease process that activates a massive systemic inflammatory response.

A 50-year-old woman with a suspected brain tumor is scheduled for a computed tomography (CT) scan with contrast media. The nurse notifies the physician that the patient reported an allergy to shellfish. Which response by the physician should the nurse question? A. Infuse IV diphenhydramine prior to the procedure. B. Administer lorazepam (Ativan) before the procedure. C. Complete the CT scan without the use of contrast media. D. Premedicate with hydrocortisone sodium succinate (Solu-Cortef).

Administer lorazepam (Ativan) before the procedure. Rationale: An individual with an allergy to shellfish is at an increased risk to develop anaphylactic shock if contrast media is injected for a CT scan. To prevent anaphylactic shock, the nurse should always confirm the patient's allergies before diagnostic procedures (e.g., CT scan with contrast media). Appropriate interventions may include cancelling the procedure, completing the procedure without contrast media, or premedication with diphenhydramine or hydrocortisone. IV fluids may be given to promote renal clearance of the contrast media and prevent renal toxicity and acute kidney injury. The use of an antianxiety agent such as lorazepam would not be effective in preventing an allergic reaction to the contrast media.

A 20-year-old has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. Blood pressure (BP) is 114/54, and the student denies any health problems. What action by the nurse is most appropriate? a. Allow the student to participate on the soccer team. b. Refer the student to a cardiologist for further diagnostic testing. c. Tell the student to stop playing immediately if any dyspnea occurs. d. Obtain more detailed information about the student's family health history.

Allow the student to participate on the soccer team. Rationale: In an aerobically trained individual, sinus bradycardia is normal. The student's normal BP and negative health history indicate that there is no need for a cardiology referral or for more detailed information about the family's health history. Dyspnea during an aerobic activity such as soccer is normal

The nurse is watching the cardiac monitor, and a patient's rhythm suddenly changes. There are no P waves. Instead there are fine, wavy lines between the QRS complexes. The QRS complexes measure 0.08 sec (narrow), but they occur irregularly with a rate of 120 beats/min. The nurse correctly interprets this rhythm as what? A. Sinus tachycardia B. Atrial fibrillation C. Ventricular fibrillation D. Ventricular tachycardia

Atrial fibrillation Rationale: Atrial fibrillation is represented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atria are not truly contracting, just fibrillating. Sinus tachycardia is a sinus rate above 100 beats/minute with normal P waves. Ventricular fibrillation is seen on the ECG without a visible P wave; an unmeasurable heart rate, PR or QRS; and the rhythm is irregular and chaotic. Ventricular tachycardia is seen as three or more premature ventricular contractions (PVCs) that have distorted QRS complexes with regular or irregular rhythm, and the P wave is usually buried in the QRS complex without a measurable PR interval.