EXAM 5 - PERFUSION STRIP READINGS - third semester

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ANS: A You can still see QRS complexes routinely throughout suggesting that the other is caused by some movement.

A 36 year old male is talking to you while shaving and then this appears on the monitor. What is the interpretation of this strip and the appropriate nursing action? a. This reflects an artifact and the nurse should check electrode placement and assess patient. b. This is sinus bradycardia and the nurse would assess the need to oxygen supplement. c. This is ventricular tachycardia and the nurse would check for a pulse and defibrillate if necessary. d. These are premature ventricular contractions and Lidocaine should be given.

ANS: B The patient is symptomatic with a low BP and in a critical 3rd degree AV block.

A client comes in with Digoxin toxicity. The patient is talking to the nurse with a BP of 80/40 mmHg. Which intervention should the nurse advocate for a patient with this rhythm? a. Administration of Amiodarone for the PVCs. b. Begin Transcutaneous Pacing (TCP) for the patient. c. Cardiovert the patient. d. Defibrillate the patient.

ANS: B, C, D B: Before intervening, an assessment of symptoms is important to direct care. C: It is a wide complex, unifocal PVC and we need to assess vital signs and any symptoms patient is having. If no issues, then we just monitor the patient. D: A BP will help determine if the arrhythmia is causing a decrease in cardiac output.

A client comes in with an abnormal rhythm. What should be the nurse do? SELECT ALL THAT APPLY a. Give Digoxin IV push b. Assess the client for symptoms c. Monitor the client closely d. Get a blood pressure e. Give Amiodarone IV push over 10 minutes

ANS: B, C, E B: NO RESPONSE indicates that the patient is not responding and code blue or emergency response system should be called. C: After Code Blue has been called, then start CPR with Chest Compressions. E: This is appropriate for the nurse to treat the client along the PEA algorithm.

A client comes in with this rhythm and no response. What actions would be appropriate for the to perform? SELECT ALL THAT APPLY a. Cardiovert the client b. Activate the code blue system c. Check a pulse and begin CPR (Cardiopulmonary Resuscitation) if no pulse d. Secure the airway by intubation e. Start an IV and give Epinephrine.

ANS: A, D, E A: PEA is any rhythm except V Fib or V Tach D: This is always appropriate for an unresponsive patient with no pulse. E: Ventricular Fibrillation, check responsiveness, call a code, and begin CPR until an AED or crash cart is available to defibrillate.

A client comes in with this rhythm and unresponsive. What interventions are appropriate for the nurse to perform? SATA a. Give Epinephrine IV push. b. Set up for Transcutaneous Pacing. c. Set up for cardioversion. d. Check a pulse, if none, begin chest compressions. e. Set up the defibrillator to shock.

ANS: A, C, E A: With that dramatic drop in HR, beginning pacing would be a good option. C: Assessing for signs or symptoms of the bradycardia will determine whether to give medications or not. E: Atropine is the first line choice for a patient in a bradycardic algorithm

A client comes in with this rhythm on a six second strip. The client normally has a HR of 110. The client is talking to you about their chest pain. What actions would be appropriate? SELECT ALL THAT APPLY a. Begin Transcutaneous Pacing b. Give 1 mg IV Epinephrine c. Assess the client d. Give Amiodarone 150 mg IV over 10 minutes e. Give Atropine 1 mg IV push

ANS: C Yes, for a narrow complex tachycardia (atrial fibrillation)

A client has this new onset rhythm with decreased level of consciousness. He is telling you about is shortness of breath. For which of the following medication orders can the nurse advocate? a. Heparin infusion at 1200 Units/hr. b. Atropine 1 mg IV push. c. Amiodarone 150 mg IV over 10 mins. d. Dopamine infusion at 5 mcg/kg/min.

ANS: B The patient is symptomatic and should get Atropine.

A client presents with symptoms of altered mental status for this new onset rhythm change. Vital signs: BP 92/44 mmHg; RR - 26. Which of the following orders should the nurse advocate? a. Start Amiodarone IV infusion as ordered. b. Administer Atropine IV push as ordered. c. Administer Metoprolol IV as ordered. d. Increase IVFs as ordered.

ANS: A, C, E a: Checking for Hypotension, altered mental status, shock, ischemic chest discomfort, or signs of acute heart failure would mean that the client is unstable with a narrow complex tachycardia. This assessment directs the treatment options. c. Diltiazem is a calcium channel blocker used to lower the heart rate. e. With a rhythm change and a rapid increase in heart rate, one would like to check the BP to see if the patient is still has adequate Cardiac Output.

A client status-post heart surgery is visiting the nurse after he just walked from the bed to the chair for the first time. The monitor shows a change in rhythm to this. Which of the following actions should be performed? SELECT ALL THAT APPLY a. Assess for signs of altered mental status. b. Administer atropine 0.5 mg IV push per protocol c. Administer Diltiazem IV per protocol d. Start Epinephrine IV infusion per protocol. e. Check the blood pressure.

ANS: D Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometimes precede atrial depolarization. The PVC would exhibit as a widened QRS without a preceding p wave. Ventricular tachycardia and ventricular fibrillation rhythms would not have sinus beats present. Premature atrial contractions are atrial contractions initiated from another region of the atria before the sinus node initiates atrial depolarization.

A nurse assesses a client's electrocardiogram (ECG) and observes the reading shown: How would the nurse document this client's ECG strip? a. Ventricular tachycardia b. Ventricular fibrillation c. Sinus rhythm with premature atrial contractions(PACs) d. Sinus rhythm with premature ventricular contractions(PVCs)

ANS: A Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a potentially lethal dysrhythmia. The nurse would first assess if the client is alert, breathing, and has a pulse. If this client is pulseless, then the nurse would call a Code Blue and begin CPR. The treatment of choice for pulseless ventricular tachycardia is defibrillation. If the client has a pulse, then cardioversion would be indicated. Amiodarone is an appropriate antidysrhythmic, but it is not the first action.

A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown: What action would the nurse take first? a. Assess airway, breathing, and circulation. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR).

ANS: C This client is stable and therefore does not require any intervention except to determine the cause of the bradycardia. Bradycardia is often caused by medications. Clients who have multiple chronic diseases are often on multiple medications that can interact with each other. The nurse would assess the client's current medications first. Pacing is not necessary. Peripheral pulses are assessed with a full assessment since this client is stable. Atropine is not needed.

A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The client's blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 L per nasal cannula. The nurse assesses the client's rhythm on the cardiac monitor and observes the reading shown: What action would the nurse take first? a. Begin external temporary pacing. b. Assess peripheral pulse strength. c. Ask the client what medications he or she takes. d. Administer 1 mg of atropine.

ANS: D Always assess the client prior to intervention.

A nurse sees this rhythm at the telemetry station. What should be the nurse's first action? a. Prepare for a cardioversion after administering a brief trial of medications. b. Call a code at the telemetry station and prepare take the crash cart to the room. c. Administer amiodarone or procainamide per protocol. d. Assess the patient for responsiveness, if not responsive, call a code, begin CPR.

ANS: D This is a normal sinus rhythm, monitor the patient

The client is admitted and talking to the nurse. Which intervention would be included in the plan of care for a patient with this rhythm? a. Defibrillate. b. Begin transcutaneous pacing on the patient. c. Teach the patient about precautions when taking anticoagulants. d. Assess the patient and monitor for symptoms.

ANS: B IV push epinephrine is for dead rhythms. I would utilize the SBAR format to question the order from the provider since the patient is talking to you.

The client is sitting talking when you look at the monitor and see the rhythm change to this. Which order would you question? a. Assess the Blood Pressure. b. Administer IV push epinephrine. c. Administer 81 mg Aspirin now. d. Get a 12-lead ECG.

ANS: B The client's rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse would start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The client's code status would already be known by the nurse prior to this event.

The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows this rhythm: After calling for assistance and a defibrillator, what action would the nurse take next? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d. Ask the client's family about code status.

atrial depolarization

What does the P wave represent?

ventricular depolarization and atrial repolarization

What does the QRS complex represent?

ventricular repolarization

What does the T wave represent?

ANS: A This shows 5 regular beats plus 1 premature ventricular beat, so HR is 60 with PRI 0.20 and QRS 0.08

What is the rate and PR interval and QRS complex for this six second strip? a. HR 60 PRI 0.20 QRS 0.08 with a PVC b. HR 40 PRI 0.16 QRS 0.20 with a PAC c. HR 80 PRI 0.24 QRS 0.16 with a PAC d. HR 110 PRI 0.22 QRS 0.08 with a PVC

Atrial Fibrillation-Has "chaotic" atrial electrical activity (no P waves, f-waves instead) with irregular R-R intervals.

What rhythm is this?

First Degree AV Block, the PR interval is constant and measures greater than 0.20 second.

What rhythm is this?

Second Degree AV Blocok Mobitz I (Wenkebach) has a cyclical prolonging PR interval until the QRS is dropped. Then the cycle begins again. ***Remember the clue "lengthen, lengthen drop Wenkebach.

What rhythm is this?

Third Degree (Complete) Heart Block, the P-P and R-R intervals are regular (constant) but firing at different rates.

What rhythm is this?

second degree AV block: Mobitz type II

What rhythm is this?

ANS: B The patient is showing unstable narrow complex tachycardia and should be cardioverted.

Which intervention would be appropriate for a new onset Atrial Flutter in a client with a BP of 60/30 mmHg? a. Start a dopamine infusion for the low BP. b. Cardiovert this patient stat. c. Give the patient's routine digoxin now. d. Give that suppository for the constipation.

ANS: D Lowers HR

Which medication should the nurse administer to this client with BP of 80/40 mmHg? a. Administer Epinephrine 1mg IV push. b. Administer Atropine 1 mg IV push. c. Administer Dopamine infusion at 5 mcg/kg/min IV. d. Administer Adenosine 6 mg IV push.

Atrial Flutter -has a "saw tooth or picket fence" atrial pattern (no P waves, F-waves in stead that may be in a ratio) between the QRS complexes.

Which rhythm is this?

An ST segment below the isoelectric line is known as ST segment depression and may indicate myocardial ischemia

what is occurring here and what can it indicate?

A PVC is an early QRS complex that is wide (0.12 second or greater) and has a bizarre appearance. There is no P wave. PVC's may come in different shapes.

what is occurring here?

Sinus Arrest has regularly occurring PQRST's both before and after the arrest period. No electrical activity during the arrest period.

what is occurring here?

Agonal Rhythm has an absence of P waves, a ventricular rate of less than 20 bpm and wide-bizarre QRS complexes