HESI Week 3

Which action would the nurse perform when a client is in ventricular fibrillation? Select all that apply. One, some, or all responses may be correct. 1. Initiating CPR 2. Assessing the EKG 3. Using a defibrillator 4. Obtaining electrolytes 5. Administering epinephrine

1. Initiating CPR 2. Assessing the EKG 3. Using a defibrillator 4. Obtaining electrolytes 5. Administering epinephrine

which dysrhythmia is this client with weakness, dizziness, and dyspnea exhibiting? A. atrial fibrillation B. ventricular tachycardia C. junctional tachycardia D. supraventricular tachycardia

a. atrial fibrillation as seen from the wavy baseline with uncoordinated atrial electrical activity and irregular ventricular rhythm with normal QRS complexes

when a client's cardiac monitor shows ventricular tachycardia, which action would the nurse take first? a. check for a pulse b. start cardiac compressions c. prepare to defibrillate the client d. administer oxygen via an ambu bag

a. check for a pulse CHECK THE PATIENT first and ensure they have a pulse

When the nurse is monitoring a patient who is undergoing exercise (stress) testing on a treadmill, which assessment finding requires the most rapid action by the nurse? a. Patient reports feeling SOB b. Heart rate of 120 beats/min c. ST segment depression d. Blood pressure (BP) of 160/92 mm Hg

c. ST segment depression Indicates ischemia; the nurse would have the client stop exercising and would continue to monitor ECG and blood pressure

When admitting a client with syncope and this electrocardiogram rhythm, which medication will the nurse anticipate administering? a. digoxin b. enalapril c. atropine d. metoprolol

c. atropine This rhythm strip reflects sinus bradycardia. Sinus bradycardia has PQRST complexes within acceptable limits, but the rate is less than 60 beats per minute. In this strip the PR interval is 0.16, the rhythm is regular, and the rate is 40 beats per minute. Atropine, an anticholinergic that increases the heart rate, is administered when the heart rate is so slow that it causes symptoms. Digoxin is a cardiac glycoside that slows the heart rate. Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that slows the heart rate. Metoprolol is a beta blocker that slows the heart rate.

Which rhythm would the nurse document when observing the following dysrhythmia on a client's cardiac monitor? a. atrial flutter b. atrial fibrillation c. ventricular fibrillation d. ventricular tachycardia

c. ventricular fibrillation reflects a rapid, feeble twitching/quivering of the ventricles; it has irregular sawtooth configuration with unidentifiable PR intervals and QRS complexes

To determine whether a client is experiencing acute coronary syndrome (ACS), which component of the electrocardiogram would the nurse analyze? a. P wave b. PR interval c, QRS complex d. ST segment

d. ST segment (Elevation or depression of the ST segment is indicative of ACS because of changes in cardiac electrical activity that occur with ischemia and injury. P wave changes are not used to diagnose ACS. Changes in the QRS complex do not occur with ACS. Changes in the PR interval are not diagnostic of ACS.)

Which dysrhythmia would the nurse identify on this client's electrocardiogram (ECG) strip? a. asystole b. atrial flutter c. ventricular fibrillation d. premature ventricular complexes

d. premature ventricular complexes

When caring for a client who presents to the emergency department with an ST-segment-elevation myocardial infarction (STEMI), which laboratory result will the nurse expect? a. Decreased white blood cell count b. Elevated serum troponins I and T c. Decreased creatine kinase-MB (CK-MB) d. Decreased B-type natriuretic peptide (BNP)

b. elevated serum troponins I and T Elevations of troponin I and T levels are indicative and specific for cardiac muscle damage as would occur with STEMI. White blood cell count would increase in the first days after myocardial infarction because of the inflammatory response associated with myocardial cell death. CK-MB is found in cardiac muscle and levels increase with myocardial cell death. BNP levels are not directly reflective of myocardial infarction, but might increase if the client develops heart failure as a complication of myocardial infarction.

Which dysrhythmia is this client on the telemetry unit exhibiting? a. atrial flutter b. atrial fibrillation c. ventricular fibrillation d. ventricular tachycardia

d. ventricular tachycardia has a heart rate of 149 beats/min to 200 beats/min or even 250 beats/min; the rhythm is usually regular but may vary; P waves unidentifiable and PR intervals unmeasurable; QRS complexes are wide and bizarre