Saunders: Ex.1

When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for a. diastolic murmur. c. shortness of breath on exertion. b. peripheral edema. d. right upper quadrant tenderness.

ANS: C The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs, resulting in hypoxemia and dyspnea. The other findings also may be associated with mitral valve disease but are not indicators of possible hypoxemia, which is a priority.

The nurse is developing a plan of care for a client recovering from pulmonary edema. The nurse establishes a goal to have the client participate in activities that reduce cardiac workload. The nurse should identify which client action as contributing to this goal? 1.Using a bedside commode 2.Sleeping in the supine position 3.Elevating the legs when in bed 4.Using seasonings to improve the taste of food

1 Using a bedside commode decreases the work of getting to the bathroom or struggling to use the bedpan. The supine position increases respiratory effort and decreases oxygenation.

A client is seen in the emergency department for complaints of chest pain that began 3 hours ago. The nurse should suspect myocardial injury or infarction if which laboratory value comes back elevated? 1.Troponin 2.Myoglobin 3.C-reactive protein 4.Creatine kinase (CK)

1

A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective? a. No new heart murmurs c. Warm, pink, and dry skin b. Decreased troponin level d. Blood pressure of 92/40 mm Hg

ANS: C Warm, pink, and dry skin indicates that perfusion to tissues is improved. Because nitroprusside is a vasodilator, the blood pressure may be low even if the drug is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock.

The client who has experienced a myocardial infarction (MI) is recovering from cardiogenic shock. The nurse knows that which observation of the client's clinical condition is most favorable? 1.Urine output of 40 mL/hr 2.Heart rate of 110 beats/minute 3.Frequent premature ventricular contractions 4.Central venous pressure (CVP) of 15 mm Hg

1 Urine output of greater than 30 mL/hr indicates adequate perfusion to the kidneys, so the other organs are most likely equally perfused. Classic cardiovascular signs of cardiogenic shock include low blood pressure and tachycardia. Dysrhythmias commonly occur as a result of decreased oxygenation to the myocardium and are not a favorable sign. The CVP rises as the effects of the backward blood flow caused by the left ventricular failure become apparent.

The client is in ventricular fibrillation. Which interventions should the nurse implement? Select all that apply. 1. Start cardiopulmonary resuscitation. 2. Prepare to administer the antidysrhythmic adenosine IVP. 3. Prepare to defibrillate the client. 4. Bring the crash cart to the bedside. 5. Prepare to administer the antidysrhythmic amiodarone IVP.

1. Start cardiopulmonary resuscitation. 3. Prepare to defibrillate the client. 4. Bring the crash cart to the bedside. 5. Prepare to administer the antidysrhythmic amiodarone IVP.

A client is admitted to the hospital with a diagnosis of pericarditis. The nurse should assess the client for which manifestation that differentiates pericarditis from other cardiopulmonary problems? 1.Anterior chest pain 2.Pericardial friction rub 3.Weakness and irritability 4.Chest pain that worsens on inspiration

2

A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for? 1.Bradycardia 2.Ventricular dysrhythmias 3.Rising diastolic blood pressure 4.Falling central venous pressure

2

The primary health care provider prescribes digoxin 0.25 mg orally daily for a client with heart failure. The medication label states 0.125 mg per tablet. The nurse should administer how many tablet(s) to the client? Fill in the blank.

2 tabs

A patient has severe aortic stenosis. When assessing the patient, which of these findings would be expected?Please choose from one of the following options. 1.Hypertension 2. Bounding pulses 3. Narrowed pulse pressure 4. Diastolic murmur

3

The home health nurse is visiting a client who has had a mechanical valve replacement for severe mitral valve stenosis. Which statement by the client reflects an understanding of specific postoperative care after this surgery? 1."I need to count my pulse every day." 2."I have to do deep-breathing exercises every 2 hours." 3."I need to throw away my straight razor and buy an electric razor." 4."I have to go to the bathroom frequently because of my medication."

3

Which readings obtained from a client's pulmonary artery catheter suggest that the client is in left-sided heart failure? 1.Cardiac output of 5 L/min 2.Right atrial pressure of 9 mm Hg 3.Pulmonary capillary wedge pressure (PCWP) of 20 mm Hg 4.Pulmonary artery systolic/diastolic pressures of 24/10 mm Hg

3 Normal PCWP ranges from 8 to 15 mm Hg. A PCWP of 20 mm Hg is elevated and corresponds to volume overload of the left ventricle, such as occurs in heart failure. Options 1, 2, and 4 are normal values.

The nurse recognizes that which patient would be most likely to develop hypovolemic shock? A patient with: 1. Decreased cardiac output 2. Severe constipation, causing watery diarrhea 3. Ascites 4. Syndrome of inappropriate ADH (SIADH)

3 Third spacing shifts move the fluids from the intravascular space into the interstitial space, causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the development of hypovolemic shock.

A client is being discharged from the hospital after being treated for infective endocarditis. The nurse should provide the client with which discharge instruction? 1.Take acetaminophen if the chest pain worsens. 2.Take antibiotics until the chest pain is fully resolved. 3.Use a firm-bristle toothbrush and floss vigorously to prevent cavities. 4.Notify all primary health care providers (PHCPs) of the history of infective endocarditis before any invasive procedures.

Notify all primary health care providers (PHCPs) of the history of infective endocarditis before any invasive procedures.

The nurse is caring for a patient with mitral regurgitation. Referring to the figure below, where should the nurse listen to best hear a murmur typical of mitral regurgitation?

4

The nurse is caring for a client with acute pulmonary edema. The primary health care provider (PHCP) tells the nurse that medication will be prescribed to help reduce preload and afterload. Based on the PHCP's statement, what medication should the nurse anticipate administering? 1.Digoxin 2.Prednisone 3.Furosemide 4.Nitroprusside sodium

4 Intravenous nitroprusside is a potent vasodilator that reduces preload and afterload. It is a medication used to treat the client with pulmonary edema. Prednisone is a steroidal anti-inflammatory medication that is not usually prescribed for acute pulmonary edema and could aggravate the symptoms due to sodium and retention effects of this medication. Digoxin is a cardiac glycoside that increases cardiac contractility. Furosemide is a loop diuretic and can reduce preload by enhancing the renal excretion of sodium and water, which reduces circulating blood volume. Furosemide is often prescribed for acute pulmonary edema, but the action of the medication is not to decrease both preload and afterload.

The home health nurse visits a client recovering after an episode of cardiogenic shock secondary to an anterior myocardial infarction (MI) and provides home care instructions to the client. Which statement by the client indicates an understanding of these home care measures? 1."I exercise every day after breakfast." 2."I've gained 8 lb (3.6 kg) since discharge." 3."I take an antacid when I experience epigastric pain." 4."I have planned periods of rest at 10:00 a.m. and 3:00 p.m. daily."

4 The client recovering from an episode of cardiogenic shock secondary to an MI will require a progressive rehabilitation related to physical activity. The heart requires several months to heal from an uncomplicated MI.

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? a. Skin cool and clammy c. Blood pressure of 92/56 mm Hg b. Heart rate of 118 beats/min d. O2 saturation of 93% on room air

A

In a client with mitral regurgitation the nurse would expect to see which of the following signs and symptoms?a. Crushing chest pain b. Exertional dyspnea c. Elevated white blood cell count d. Low red blood cell count

b Fluid retention and diminished heart function cause exterional dyspnea in clients with mitral regurgitation as heart failure worsens. This is due to a rise in left atrial pressure and subsequent pulmonary and venous congestion.

The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on which assessment finding(s)? a. Fever, chills, and diaphoresis b. Urine output less than 30 mL/hr c. Petechiae on the inside of the mouth and conjunctiva d. Increase in heart rate of 15 beats/minute with walking

ANS: B Decreased renal perfusion caused by inadequate cardiac output will lead to decreased urine output. Petechiae, fever, chills, and diaphoresis are symptoms of IE but are not caused by decreased cardiac output. An increase in pulse rate of 15 beats/min is normal with exercise.

When caring for a patient with infective endocarditis of the tricuspid valve, the nurse should monitor the patient for the development of a. flank pain. c. shortness of breath. b. splenomegaly. d. mental status changes.

ANS: C Embolization from the tricuspid valve would cause symptoms of pulmonary embolus. Flank pain, changes in mental status, and splenomegaly would be associated with embolization from the left-sided valves

When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention is most appropriate for the nurse to include? a. Arrange for placement of a long-term IV catheter. b. Monitor labs for levels of streptococcal antibodies. c. Teach the importance of completing all oral antibiotics. d. Encourage the patient to begin regular aerobic exercise.

A Treatment for IE involves 4 to 6 weeks of IV antibiotic therapy to eradicate the bacteria, which will require a long-term IV catheter such as a peripherally inserted central catheter (PICC) line. Rest periods and limiting physical activity to a moderate level are recommended during the treatment for IE. Oral antibiotics are not effective in eradicating the infective bacteria that cause IE. Blood cultures, rather than antibody levels, are used to monitor the effectiveness of antibiotic therapy.

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)? a. Ambulate postoperative patients as soon as possible after surgery. b. Use aseptic technique when manipulating invasive lines or devices. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Administer prescribed antibiotics within 1 hour for patients with possible sepsis. e. Advocate for parenteral nutrition for patients who cannot take in adequate calories.

A: Ambulate postoperative patients as soon as possible after surgery. B: Use aseptic technique when manipulating invasive lines or devices. C:Remove indwelling urinary catheters as soon as possible after surgery. D:Administer prescribed antibiotics within 1 hour for patients with possible sepsis.

When preparing to defibrillate a patient, in which order will the nurse perform the following steps? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Turn the defibrillator on. b. Deliver the electrical charge. c. Select the appropriate energy level. d. Place the hands-free, multifunction defibrillator pads on the patient's chest. e. Check the location of other staff and call out "all clear." ANS:

A: Turn the defibrillator on. C : Select the appropriate energy level. D: Place the hands-free, multifunction defibrillator pads on the patient's chest. E: Check the location of other staff and call out "all clear." B: Deliver the electrical charge.

Which of the following patients is a balloon valvuloplasty indicated for? A. Young adults with mitral stenosisB. Middle-aged adults with mitral regurgitationC. Adults who are nonsurgical candidatesD. Older adults needing replacement valves.E. Older adults with aortic valve stenosis

ACE

patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. Teaching for this patient would include information about a. anticoagulant therapy. c. emergency cardioversion. b. permanent pacemakers. d. IV adenosine (Adenocard).

ANS: A Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant treatment for 3 weeks before attempting cardioversion. This is done to prevent embolization of clots from the atria. Cardioversion may be done after several weeks of anticoagulation therapy. Adenosine is not used to treat atrial fibrillation. Pacemakers are routinely used for patients with bradydysrhythmias. Information does not indicate that the patient has a slow heart rate.

A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Give acetaminophen (Tylenol) 650 mg rectally. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Start norepinephrine to keep systolic blood pressure above 90 mm Hg.

ANS: A Because of the decreased preload associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well.

The nurse is caring for a patient with aortic stenosis. Which assessment data obtained by the nurse would be most important to report to the health care provider? a. The patient complains of chest pressure when ambulating. b. A loud systolic murmur is heard along the right sternal border. c. A thrill is palpated at the second intercostal space, right sternal border. d. The point of maximum impulse (PMI) is at the left midclavicular line.

ANS: A Chest pressure (or pain) occurring with aortic stenosis is caused by cardiac ischemia, and reporting this information would be a priority. A systolic murmur and thrill are expected in a patient with aortic stenosis. A PMI at the left midclavicular line is normal.

A 20-yr-old patient 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 mm Hg, 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 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.

ANS: A 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.

While caring for a patient with aortic stenosis, the nurse identifies a nursing diagnosis of acute pain related to decreased coronary blood flow. An appropriate nursing intervention for this patient would be to a. promote rest to decrease myocardial oxygen demand. b. teach the patient about the need for anticoagulant therapy. c. teach the patient to use sublingual nitroglycerin for chest pain. d. raise the head of the bed 60 degrees to decrease venous return.

ANS: A Rest is recommended to balance myocardial oxygen supply and demand and to decrease chest pain. The patient with aortic stenosis requires higher preload to maintain cardiac output, so nitroglycerin and measures to decrease venous return are contraindicated. Anticoagulation is not recommended unless the patient has atrial fibrillation.

During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? a. New onset of confusion c. Heart rate 112 beats/min b. Decreased bowel sounds d. Pale, cool, and dry extremities

ANS: A The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patient's serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patient's extremities are cool and pulses are weak. d. The patient has bilateral crackles throughout lung fields.

ANS: A The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all symptoms consistent with the patient's diagnosis of cardiogenic shock

After change-of-shift report in the progressive care unit, who should the nurse care for first? a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases b. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics c. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute d. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg

ANS: B

Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin? a. Explain the association between dysrhythmias and syncope. b. Instruct the patient to call for assistance before getting out of bed. c. Teach the patient about the need to avoid caffeine and other stimulants. d. Tell the patient about the benefits of implantable cardioverter-defibrillators.

ANS: B A patient with fainting episodes is at risk for falls. The nurse will plan to minimize the risk by having assistance whenever the patient is up. The other actions may be needed if dysrhythmias are found to be the cause of the patient's syncope but are not appropriate for syncope of unknown origin.

Which action by a new registered nurse (RN) who is orienting to the telemetry unit indicates a good understanding of the treatment of heart dysrhythmias? a. Prepares defibrillator settings at 360 joules for a patient whose monitor shows asystole. b. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia c. Turns the synchronizer switch to the "on" position before defibrillating a patient with ventricular fibrillation d. Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second degree AV block

ANS: B Adenosine must be given over 1 to 2 seconds to be effective. The other actions indicate a need for more teaching about treatment of heart dysrhythmias. The RN should hold the diltiazem until discussing it with the health care provider. The treatment for asystole is immediate CPR. The synchronizer switch should be "off" when defibrillating.

Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective? a. Hemoglobin is within normal limits. b. Urine output is 65 mL over the past hour. c. Central venous pressure (CVP) is normal. d. Mean arterial pressure (MAP) is 72 mm Hg.

ANS: B Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 mL/kg/hr. The hemoglobin level, CVP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion.

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Check temperature every 2 hours. b. Monitor breath sounds frequently. c. Maintain patient in supine position. d. Assess skin for flushing and itching.

ANS: B Because pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.

Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to report the finding to the health care provider? a. The patient's urine output is 18 mL/hr. b. The patient is complaining of chest pain. c. The patient's peripheral pulses are weak. d. The patient's heart rate is 110 beats/minute.

ANS: B Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the patient's diagnosis, and should be reported to the health care provider but does not indicate an immediate need for a change in therapy.

After receiving change-of-shift report on four patients, which patient should the nurse assess first? a. Patient with rheumatic fever who has sharp chest pain with a deep breath b. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg c. Patient with infective endocarditis who has a murmur and splinter hemorrhages d. Patient with dilated cardiomyopathy who has bilateral crackles at the lung bases

ANS: B Hypotension in patients with acute aortic regurgitation may indicate cardiogenic shock. The nurse should immediately assess this patient for other findings such as dyspnea, chest pain or tachycardia. The findings in the other patients are typical of their diagnoses and do not indicate a need for urgent assessment and intervention.

During the assessment of a young adult patient with infective endocarditis (IE), the nurse would expect to find a. substernal chest pressure. c. a pruritic rash on the chest. b. a new regurgitant murmur. d. involuntary muscle movement.

ANS: B New regurgitant murmurs occur in IE because vegetations on the valves prevent valve closure. Substernal chest discomfort, rashes, and involuntary muscle movement are clinical manifestations of other cardiac disorders such as angina and rheumatic fever.

Which assessment finding in a patient who is admitted with infective endocarditis (IE) is most important to communicate to the health care provider? a. Generalized muscle aching c. Janeway's lesions on the palms b. Sudden onset right flank pain d. Temperature 100.7°F (38.1°C)

ANS: B Sudden onset of flank pain indicates possible embolization to the kidney and may require diagnostic testing such as a renal arteriogram and interventions to improve renal perfusion. The other findings are typically found in IE but do not require any new interventions.

A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic, and has no palpable pulses. What action should the nurse take next? a. Perform synchronized cardioversion. b. Start cardiopulmonary resuscitation (CPR). c. Give atropine per agency dysrhythmia protocol. d. Provide supplemental O2 via non-rebreather mask.

ANS: B 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.

A nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of 92/54 mm Hg, a pulse of 64 beats/min, and an elevated pulmonary artery wedge pressure (PAWP). Which intervention ordered by the health care provider should the nurse question? a. Elevate head of bed to 30 degrees. b. Infuse normal saline at 250 mL/hr. c. Hold nitroprusside if systolic BP is less than 90 mm Hg. d. Titrate dobutamine to keep systolic BP is greater than 90 mm Hg.

ANS: B The patient's elevated PAWP indicates volume excess in relation to cardiac pumping ability, consistent with cardiogenic shock. A saline infusion at 250 mL/hr will exacerbate the volume excess. The other actions will help to improve cardiac output, which should lower the PAWP and may raise the BP.

A patient's heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious, apneic, and pulseless. Which action should the nurse take first? a. Give epinephrine (Adrenalin) IV. b. Perform immediate defibrillation. c. Prepare for endotracheal intubation. d. Ventilate with a bag-valve-mask device.

ANS: B The patient's rhythm and assessment indicate ventricular fibrillation and cardiac arrest; the initial action should be to defibrillate. If a defibrillator is not immediately available or is unsuccessful in converting the patient to a better rhythm, begin chest compressions. The other actions may also be appropriate but not first.

Which admission order written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever would be a priority for the nurse to implement? a. Administer ceftriaxone 1 g IV. b. Order blood cultures drawn from two sites. c. Give acetaminophen (Tylenol) PRN for fever. d. Arrange for a transesophageal echocardiogram.

ANS: B Treatment of the IE with antibiotics should be started as quickly as possible, but it is essential to obtain blood cultures before starting antibiotic therapy to obtain accurate sensitivity results. The echocardiogram and acetaminophen administration also should be implemented rapidly, but the blood cultures (and then administration of the antibiotic) have the highest priority.

Which action should the nurse perform when preparing a patient with supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm Hg? a. Turn the synchronizer switch to the "off" position. b. Give a sedative before cardioversion is implemented. c. Set the defibrillator/cardioverter energy to 360 joules. d. Provide assisted ventilations with a bag-valve-mask device.

ANS: B When a patient has a nonemergency cardioversion, sedation is used just before the procedure. The synchronizer switch is turned "on" for cardioversion. The initial level of joules for cardioversion is low (e.g., 50). Assisted ventilations are not indicated for this patient.

A 19-yr-old student comes to the student health center at the end of the semester complaining that, "My heart is skipping beats." An electrocardiogram (ECG) shows occasional unifocal premature ventricular contractions (PVCs). What action should the nurse take next? a. Insert an IV catheter for emergency use. b. Start supplemental O2 at 2 to 3 L/min via nasal cannula. c. Ask the patient about current stress level and caffeine use. d. Have the patient taken to the nearest emergency department (ED).

ANS: C

Which action by the nurse will determine if the therapies ordered for a patient with chronic constrictive pericarditis are most effective? a. Assess for the presence of a paradoxical pulse. b. Monitor for changes in the patient's sedimentation rate. c. Assess for the presence of jugular venous distention (JVD). d. Check the electrocardiogram (ECG) for ST segment changes.

ANS: C Because the most common finding on physical examination for a patient with chronic constrictive pericarditis is jugular venous distention, a decrease in JVD indicates improvement. Paradoxical pulse, ST segment ECG changes, and changes in sedimentation rates occur with acute pericarditis but are not expected in chronic constrictive pericarditis.

The nurse will plan discharge teaching about prophylactic antibiotics before dental procedures for which patient? a. Patient admitted with a large acute myocardial infarction b. Patient being discharged after an exacerbation of heart failure c. Patient who had a mitral valve replacement with a mechanical valve d. Patient being treated for rheumatic fever after a streptococcal infection

ANS: C Current American Heart Association guidelines recommend the use of prophylactic antibiotics before dental procedures for patients with prosthetic valves to prevent infective endocarditis (IE). The other patients are not at risk for IE.

A 21-yr-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. Which information should the nurse include when explaining the advantages of valvuloplasty over valve replacement to the patient? a. Biologic valves will require immunosuppressive drugs after surgery. b. Mechanical mitral valves need to be replaced sooner than biologic valves. c. Lifelong anticoagulant therapy is needed after mechanical valve replacement. d. Ongoing cardiac care by a health care provider is not necessary after valvuloplasty.

ANS: C Long-term anticoagulation therapy is needed after mechanical valve replacement, and this would restrict decisions about career and childbearing in this patient. Mechanical valves are durable and last longer than biologic valves. All valve repair procedures are palliative, not curative, and require lifelong health care. Biologic valves do not activate the immune system and immunosuppressive therapy is not needed.

10. Which information will the nurse include when teaching a patient who is scheduled for a radiofrequency catheter ablation for treatment of atrial flutter? a. The procedure prevents or minimizes the risk for sudden cardiac death. b. The procedure uses cold therapy to stop the formation of the flutter waves. c. The procedure uses electrical energy to destroy areas of the conduction system. d. The procedure stimulates the growth of new conduction pathways between the atria.

ANS: C Radiofrequency catheter ablation therapy uses electrical energy to "burn" or ablate areas of the conduction system as definitive treatment of atrial flutter (i.e., restore normal sinus rhythm) and tachydysrhythmias. All other statements regarding the procedure are incorrect.

Which assessment finding obtained by the nurse when assessing a patient with acute pericarditis should be reported immediately to the health care provider? a. Pulsus paradoxus 8 mm Hg b. Blood pressure (BP) of 168/94 mm Hg c. Jugular venous distention (JVD) to jaw level d. Level 6 (0 to 10 scale) chest pain with a deep breath

ANS: C The JVD indicates that the patient may have developed cardiac tamponade and may need rapid intervention to maintain adequate cardiac output.

A patient who was admitted with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/min. Which action should the nurse take next? a. Immediately notify the health care provider. b. Document the rhythm and continue to monitor the patient. c. Prepare to give IV amiodarone per agency dysrhythmia protocol. d. Perform synchronized cardioversion per agency dysrhythmia protocol.

ANS: C The burst of sustained ventricular tachycardia indicates that the patient has significant ventricular irritability, and antidysrhythmic medication administration is needed to prevent further episodes. The nurse should notify the health care provider after the medication is started. Cardioversion is not indicated given that the patient has returned to a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation.

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

ANS: C The inconsistency between the atrial and ventricular rates and the variable PR interval indicate that the rhythm is third-degree AV block. Sinus rhythm with PACs will have a normal rate and consistent PR intervals with occasional PACs. An accelerated idioventricular rhythm will not have visible P waves.

A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. obtain the blood pressure. b. check the level of orientation. c. administer supplemental oxygen. d. obtain a 12-lead electrocardiogram.

ANS: C The initial actions of the nurse are focused on the ABCs—airway, breathing, and circulation—and administration of O2 should be done first. The other actions should be accomplished as rapidly as possible after providing O2.

After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the health care provider? Physical Assessment Laboratory Data Vital Signs ∙ Petechiae noted on chest and legs ∙ Crackles heard bilaterally in lung bases ∙ No redness or swelling at central line IV site ∙ Blood urea nitrogen (BUN) 34 mg/Dl ∙ Hematocrit 30% ∙ Platelets 50,000/µL ∙ Temperature 100°F (37.8°C) ∙ Pulse 102/min ∙ Respirations 26/min ∙ BP 110/60 mm Hg ∙ O2 saturation 93% on 2L O2 via nasal cannula a. Temperature and IV site appearance b. Oxygen saturation and breath sounds c. Platelet count and presence of petechiae d. Blood pressure, pulse rate, respiratory rate.

ANS: C The low platelet count and presence of petechiae suggest that the patient may have disseminated intravascular coagulation and that multiple organ dysfunction syndrome is developing. The other information will also be discussed with the health care provider but does not indicate that the patient's condition is deteriorating or that a change in therapy is needed immediately.

A patient who is complaining of a "racing" heart and feeling "anxious" comes to the emergency department. The nurse places the patient on a heart monitor and obtains the following electrocardiographic (ECG) tracing. Which action should the nurse take next? a. Prepare to perform electrical cardioversion. b. Have the patient perform the Valsalva maneuver. c. Obtain the patient's vital signs including O2 saturation. d. Prepare to give a β-blocker medication to slow the heart rate.

ANS: C The patient has sinus tachycardia, which may have multiple etiologies such as pain, dehydration, anxiety, and myocardial ischemia. Further assessment is needed before determining the treatment. Vagal stimulation or β-blockade may be used after further assessment of the patient. Electrical cardioversion is used for some tachydysrhythmias but would not be used for sinus tachycardia.

Which intervention by a new nurse who is caring for a patient who has just had an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more teaching about the care of patients with ICDs? a. The nurse administers amiodarone (Cordarone) to the patient. b. The nurse helps the patient fill out the application for obtaining a Medic Alert device. c. The nurse encourages the patient to do active range of motion exercises for all extremities. d. The nurse teaches the patient that sexual activity can be resumed when the incision is healed.

ANS: C The patient should avoid moving the arm on the ICD insertion site until healing has occurred to prevent displacement of the ICD leads. The other actions by the new nurse are appropriate for this patient.

After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for a. furosemide . c. norepinephrine . b. nitroglycerin . d. sodium nitroprusside .

ANS: C When fluid resuscitation is unsuccessful, vasopressor drugs are given to increase the systemic vascular resistance (SVR) and blood pressure and improve tissue perfusion. Furosemide would cause diuresis and further decrease the BP. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Nitroprusside is an arterial vasodilator and would further decrease SVR.

Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective? a. Heart rate c. Blood pressure b. Orientation d. Oxygen saturation

ANS: D

The emergency department (ED) nurse receives report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. In preparation for the patient's arrival, the nurse will obtain a. a dopamine infusion. c. lactated Ringer's solution. b. a hypothermia blanket. d. two 16-gauge IV catheters.

ANS: D A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large-bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool.

When analyzing the rhythm of a patient's electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n) a. isoelectric ST segment. c. QT interval of 0.38 second. b. PR interval of 0.18 second. d. QRS interval of 0.14 second.

ANS: D Because the normal QRS interval is less than 0.12 seconds, the patient's QRS interval of 0.14 seconds indicates that the conduction through the ventricular conduction system is prolonged. The PR interval and QT interval are within normal range and ST segment should be isoelectric (flat).

The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. An appropriate intervention by the nurse for this problem is to a. teach the patient to take deep, slow breaths to control the pain. b. force fluids to 3000 mL/day to decrease fever and inflammation. c. provide a fresh ice bag every hour for the patient to place on the chest. d. place the patient in Fowler's position, leaning forward on the overbed table.

ANS: D Sitting upright and leaning forward frequently will decrease the pain associated with pericarditis. Forcing fluids will not decrease the inflammation or pain. Taking deep breaths will tend to increase pericardial pain. Ice does not decrease this type of inflammation and pa

The nurse has received a change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first? a. A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due b. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating c. A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago d. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due

ANS: D The frequent firing of the ICD indicates that the patient's ventricles are very irritable and the priority is to assess the patient and give the amiodarone. The other patients can be seen after the amiodarone is given.

A patient develops sinus bradycardia at a rate of 32 beats/min, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which action should the nurse take next? a. Recheck the heart rhythm and BP in 5 minutes. b. Have the patient perform the Valsalva maneuver. c. Give the scheduled dose of diltiazem (Cardizem). d. Apply the transcutaneous pacemaker (TCP) pads.

ANS: D The patient is experiencing symptomatic bradycardia and treatment with TCP is appropriate. Continued monitoring of the rhythm and BP is an inadequate response. Calcium channel blockers will further decrease the heart rate and the diltiazem should be held. The Valsalva maneuver will further decrease the rate.

The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first?1. Administer lidocaine, an antidysrhythmic, IVP. 2. Prepare to defibrillate the client. 3. Assess the client's apical pulse and blood pressure. 4. Start basic cardiopulmonary resuscitation.

Assess the client's apical pulse and blood pressure.

A patient is admitted to the hospital with possible acute pericarditis. The nurse should plan to teach the patient about the purpose of a. blood cultures. c. cardiac catheterization. b. echocardiography. d. 24-hour Holter monitor.

B

A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased, and cardiac output is low. The nurse will anticipate an order for which medication? a. 5% albumin infusion c. epinephrine (Adrenalin) drip b. furosemide (Lasix) IV d. hydrocortisone (Solu-Cortef)

B The PAWP indicates that the patient's preload is elevated, and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase the heart rate and myocardial oxygen demand. 5% albumin would also increase the PAWP. Hydrocortisone might be considered for septic or anaphylactic shock.

. Which nursing action can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) working as telemetry technicians on the cardiac care unit? a. Decide whether a patient's heart rate of 116 requires urgent treatment. b. Observe heart rhythms for multiple patients who have telemetry monitoring. c. Monitor a patient's level of consciousness during synchronized cardioversion. d. Select the best lead for monitoring a patient admitted with acute coronary syndrome.

B UAP serving as telemetry technicians can monitor heart rhythms for individuals or groups of patients. Nursing actions such as assessment and choice of the most appropriate lead based on ST segment elevation location require RN-level education and scope of practice.

A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of _____ beats/min. a. 15 to 20 b. 20 to 40 c. 40 to 60 d. 60 to 100

c. 40 to 60 If the sinoatrial (SA) node fails to discharge, the atrioventricular (AV) node will automatically discharge at the normal rate of 40 to 60 beats/minute. The slower rates are typical of the bundle of His and Purkinje system and may be seen with failure of both the SA and AV node to discharge.

To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? a. Auscultate bowel sounds. c. Check stools for occult blood. b. Ask the patient about nausea. d. Palpate for abdominal tenderness.

C

While caring for a 23-yr-old patient with mitral valve prolapse (MVP) without valvular regurgitation, the nurse determines that discharge teaching has been effective when the patient states that it will be necessary to a. take antibiotics before any dental appointments. b. limit physical activity to avoid stressing the heart. c. avoid over-the-counter (OTC) drugs that contain stimulants. d. take an aspirin a day to prevent clots from forming on the valve.

C Use of stimulant drugs should be avoided by patients with MVP because they may exacerbate symptoms. Daily aspirin and restricted physical activity are not needed by patients with mild MVP. Antibiotic prophylaxis is needed for patients with MVP with regurgitation but will not be necessary for this patient.

The nurse is preparing medications for a patient being treated for cardiogenic shock. Which medications will the nurse most likely provide to this patient?Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply. 1. Dopamine 2. Norepinephrine 3. Dobutamine 4. Epinephrine 5. Phenylephrine

Correct Answer: 1,2,3,5Rationale 1: Dopamine is commonly used in the treatment of cardiogenic shock.Rationale 2: Norepinephrine is commonly used in the treatment of cardiogenic shock.Rationale 3: Dobutamine may be used in the patient with cardiogenic shock who has an adequate blood pressure.Rationale 5: Phenylephrine is a vasopressor and may be used in the patient with cardiogenic shock who is receiving dobutamine.

During an assessment the nurse is concerned that a patient is developing cardiogenic shock. What did the nurse assess in this patient?Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.1. Systolic blood pressure 82 mm Hg2. Capillary refill 10 seconds3. Crackles bilateral lung bases4. Heart rate 55 and regular5. Warm dry skin

Correct Answer: 1,2,3Rationale 1: Hypotension is a manifestation of cardiogenic shock.Rationale 2: Delayed capillary refill is a manifestation of cardiogenic shock.Rationale 3: Crackles are a manifestation of cardiogenic shock.

Which laboratory finding should cause the nurse to suspect that a patient is developing hypovolemic shock? 1. Serum sodium of 130 mEq/L (130 mmol/L) 2. Metabolic acidosis validated by arterial blood gases 3. Serum lactate of 3 mmol/L 4. SvO2 greater than 80%

Correct Answer: 2 Rationale 2: Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate deficit from decreased tissue perfusio

The emergency department (ED) nurse receives report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. In preparation for the patient's arrival, the nurse will obtain a. a dopamine infusion. c. lactated Ringer's solution. b. a hypothermia blanket. d. two 16-gauge IV catheters.

D

The nurse knows that discharge teaching about the management of a new permanent pacemaker has been most effective when the patient states a. "It will be several weeks before I can return to my usual activities." b. "I will avoid cooking with a microwave oven or being near one in use." c. "I will notify the airlines when I make a reservation that I have a pacemaker." d. "I won't lift the arm on the pacemaker side until I see the health care provider."

D

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 of 243 mg/dL c. Serum sodium of 134 mEq/L b. Serum chloride of 92 mEq/L d. Serum potassium of 2.9 mEq/L

D

The client shows ventricular fibrillation on the telemetry at the nurse's station. Which action should the telemetry nurse implement first? 1. Administer epinephrine IVP 2. Prepare to defibrillate the client. 3. Call a STAT code. 4. Start cardiopulmonary resuscitation.

Call a STAT code.

The telemetry nurse is unable to read the telemetry monitor at the nurse's station. Which intervention should the telemetry nurse implement first? 1. Go to the client's room to check the client 2. Instruct the primary nurse to assess the client. 3. Contact the client on the client call system. 4. Request the nursing assistant to take the crash cart to the client's room.

Contact the client on the client call system.

A patient has a sinus rhythm and a heart rate of 72 beats/min. The nurse determines that the PR interval is 0.24 seconds. The most appropriate intervention by the nurse would be to a. notify the health care provider immediately. b. document the finding and monitor the patient. c. give atropine per agency dysrhythmia protocol. d. prepare the patient for temporary pacemaker insertion.

b

The client who is one day postoperative coronary artery bypass surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement? 1. Assess the apical heart rate for one full minute. 2. Notify the client's cardiac surgeon. 3. Prepare the client for synchronized cardioversion. 4. Determine if the client is having pain.

Determine if the client is having pain.

The health care provider orders the following interventions for a 67-kg patient who has septic shock with a blood pressure of 70/42 mm Hg and O2 saturation of 90% on room air. In which order will the nurse implement the actions? (Put a comma and a space between each answer choice a. Give vancomycin 1 g IV. b. Obtain blood and urine cultures c. Start norepinephrine 0.5 mcg/min. d. Infuse normal saline 2000 mL over 30 minutes. e. Titrate oxygen administration to keep O2 saturation above 95%.

E, D, C, B, A

The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client? 1. Instruct the client to use a soft-bristle toothbrush. 2. Discuss the importance of getting a monthly partial thromboplastin time (PTT). 3. Teach the client about signs of pacemaker malfunction. 4. Explain to the client the procedure for synchronized cardioversion.

Instruct the client to use a soft-bristle toothbrush.

The client is exhibiting sinus bradycardia, is complaining of syncope and weakness, and has a BP of 98/60. Which collaborative treatment should the nurse anticipate being implemented? 1. Administer a thrombolytic medication. 2. Assess the client's cardiovascular status. 3. Prepare for insertion of a pacemaker. 4. Obtain a permit for synchronized cardioversion.

Prepare for insertion of a pacemaker.

The nurse is assessing a client hospitalized with acute pericarditis. The nurse monitors the client for cardiac tamponade, knowing that which signs are associated with this complication of pericarditis? Select all that apply. 1.Bradycardia 2.Pulsus paradoxus 3.Distant heart sounds 4.Falling blood pressure (BP) 5.Distended jugular veins

Pulsus paradoxus Distant heart sounds Falling blood pressure (BP) Distended jugular veins Assessment findings with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling BP, accompanied by pulsus paradoxus (a drop in inspiratory BP by more than 10 mm Hg).

A patient is brought to the emergency department with hypotension, tachycardia, reduced capillary refill, and oliguria. During the assessment, the nurse determines the patient is experiencing cardiogenic shock because of which additional finding?1. Jugular vein distention2. Dry mucous membranes3. Poor skin turgor4. Thirst

Rationale 1: Jugular vein distention is a manifestation of cardiogenic shock.

A patient is demonstrating pulmonary edema, hypotension, and delayed capillary refill. The nurse suspects the patient is experiencing which type of shock? 1. Hypovolemic 2. Cardiogenic 3. Anaphylactic 4. Obstructive

Rationale 2: In cardiogenic shock, there is a low cardiac output, hypotension, and pulmonary edema.

Which solution would be the most appropriate initial volume replacement for a patient with severe GI bleeding? 1. 200 mL of normal saline (NS) per hour for 5 hours 2. A liter of Ringer's lactate (RL) over 15 minutes 3. Two liters of D5W over half an hour 4. 500 mL of 0.45% normal saline (1/2 NS) over half an hour

Rationale 2: The patient requires immediate infusion of an adequate amount of fluid. Fluid resuscitation begins with 500 to 1,000 mL of an isotonic solution.

The nurse, caring for a patient in hypovolemic shock, will not utilize a hypotonic solution for fluid resuscitation because hypotonic solutions:1. Move quickly into the interstitial spaces and can cause third spacing2. Stay longer to expand the intravascular space but deplete intracellular fluid levels3. Do not stay in the intravascular space long enough to expand the circulating blood volume4. Need a smaller bore needle to run at a slower rate to keep the intravascular space low

Rationale 3: Hypotonic solutions do not stay in the intravascular space long enough to expand the circulating blood volume.

After a defibrillation attempt with 120 J, an organized rhythm is observed on the monitor. Which is the next action for the nurse? A. Turn off the defibrillator. B. Check for a pulse. C. Resume CPR. D. Continue to monitor respiratory effort.

Resume CPR.

Which intervention should the nurse implement when defibrillating a client who is in ventricular fibrillation? 1. Defibrillate the client at 50, 100, and 200 joules. 2. Do not remove the oxygen source during defibrillation. 3. Place petroleum jelly on the defibrillator pads. 4. Shout "all" clear prior to defibrillating the client.

Shout "all" clear prior to defibrillating the client.

A patient recovering from heart surgery develops pericarditis and complains of level 6 (0 to 10 scale) chest pain with deep breathing. Which prescribed PRN medication will be the most appropriate for the nurse to give? a. Fentanyl 1 mg IV c. Oral ibuprofen (Motrin) 600 mg b. IV morphine sulfate 4 mg d. Oral acetaminophen (Tylenol) 650 mg

The pain associated with pericarditis is caused by inflammation, so nonsteroidal antiinflammatory drugs (e.g., ibuprofen) are most effective. Opioid analgesics and acetaminophen are not very effective for the pain associated with pericarditis.

Two days after an acute myocardial infarction (MI), a patient complains of stabbing chest pain that increases with a deep breath. Which action will the nurse take first? a. Auscultate the heart sounds. b. Check the patient's temperature. c. Give the PRN acetaminophen (Tylenol). d. Notify the patient's health care provider.

aNS: A The patient's clinical manifestations and history are consistent with pericarditis, and the first action by the nurse should be to listen for a pericardial friction rub.

Which of the following self-care measures will the nurse teach the patient who has had infective endocarditis? (Select all that apply ) A. Report a fever of more than seven days duration to the health care provider.B. Avoid body piercings, branding, and tattooingC. Administer prophylactic antibiotics for dental procedures that involve gingival tissueD. Weigh themselves daily and then report it to their physician

abc

Which finding indicates that rehydration is complete and hypovolemic shock has been successfully treated in a patient? 1. CVP = 8 mm Hg 2. MAP = 45 mm Hg 3. Urinary output of 0.1 mL/kg/hr 4. Hct = 54%

ationale 1: A CVP reading of 8 mm Hg is within normal range and rehydration has been restored.

The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use? a. Count the number of large squares in the R-R interval and divide by 300. b. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes. c. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10. d. Calculate the number of small squares between one QRS complex and the next and divide into 1500.

c. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.

The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, and QRS complex wide and distorted, and QRS duration of 0.18 second. The nurse interprets the patient's cardiac rhythm as a. atrial flutter. c. ventricular fibrillation. b. sinus tachycardia. d. ventricular tachycardia.

d. ventricular tachycardia. The absence of P waves, wide QRS, rate greater than 150 beats/min, and the regularity of the rhythm indicate ventricular tachycardia. Atrial flutter is usually regular, has a narrow QRS configuration, and has flutter waves present representing atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration.

To determine whether there is a delay in impulse conduction through the ventricles, the nurse will measure the duration of the patient's a. P wave. c. PR interval. b. Q wave. d. QRS complex.

d. QRS complex. The QRS complex represents ventricular depolarization. The P wave represents the depolarization of the atria. The PR interval represents depolarization of the atria, atrioventricular node, bundle of His, bundle branches, and the Purkinje fibers.