UNIT 1 EXAM: Perfusion Exemplars (HF, MI, Dysryhthmias)

Ventricular Fibrillation (VF)

Not measurable and chaotic No CO --> *NO PULSE* *FATAL* Call Code immediately! Follows PVCs and VT

Atrial Fibrillation (A-Fib)

Irregular *350-600bpm* ABSENT P WAVES Fibrillatory (f) waves *squiggles* PR interval: immeasurable QRS: usually normal Life-threatening dep. on ability to perfuse

Premature Atrial Contraction (PAC)

Irregular 60-100bpm P wave: abnormal, peaked, biphasic PR interval: abnormal and inconsistent QRS: normal and narrow

Sinus Tachycardia

Regular 101-200bpm P wave: normal PR interval: normal QRS: normal Not life-threatening

Supraventricular Tachycardia (SVT)

Regular 150-250bpm P wave: pointed/hidden in T PR interval: immeasurable QRS: normal but narrow Life-threatening dep. on rate and pt's ability to tolerate

T wave

ventricular repolarization upright 0.16 secs

A client with heart failure is to receive digoxin and asks the nurse why the medication is necessary. What physiologic response will the nurse include when answering the client's question? 1.Reduces edema 2.Increases cardiac conduction 3.Increases rate of ventricular contractions 4.Slows and strengthens cardiac contractions

4 *Rationale*: Digoxin increases the strength of myocardial contractions (positive inotropic effect) and, by altering the electrophysiological properties of the heart, slows the heart rate (negative chronotropic effect). Digoxin increases the strength of the contractions but decreases the heart rate. Although a reduction in edema may result from the increased blood supply to the kidneys, it is not the reason for administering digoxin. Digoxin decreases, not increases, cardiac impulses through the conduction system of the heart.

Second-Degree AV Block (Mobitz I, Wenckenbach)

Atrial: Normal and regular Ventricular: slower + irregular P wave: normal *PR interval: progressive lengthening* QRS: normal width w/pattern of one nonconducted (blocked) QRS *Progressively gets longer then BLOCKED QRS!*

Second-Degree AV Block Type 2 (Mobitz II)

Atrial: normal + regular Ventricular: slower, regular/irreg *More P waves than QRS* can be 2:1, 3:1 PR interval: normal/prolonged but consistent for every QRS Widened QRS preceded by >/= 2 P waves w/blocked QRS

First-Degree AV Block

Normal and regular rhythm P wave: normal *PR interval: >0.20 secs* QRS: normal

Atrial Flutter

Regular 200-350bpm ABSENT P WAVES Flutter(F) waves *sawtooth* *more flutters than QRS* may occur 2:1, 3:1, 4:1 PR interval: immeasurable QRS: normal Life-threatening dep. on ventricular rate

The Heart Block Poem

-If the *R is far from the P then you have a first degree* -*Longer, longer, longer drop then you have a Wenkebach* -if *some Ps don't get through then you have a Mobitz II* -If *Ps and Qs don't agree then you have a third degree*

The nurse is assessing a client with the diagnosis of chronic heart failure. Which clinical finding should the nurse expect the client to experience? 1.Dependent edema in the evening 2.Chest pain that decreases with rest 3.Palpitations in the chest when resting 4.Frequent coughing with yellow sputum

1 *Rationale*: Decreased cardiac output causes fluid retention, which results in dependent edema; this is often noticed in the evening after the client has been standing or sitting for prolonged periods. Chest pain is indicative of cardiac ischemia. Palpitations are indicative of cardiac dysrhythmias. Coughing with yellow sputum is indicative of an infectious process in the respiratory tract; pink, frothy sputum is associated with pulmonary edema that can result from heart failure.

A client comes to the emergency department with pressure in the chest and shortness of breath. The client is admitted for observation after receiving a tentative diagnosis of a myocardial infarction. Which assessment finding should the nurse monitor for in this client that supports this diagnosis? 1.Vomiting 2.Bradycardia 3.Severe headache 4.Pain radiating to the abdomen

1 *Rationale*: Nausea and vomiting are clinical manifestations that are associated with a myocardial infarction. The heart rate will increase, not decrease, in an attempt to meet oxygen demands of the body. Headaches are associated with a stroke, not with a myocardial infarction. Chest pain associated with a myocardial infarction may radiate to the jaw, back, or left shoulder and arm, not the abdomen.

A nurse begins to develop a plan of care with a client who has left ventricular heart failure that resulted from a myocardial infarction (MI). Which goal is priority during the acute phase of recovery? 1.Promote pain relief 2.Increase activity tolerance 3.Prevent cardiac dysrhythmias 4.Maintain potassium and sodium intake

1 *Rationale*: The major goal is to manage pain. Pain relief helps increase the oxygen supply and decrease myocardial oxygen demand, decreasing the workload of the heart. Increasing activity tolerance is the primary focus during the rehabilitative phase after an MI, not during the acute phase. While preventing dysrhythmia is important, it is not the priority. Although maintaining potassium intake is important, sodium should be limited to minimize fluid retention, which increases the workload on the heart.

The primary healthcare provider has prescribed a stat chest x-ray exam and electrocardiogram for a client with a history of heart failure. The pulse oximeter has changed from 90% to 86% oxygen saturation. Which immediate actions will the nurse take? Select all that apply. 1.Tell a staff member to get the electrocardiogram machine. 2.Notify the x-ray department that a chest x-ray exam must be done stat. 3.Have a staff member notify the nursing supervisor of the change in client status. 4.Notify the healthcare provider of the change in the oxygen saturation to ask what to do. 5.Tell the certified nursing assistant to get a prescription from the healthcare provider to increase the oxygen. 6.Increase the supplemental oxygen without a prescription from 2 L nasal cannula to 4 L nasal cannula and notify the healthcare provider.

1,2,3,6 *Rationale*: A staff member can get the electrocardiogram machine and start the procedure. Ancillary personnel are trained to do electrocardiograms even if they are not able to interpret the results. Anyone can notify the x-ray department that the chest x-ray exam must be done. It is important to delegate the tasks to a specific person. Increasing the oxygen without a prescription is appropriate in the short term, but the nurse must obtain a prescription when notifying the healthcare provider. Notifying the healthcare provider of the change in oxygen saturation is appropriate, but it would be expected that nursing judgment had taken place and the oxygen already was increased from 2 L/min. Telling the certified nursing assistant (CNA) to get a prescription is an inappropriate action as a CNA is not allowed to take medical prescriptions. Taking a medical prescription is a nursing role.

Which nursing interventions may promote safe drug administration in a child diagnosed with heart failure who is receiving digoxin? Select all that apply. 1.Checking for compliance with the client's drug regimen 2.Monitoring the client's serum potassium and magnesium levels regularly 3.Administering digoxin only through the intramuscular route 4.Calculating the correct dosage form, prescribed amounts, and the prescriber's order 5.Monitoring and recording the client's intake and output, heart rate, blood pressure, daily weight, and respiration rate regularly

1,2,4,5 *Rationale*: Digoxin may alter the serum potassium and serum magnesium levels, which affects heart function. Calculating the correct dose according to the healthcare provider's orders helps to prevent drug toxicity. Checking for compliance with the client's drug regimen is important so that the child does not have drug to drug interactions. Monitoring and recording drug intake and output, heart rate, blood pressure, daily weight, and respiration rate is a part of general nursing care. Administering digoxin through the intramuscular route is not advised because this method is very painful.

A client who is suspected of having had a silent myocardial infarction has an electrocardiogram (ECG) prescribed by the primary healthcare provider. While the nurse prepares the client for this procedure, the client asks, "Why was this test prescribed?" Which is the best reply by the nurse? 1."This test will detect your heart sounds." 2."This test will reflect any heart damage." 3."This procedure helps us change your heart's rhythm." 4."The ECG will tell us how much stress your heart can tolerate."

2 *Rationale*: Changes in an ECG will reflect the area of the heart that is damaged because of hypoxia. A stethoscope is used to detect heart sounds. Medical interventions, such as cardioversion or cardiac medications, not an ECG, can alter heart rhythm. An ECG will reflect heart rhythm, not change it. Identifying how much stress a heart can tolerate is accomplished through a stress test; this uses an ECG in conjunction with physical exercise.

A neonate diagnosed with congestive heart failure has been prescribed furosemide. What changes to the dosage or time intervals between doses should be made? 1.The time between doses should be shortened. 2.The time between doses should be lengthened. 3.The dosage should be doubled. 4.The dosage should be cut in half.

2 *Rationale*: In neonates, the half-life of furosemide is increased. To avoid toxicity of the drug, the nurse should lengthen the time interval between the doses. If the time interval is shortened or the dosage is doubled, the level of drug circulating in the blood will be increased leading to toxic effects of the drug. Halving the dose is not an appropriate solution.

A client is admitted to the hospital with a diagnosis of heart failure and acute pulmonary edema. The healthcare provider prescribes furosemide 40 mg intravenous (IV) stat to be repeated in 1 hour. What nursing action will best evaluate the effectiveness of the furosemide in managing the client's condition? 1.Perform daily weights 2.Auscultate breath sounds 3.Monitor intake and output 4.Assess for dependent edema

2 *Rationale*: Maintaining adequate gas exchange and minimizing hypoxia with pulmonary edema are critical; therefore, assessing the effectiveness of furosemide therapy as it relates to the respiratory system is most important. Furosemide inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule, causing diuresis; as diuresis occurs fluid moves out of the vascular compartment, thereby reducing pulmonary edema and the bilateral crackles. Although a liter of fluiterm-40d weighs approximately 2.2 pounds (1 kilogram) and weight loss will reflect the amount of fluid lost, it will take time before a change in weight can be measured. Although identifying a greater output versus intake indicates the effectiveness of furosemide, it is the client's pulmonary status that is most important with acute pulmonary edema. Although the lessening of a client's dependent edema reflects effectiveness of furosemide therapy, it is the client's improving pulmonary status that is most important.

Heart failure develops in a 4-month-old infant with a congenital heart defect, and the infant exhibits marked dyspnea at rest. What should the nurse immediately assess the infant for? 1.Hypovolemia 2.Bilateral crackles 3.A decreased red blood cell count 4.Decreased pH and carbon dioxide values

2 *Rationale*: The increased blood volume and pressure in the lungs from impaired myocardial function results in pulmonary edema, which causes dyspnea; it is a sign of heart failure. Oxygenation is a priority concern that should be addressed immediately. Polycythemia, not anemia, is more common, because red blood cell production is increased to counteract hypoxia. Hypervolemia, not hypovolemia, is related to heart failure and pulmonary edema. Respiratory, not metabolic, acidosis can develop because of pulmonary insufficiency resulting in retention of carbon dioxide

A client is brought to the emergency department with chest pain. A myocardial infarction is suspected, and 500 mL of D 5W with 50 mg of nitroglycerin intravenously (IV) has been prescribed. The nurse should monitor the client for what most common side effect? 1.Bradycardia 2.Postural hypotension 3.Nausea and vomiting 4.Cherry red lips and cheeks

2 *Rationale*: The major action of intravenous nitroglycerin is venous and then arterial dilation, leading to a decrease in blood pressure; orthostatic hypotension can occur. Bradycardia is not an anticipated response. Nausea and vomiting may occur but are not the most common side effects of IV nitroglycerin. Cherry red lips and cheeks occur with carbon monoxide poisoning.

A client is admitted to the cardiac care unit with a myocardial infarction. The cardiac monitor reveals several runs of ventricular tachycardia. The nurse anticipates that the client will be receiving a prescription for which drug? 1.Atropine 2.Epinephrine 3.Amiodarone 4.Sodium bicarbonate

3 *Rationale*: Amiodarone suppresses ventricular activity; therefore, it is used for treatment of premature ventricular complexes (PVCs). It works directly on the heart tissue and slows the nerve impulses in the heart. Atropine blocks vagal stimulation; it increases the heart rate and is used for bradycardia, not PVCs. Epinephrine increases myocardial contractility and heart rate; therefore, it is contraindicated in the treatment of PVCs. Sodium bicarbonate increases the serum pH level; therefore, it combats metabolic acidosis.

A client presenting to the emergency department with chest pain and dizziness is found to be having a myocardial infarction and subsequently suffers cardiac arrest. The healthcare team is able to successfully resuscitate the client. Lab work shows that the client now is acidotic. How does the nurse interpret the cause of the acidosis? 1.The fat-forming ketoacids were broken down. 2.The irregular heartbeat produced oxygen deficit. 3.The decreased tissue perfusion caused lactic acid production. 4.The client received too much sodium bicarbonate during resuscitation efforts

3 *Rationale*: Cardiac arrest causes decreased tissue perfusion, which results in ischemia and cardiac insufficiency. Cardiac insufficiency causes anaerobic metabolism, which leads to lactic acid production. Fat-forming ketoacids occur in diabetes. An irregular heartbeat does not cause acidosis. Too much sodium bicarbonate causes alkalosis, not acidosis

The family of a client with right ventricular heart failure expresses concern about the client's increasing abdominal girth. What physiologic change should the nurse consider when explaining the client's condition? 1.Loss of cellular constituents in blood 2.Rapid osmosis from tissue spaces to cells 3.Increased pressure within the circulatory system 4.Rapid diffusion of solutes and solvents into plasma

3 *Rationale*: Failure of the right ventricle causes an increase in pressure in the systemic circulation. To equalize this pressure, fluid moves into the tissues, causing edema, and into the abdominal cavity, causing ascites; ascites leads to an increased abdominal girth. There is no loss of the cellular constituents in blood with right ventricular heart failure. Ascites is the accumulation of fluid in an extracellular space, not intracellular. The opposite of rapid diffusion of solutes and solvents into plasma results when there is a pressure increase in the systemic circulation.

A nurse is reviewing the clinical records of infants and children with cardiac disorders in whom heart failure developed. What does the nurse identify as the last sign of heart failure? 1.Tachypnea 2.Tachycardia 3.Peripheral edema 4.Periorbital edema

3 *Rationale*: Heart failure is characterized by a decrease in blood flow to the kidneys, causing sodium and water reabsorption and resulting in peripheral edema. The peripheral edema indicates severe cardiac decompensation. Tachypnea and tachycardia constitute an early attempt by the body to compensate for decreased cardiac output. Periorbital edema occurs most noticeably in children with acute poststreptococcal glomerulonephritis, not heart failure.

What feeding instruction should a nurse give the parent of a 2-month-old infant with the diagnosis of heart failure? 1.Use double-strength formula. 2.Avoid using a preemie nipple. 3.Refrain from feeding until crying from hunger begins. 4.Feed slowly while allowing time for adequate periods of rest.

4 *Rationale*: Because of limited exercise tolerance and fatigue, infants with heart failure become too tired to feed; allowing rest and feeding slowly limit the fatigue associated with feeding. Although the infant may be given a formula with a higher caloric value (30kcal/oz (30 kcal/30 mL) rather than 20 kcal/oz (20 kcal/30 mL)), double-strength formula is too high an osmotic load for the infant. A soft nipple used for preterm infants or a regular nipple with an enlarged opening is preferred to conserve the energy required for sucking. Crying consumes energy and is exhausting. The infant should be fed when exhibiting signs of hunger, such as sucking on a fist.

A client takes isosorbide dinitrate daily. The client states, "I would like to start taking sildenafil for erectile dysfunction." The nurse explains that taking both of these medications concurrently may result in which complication? 1.Constipation 2.Protracted vomiting 3.Respiratory distress 4.Severe hypotension

4 *Rationale*: Concurrent use of sildenafil and a nitrate, which causes vasodilation, may result in severe, potentially fatal hypotension. Protracted vomiting and respiratory distress are not adverse effects associated with concurrent use of sildenafil and a nitrate. Sildenafil may cause diarrhea; adding a nitrate will not constipation.

A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect? 1."My ankles are swollen." 2."I am tired at the end of the day." 3."When I eat a large meal, I feel bloated." 4."I have trouble breathing when I walk rapidly."

4 *Rationale*: Dyspnea on exertion often occurs with left ventricular heart failure because the heart is unable to pump enough oxygenated blood to meet the energy requirements for muscle contractions related to the activity. The statement "My ankles are swollen" is more likely with right ventricular heart failure. The statement "I am tired at the end of the day" is not specific to left ventricular heart failure. The statement "When I eat a large meal, I feel bloated" is not specific to left ventricular heart failure.

The nurse is conducting a nutrition class for a group of clients with heart failure (HF). Which information is most important for the nurse to share with the class? 1.Restricting fluid intake 2.Eating a low caloric diet to reduce weight 3.Recognizing which products are high in cholesterol 4.Choosing fresh or frozen vegetables instead of canned ones

4 *Rationale*: The key principle to teach HF clients is the importance of decreasing sodium in their diet and which foods contain sodium. If sodium is decreased, water retention will decrease also. Fresh or frozen vegetables have less sodium than canned ones. If the client is on a low-sodium diet and receiving diuretics but continues to be fluid overloaded, then fluid restriction may be instituted. A low caloric diet is not indicated for all HF clients. Some are very thin because of various factors, including the work of breathing and rapid heart rate. A low cholesterol diet is important for clients with coronary artery disease and for the American population in general but is not specifically related to HF.

A client with myocardial infarction is admitted in the emergency department, and the primary health care provider recommended the placement of a stent. The client is incompetent to understand the situation. What model does the nurse manager think would be beneficial in this situation? 1.Decision model 2.Autonomy model 3.Social justice model 4.Patient-benefit model

4 *Rationale*: The patient-benefit model uses substituted judgment such as determining what the client would want for himself or herself if capable of making these issues known, and thereby facilitates decision making for incompetent clients. The decision model is used for nurses; it depends on specific circumstances to know if the situation is routine and predictable or complex and uncertain. The autonomy model facilitates decision making for competent clients. The social justice model considers broad social issues and is accountable to the overall institution.

The nurse should evaluate that defibrillation of a client was most successful if which observation was made? 1.Arousable, sinus rhythm, blood pressure (BP) 116/72 mm Hg 2.Nonarousable, sinus rhythm, BP 88/60 mm Hg 3.Arousable, marked bradycardia, BP 86/54 mm Hg 4.Nonarousable, supraventricular tachycardia, BP 122/60 mm Hg

Answer: 1 *Rationale*: After defibrillation, the client requires continuous monitoring of electrocardiographic rhythm, hemodynamic status, and neurological status. Respiratory and metabolic acidosis develop during ventricular fibrillation because of lack of respiration and cardiac output. These can cause cerebral and cardiopulmonary complications. Arousable status, adequate BP, and a sinus rhythm indicate successful response to defibrillation.

The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse interpret the client's heart rhythm? 1.Atrial fibrillation 2.Sinus tachycardia 3.Ventricular fibrillation 4.Ventricular tachycardia

Answer: 1 *Rationale*: Atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each QRS complex. The atria quiver, which can lead to thrombus formation.

A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal. The nurse should alert the primary health care provider because the vital sign changes and client assessment are most consistent with which complication? Refer to chart. *Chart showed steadily increasing HR, RR with decreasing BP* 1.Cardiogenic shock 2.Cardiac tamponade 3.Pulmonary embolism 4.Dissecting thoracic aortic aneurysm

Answer: 1 *Rationale*: Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include hypotension; a rapid pulse that becomes weaker; decreased urine output; and cool, clammy skin. Respiratory rate increases as the body develops metabolic acidosis from shock. Cardiac tamponade is accompanied by distant, muffled heart sounds and prominent neck vessels. Pulmonary embolism presents suddenly with severe dyspnea accompanying the chest pain. Dissecting aortic aneurysms usually are accompanied by back pain.

A client is recovering from a myocardial infarction. Which action should the nurse take before developing the client's teaching plan? 1.Identify the learning needs of the client. 2.Determine the nursing goals for the client. 3.Explore the use of group teaching for the client. 4.Evaluate the community resources available to the client

Answer: 1 *Rationale*: For teaching to be meaningful, the client must have a need to learn and a readiness to learn. These factors need to be identified before a teaching plan is formulated. Determining the nursing goals for the client eliminates the client from the goal-setting process; active participation by the client increases motivation and retention. Exploring the use of group teaching for the client is not the initial step; learning needs must be determined first to see if group learning is appropriate; also, group learning must be available as an option. Evaluating community resources is not the initial step; assessment of learning needs comes first.

A client comes to the emergency department with pressure in the chest and shortness of breath. The client is admitted for observation after receiving a tentative diagnosis of a myocardial infarction. Which assessment finding should the nurse monitor for in this client that supports this diagnosis? 1.Vomiting 2.Bradycardia 3.Severe headache 4.Pain radiating to the abdomen

Answer: 1 *Rationale*: Nausea and vomiting are clinical manifestations that are associated with a myocardial infarction. The heart rate will increase, not decrease, in an attempt to meet oxygen demands of the body. Headaches are associated with a stroke, not with a myocardial infarction. Chest pain associated with a myocardial infarction may radiate to the jaw, back, or left shoulder and arm, not the abdomen.

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

Answer: 1 *Rationale*: Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats per minute.

The nurse is caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a state of shock. The nurse knows that which intervention is the priority for this client? 1.Administration of digoxin 2.Administration of whole blood 3.Administration of intravenous fluids 4.Administration of packed red blood cells

Answer: 1 *Rationale*: The client in this question is likely experiencing cardiogenic shock secondary to heart failure exacerbation. It is important to note that if the shock state is cardiogenic in nature, the infusion of volume-expanding fluids may result in pulmonary edema; therefore, restoration of cardiac function is the priority for this type of shock. Cardiotonic medications such as digoxin, dopamine, or norepinephrine may be administered to increase cardiac contractility and induce vasoconstriction. Whole blood, intravenous fluids, and packed red blood cells are volume-expanding fluids and may further complicate the client's clinical status; therefore, they should be avoided.

A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia? 1.It can develop into ventricular fibrillation at any time. 2.It is almost impossible to convert to a normal rhythm. 3.It is uncomfortable for the client, giving a sense of impending doom. 4.It produces a high cardiac output with cerebral and myocardial ischemia

Answer: 1 *Rationale*: Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. Ventricular tachycardia can deteriorate into ventricular fibrillation at any time. Clients frequently experience a feeling of impending doom. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (if the client is awake), or defibrillation (loss of consciousness).

A client with a history of heart failure is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide? 1. 3.2 mEq/L (3.2 mmol/L) 2. 3.8 mEq/L (3.8 mmol/L) 3. 4.2 mEq/L (4.2 mmol/L) 4. 4.8 mEq/L (4.8 mmol/L)

Answer: 1 *Rationale:* The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The correct option is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. The remaining options are within the normal range.

The client has developed atrial fibrillation, with a ventricular rate of 150 beats per minute. The nurse should assess the client for which associated signs and/or symptoms? Select all that apply. 1.Syncope 2.Dizziness 3.Palpitations 4.Hypertension 5.Flat neck veins

Answer: 1,2,3 *Rationale*: The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats per 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. Hypertension and flat neck veins are not associated with the loss of cardiac output.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse immediately asks another nurse to contact the primary health care provider and prepares to implement which priority interventions? Select all that apply. 1.Administering oxygen 2.Inserting a Foley catheter 3.Administering furosemide 4.Administering morphine sulfate intravenously 5.Transporting the client to the coronary care unit 6.Placing the client in a low-Fowler's side-lying position

Answer: 1,2,3,4 *Rationale*: Extreme dyspnea, tachycardia, and lung crackles in a client with heart failure indicate pulmonary edema, a life-threatening event. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high-Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

The nurse is monitoring a client for adverse effects of medications. Which findings are characteristic of adverse effects of hydrochlorothiazide? Select all that apply 1.Sulfa allergy 2.Osteoporosis 3.Hypokalemia 4.Hypouricemia 5.Hyperglycemia 6.Hypercalcemia

Answer: 1,3,5,6 *Rationale*: Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia.

A client with myocardial infarction is developing cardiogenic shock. What condition should the nurse carefully assess the client for? 1.Pulsus paradoxus 2.Ventricular dysrhythmias 3.Rising diastolic blood pressure 4.Falling central venous pressure

Answer: 2 *Rationale*: Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium. Classic signs of cardiogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Pulsus paradoxus is a finding associated with cardiac tamponade.

A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? 1.Glipizide 2.Metformin 3.Repaglinide 4.Regular insulin

Answer: 2 *Rationale*: Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of a contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld 24 hours before and 48 hours after cardiac catheterization.

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

Answer: 2 *Rationale*: Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection.

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? 1.Call a code. 2.Check the client's status. 3.Call the primary health care provider. 4.Document the lack of complexes.

Answer: 2 *Rationale*: Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client is necessary to determine the cause and identify the appropriate intervention. The remaining options are secondary to client assessment.

Intravenous heparin therapy is prescribed for a client with atrial fibrillation. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit? 1.Vitamin K 2.Protamine sulfate 3.Potassium chloride 4.Aminocaproic acid

Answer: 2 *Rationale*: The antidote to heparin is protamine sulfate; it should be readily available for use if excessive bleeding or hemorrhage should occur. Vitamin K is an antidote for warfarin sodium. Potassium chloride is administered for a potassium deficit. Aminocaproic acid is the antidote for thrombolytic therapy.

While a client with an abdominal aortic aneurysm is being prepared for surgery, the client complains of feeling light-headed. The client is pale and has a rapid pulse. What does the nurse conclude that the client's symptoms indicate? 1.Hyperventilation 2.Shock 3.Anxiety 4.Infection

Answer: 2 *Rationale*: The clinical findings are early signs of shock. Shock ensues rapidly after a ruptured aortic aneurysm because of profound hemorrhage. The nurse can observe hyperventilation by watching the client's breathing patterns; rapid respirations are expected with hyperventilation. There are no data that indicate that the client is hyperventilating. Anxiety usually is not associated with light-headedness unless there is accompanying hyperventilation. The signs and symptoms are not inclusive enough to indicate infection; there is no indication of fever.

Two hours after a cardiac catheterization that was accessed through the right femoral route, an adult client complains of numbness and pain in the right foot. What action should the nurse take first? 1.Call the primary healthcare provider. 2.Check the client's pedal pulses. 3.Take the client's blood pressure. 4.Recognize the response is expected.

Answer: 2 *Rationale*: These symptoms are associated with compromised arterial perfusion. A thrombus is a complication of a femoral arterial cardiac catheterization and must be suspected in the absence of a pedal pulse in the extremity below the entry site. A circulatory assessment should be conducted first; the primary healthcare provider may or may not need to be notified immediately concerning the results of the assessment. Taking the client's blood pressure is unnecessary; the symptoms indicate a local peripheral problem, not a systemic or cardiac problem. These symptoms are not expected.

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? 1.Stridor 2.Crackles 3.Scattered rhonchi 4.Diminished breath sounds

Answer: 2 *Rationale*:Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway.

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription? 1.Adding a dose of heparin sodium 2.Holding the next dose of warfarin 3.Increasing the next dose of warfarin 4.Administering the next dose of warfarin

Answer: 2 *Rationale*:The normal PT is 11 to 12.5 seconds (conventional therapy and SI units). A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the value of 35 seconds is high, the nurse should anticipate that the client would not receive further doses at this time. Therefore, the prescriptions noted in the remaining options are incorrect.

The nurse is monitoring a client with heart failure who is taking digoxin. Which findings are characteristic of digoxin toxicity? Select all that apply. 1.Tremors 2.Diarrhea 3.Irritability 4.Blurred vision 5.Nausea and vomiting

Answer: 2,4,5 *Rationale*: Digoxin is a cardiac glycoside. The risk of toxicity can occur with the use of this medication. Toxicity can lead to life-threatening events and the nurse needs to monitor the client closely for signs of toxicity. Early signs of toxicity include gastrointestinal manifestations such as anorexia, nausea, vomiting, and diarrhea. Subsequent manifestations include headache; visual disturbances such as diplopia, blurred vision, yellow-green halos, and photophobia; drowsiness; fatigue; and weakness. Cardiac rhythm abnormalities can also occur. The nurse also monitors the digoxin level. The optimal therapeutic range for digoxin is 0.5 to 2.0 ng/mL (0.63 to 2.56 nmol/L).

A client returns from a cardiac catheterization procedure and is to remain in the supine position for 4 hours with the affected leg straight. What are these measures intended to prevent? 1. Orthostatic hypotension 2. Headache with disorientation 3. Bleeding at the arterial puncture site 4. Infiltration of radiopaque dye into tissue

Answer: 3 *Rationale*: Bed rest with immobilization of the leg promotes coagulation and healing at the puncture site of the femoral artery. In the absence of bleeding and the presence of adequate fluid replacement, a cardiac catheterization does not cause orthostatic hypotension. Headache with disorientation is not expected after a cardiac catheterization. A small amount of radiopaque dye is injected (via the catheter) directly into the heart, where the blood dilutes it; it does not create a problem at the puncture site.

A client with a cardiac dysrhythmia is receiving digoxin and verapamil. Because of the combined effect of these two medications, what adverse effect does the nurse anticipate? 1.Physical agitation 2.Reflex stimulation 3.Myocardial depression 4.Respiratory stimulation

Answer: 3 *Rationale*: Both digoxin and verapamil decrease cardiac impulse conduction, with resultant depression of the myocardium; verapamil decreases conduction at the sinoatrial (SA) and atrioventricular (AV) nodes, which may cause bradycardia, AV block, and cardiac arrest. Digoxin and verapamil together do not cause agitation. Side effects of verapamil include fatigue and depression, not agitation. Digoxin and verapamil do not influence the reflexes of the body. Digoxin and verapamil do not influence respirations.

A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hr. The nurse determines that the client is receiving the therapeutic effect based on which results? 1.Prothrombin time of 12.5 seconds 2.Activated partial thromboplastin time of 28 seconds 3.Activated partial thromboplastin time of 60 seconds 4.Activated partial thromboplastin time longer than 120 seconds

Answer: 3 *Rationale*: Common laboratory ranges for activated partial thromboplastin time (aPTT) are 30 to 40 seconds. Because the aPTT should be 1.5 to 2.5 times the normal value, the client's aPTT would be considered therapeutic if it was 60 seconds. Prothrombin time assesses response to warfarin therapy.

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats per minute. Which action should the nurse take? 1.Check vital signs. 2.Check laboratory test results. 3.Monitor for any rhythm change. 4.Notify the primary health care provider.

Answer: 3 *Rationale*: Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats per minute. The PR and QRS measurements are normal, measuring between 0.12 and 0.20 seconds and 0.06 and 0.12 seconds, respectively. There are no irregularities in this rhythm currently, so there is no immediate need to check vital signs or laboratory results, or to notify the primary health care provider. Therefore, the nurse would continue to monitor the client for any rhythm change.

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

Answer: 3 *Rationale*: Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders; states of hypoxemia; any number of physiological stressors, such as infection, illness, surgery, or trauma; and intake of caffeine, nicotine, or alcohol.

A client is being treated with procainamide for a cardiac dysrhythmia. Following intravenous administration of the medication, the client complains of dizziness. What intervention should the nurse take first? 1.Obtain a 12-lead electrocardiogram. 2.Check the client's fingerstick blood glucose level. 3.Auscultate the client's apical pulse and blood pressure. 4.Measure the QRS interval duration on the rhythm strip.

Answer: 3 *Rationale*: Signs of toxicity from procainamide include confusion, dizziness, drowsiness, decreased urination, nausea, vomiting, and tachydysrhythmias. If the client complains of dizziness, the nurse should assess the vital signs first. Although measuring the QRS duration on the rhythm strip and obtaining a 12-lead electrocardiogram may be interventions, these would be done after the vital signs are taken. Dizziness directly following the procainamide indicates that the medication was the likely cause and should be addressed before assessing for other possible causes such as hypoglycemia.

Sublingual nitroglycerin tablets are prescribed to control periodic episodes of chest pain in the patient with stable angina. Which instruction should the nurse include when teaching the client about sublingual nitroglycerin? 1.Once the tablet is dissolved, spit out the saliva. 2.Take tablets 3 minutes apart up to a maximum of five tablets. 3.Common side effects include headache and low blood pressure. 4.Once opened, the tablets should be refrigerated to prevent deterioration.

Answer: 3 *Rationale*: The primary side effects of nitroglycerin are headache and hypotension. It is not necessary to spit out saliva into which nitroglycerin has dissolved. For pain that is not relieved, additional tablets may be taken every 5 minutes up to a total of three tablets. It should be stored at room temperature.

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

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

The nurse is watching the cardiac monitor and notices that a client's rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats per minute. The nurse determines that the client is experiencing which dysrhythmia? 1.Sinus tachycardia 2.Ventricular fibrillation 3.Ventricular tachycardia 4.Premature ventricular contractions

Answer: 3 *Rationale*: Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 seconds), and typically a rate between 140 and 180 impulses per minute. The rhythm is regular.

Prior to administering a client's daily dose of digoxin to treat heart failure, the nurse reviews the client's laboratory data and notes the following results: serum calcium, 9.8 mg/dL (2.45 mmol/L); serum magnesium, 1.0 mEq/L (0.4 mmol/L); serum potassium, 4.1 mEq/L (4.1 mmol/L); serum creatinine, 0.9 mg/dL (79.5 mcmol/L). Which result should alert the nurse that the client is at risk for digoxin toxicity? 1.Serum calcium level 2.Serum potassium level 3.Serum creatinine level 4.Serum magnesium level

Answer: 4 *Rationale*: An increased risk of toxicity exists in clients with hypercalcemia, hypokalemia, hypomagnesemia, hypothyroidism, and impaired renal function. The calcium, creatinine, and potassium levels are all within normal limits. The normal range for magnesium is 1.8-2.6 mEq/L (0.74-1.07 mmol/L), and the results in the correct option are reflective of hypomagnesemia.

The nurse provides discharge instructions to a client with atrial fibrillation who is taking warfarin sodium. Which statement, by the client, reflects the need for further teaching? 1."I will avoid alcohol consumption." 2."I will take my pills every day at the same time." 3."I have already called my family to pick up a MedicAlert bracelet." 4."I will take coated aspirin for my headaches because it will coat my stomach."

Answer: 4 *Rationale*: Aspirin-containing products need to be avoided when a client is taking this medication. Alcohol consumption should be avoided by a client taking warfarin sodium. Taking the prescribed medication at the same time each day increases client compliance. The MedicAlert bracelet provides health care personnel with emergency information.

A primary healthcare provider prescribes an antihypertensive medication. Which over-the-counter medication should the nurse teach the client to avoid because it has the potential to counteract the effect of the antihypertensive? 1.Omeprazole 2.Acetaminophen 3.Docusate sodium 4.Pseudoephedrine

Answer: 4 *Rationale*: Pseudoephedrine has a pressor effect that may counteract antihypertensive medications, causing an increase in blood pressure. Omeprazole does not interact with antihypertensives. However, it can increase the action of phenytoin, digoxin, clopidogrel, and cyclosporine. Acetaminophen does not have to be avoided when receiving an antihypertensive. Docusate sodium does not have to be avoided when receiving an antihypertensive.

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

Answer: 4 *Rationale*: Sinus bradycardia is noted with a heart rate less than 60 beats per minute. This rhythm becomes a concern when the client becomes symptomatic. Hypotension and dizziness are signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the symptomatic client. Defibrillation is used for treatment of pulseless ventricular tachycardia and ventricular fibrillation. Digoxin will further decrease the client's heart rate. Continuing to monitor the client delays necessary intervention.

It is determined that a client with heart block will require implantation of a permanent pacemaker to assist heart function. The client expresses concern about having an increased risk of accidental electrocution. How should the nurse respond? 1."No one has been electrocuted yet by a pacemaker." 2."New technology prevents electrocution from occurring." 3."The pacemaker is pretested for safety before it is inserted." 4."The voltage emitted is not strong enough to electrocute."

Answer: 4 *Rationale*: Stating that the voltage emitted is not strong enough to electrocute the client will reduce anxiety. Milliamps are used, not volts of electricity; higher voltages are needed to electrocute. Stating that "No one has been electrocuted yet by a pacemaker" is a patronizing response and minimizes the stated concern. The voltage used in pacemakers can never cause electrocution; technology is not related. Although pacemakers are pretested for safety, this does not address the concern about the possibility of electrocution.

A client in ventricular fibrillation is about to be defibrillated. To convert this rhythm effectively, the monophasic defibrillator machine should be set at which energy level (in joules, J) for the first delivery? 1.50 J 2.120 J 3.200 J 4.360 J

Answer: 4 *Rationale*: The energy level used for all defibrillation attempts with a monophasic defibrillator is 360 joules.

The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pads on the client's chest and before discharging the device, which intervention is a priority? 1.Ensure that the client has been intubated. 2.Set the defibrillator to the "synchronize" mode. 3.Administer an amiodarone bolus intravenously. 4.Confirm that the rhythm is ventricular fibrillation

Answer: 4 *Rationale*: Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any loose connections. A nitroglycerin patch, if present, is removed. The client does not have to be intubated to be defibrillated. The machine is not set to the synchronous mode because there is no underlying rhythm with which to synchronize.

A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? 1."I should notify my cardiologist if my feet or legs start to swell." 2."I am supposed to report to my cardiologist if my pulse rate decreases below 60." 3."Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast." 4."My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."

Answer: 4 *Rationale*: Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often at rest. The pain is a result of coronary artery spasm. The treatment of choice is usually a calcium channel blocker, which relaxes and dilates the vascular smooth muscle, thus relieving the coronary artery spasm in variant angina. Adverse effects can include peripheral edema, hypotension, bradycardia, and heart failure. Grapefruit juice interacts with calcium channel blockers and should be avoided. If bradycardia occurs, the client should contact the primary health care provider or cardiologist. Clients should also be taught to change positions slowly to prevent orthostatic hypotension. Physical exertion does not cause this type of angina; therefore, the client should be able to continue morning walks with her or his spouse.

What client response indicates to the nurse that a vasodilator medication is effective? 1.Absence of adventitious breath sounds 2.Increase in the daily amount of urine produced 3.Pulse rate decreases from 110 to 75 beats/min 4.Blood pressure changes from 154/90 to 126/72 mm Hg

Answer: 4 *Rationale*: Vasodilation will lower the blood pressure. The pulse rate is not decreased and may increase. Breath sounds are not directly affected by vasodilation, although vasodilator medications can decrease preload and afterload, which could indirectly affect breath sounds in heart failure. The urine output is not affected immediately, although control of blood pressure can help preserve renal function over time.

Third-Degree AV Heart Block (Complete Heart Block)

Atrial: normal + regular Ventricular: 20-60bpm *P wave: normal but no connection w/QRS* PR interval: inconsistent QRS: normal/widened

Premature ventricular contraction (PVC)

Irregular P wave: none PR interval: N/A PR interval: N/A QRS: >0.12 wide and bizarre Inverted T wave Life-threatening dep. on frequency! *3 PVC's in a row can go into VTach!*

Torsades de pointes

Polymorphic VTach "Twisting of the Points" QRS: change back and forth from one shape,size,direction Associated w/prolonged QT interval in underlying rhythm

Normal sinus rhythm (NSR)

Regular 60-100 bpm P wave: normal PR interval: normal QRS: normal Not life-threatening

Sinus Bradycardia

Regular <60bpm P wave: normal PR interval: normal QRS: normal Life-threatening dep. on cause

Ventricular tachycardia (VT)

Regular P wave: none PR Interval: none QRS: >0.12 wide and bizarre *Life-threatening* *May/may not have a pulse* *Only pulseless VTach is shockable! Tendency to transition to VFib!!*

Paroxysmal Supraventricular Tachycardia (PSVT)

Regular 150-220 bpm P wave: abnormal, hidden in preceding T PR interval: normal/shortened QRS: usually normal

P wave

atrial depolarization (contraction) upright 0.06-0.12 secs

ST segment

time btwn ventricular depolarization and repolarization (diastole) *flat (isolectric)* 0.12 secs

PR interval

time taken for impulse to travel through atria, AV node, bundle of His, bundle branches, purkinje fibers: *point immediately before ventricular contraction* 0.12-0.20 secs

QRS complex

ventricular depolarization (systole) 0.06-0.12 secs