V sim 1
Preparing for an ECG is a priority nursing intervention for which patient?
-A patient reporting "I feel lie my heart is skipping beats" -a patient who just had a pacemaker placed -a patient newly diagnosed with mild hypokalemia -a patient experiencing diaphoresis and arm pain
The nurse and a student nurse are reviewing the ECG of a patient diagnosed with atrial fibrillation (AF). Which characteristics noted will the nurse identify as being associated with this cardiac condition?
-Absent P waves -low amplitude fibrillation waves -Irregular QRS complexes
A nurse is discussing the evaluation of an ECG recently performed on a patient with a nursing student. Which data will the nurse identify for the student as being within normal limits?
-T wave is rounded and smooth -P wave is visible before each QRS complex -HR between 60-100bpm -normal sinus rhythm -P wave that lasts 0.12-0.2 seconds -QRS complex that lasts 0.12 seconds -ST segment less than or equal to 0.1 mV, -positive in leads I,II, V3-V6 -QT interval duration varies but usually lasts 0.36 to 0.44 seconds
A patient is diagnosed with atrial fibrillation (AF) based on an ECG. Which of the following nursing assessment findings could also be demonstrated by a patient experiencing AF?
-Tachycardia -Jugular vein distension -history of chest pain
Which assessment findings suggest an Atrial vascular system abnormality?
-absence of hair over the lower legs -thin, shiny skin over calves
To assess a patients heart during a physical assessment, which actions will the nurse perform?
-assess the apex, left sternal border, and base of the heart for abnormal pulsations -ask the patient to lie on the left side to assess sounds from the apex of the heart -assess heart rate and rhythm using the diaphragm of the stethoscope -auscultating over the aortic, pulmonic, tricuspid, and mitral areas as well as Erb's point
ECG is used to identify
-conduction abnormalities -cardiac arrhythmias -myocardial infarctions
Which gender generally have Resting pulse rate thats few beats faster than the other gender?
females have a few beats faster than males
The nurse is gathering subjective data during a cardiovascular assessment from a patient's spouse. Which question is particularly appropriate for a patient who has reported that, "My heart seems to skip beats"?
have you seen periods when your spouse seems to experience uncommon fatigue?
Which action taken during a cardiovascular assessment will best assist the nurse in determining the hemodynamic of the right side of a patient's heart
inspection of the jugular venous pulse level
The nurse is providing care for a patient whose partner says, "We're told that he occasionally has an irregular heartbeat. Is that bad?" Which response should the nurse make to best address the partner's concern?
its normal to experience occasional premature beats
Which patient is expected to have the lowest rating pulse rate?
non-Hispanic Black male
Of the medications Mr. Griffin has been prescribed, which one will the nurse discuss with the surgeon regarding its possible association with the patient's irregular heartbeat?
oxycodone/actaminophen
A patient has been recently diagnosed with atrial fibrillation. Which expected outcome will the nurse include in the care plan to address the resulting anxiety?
patient will learn and demonstrate effective coping behaviors
Atrial fibrillationi s most common
patients older than 60 but affects only approximately 5% of this age group
Inspection for apical impulse is done to determine the
presence of an enlarged ventricle
right-side heart failure raises _________ and __________, thus raising ________
raises pressure and volume, thus raising jugular venous pressure
what does impaired blood flow lead to
stroke, thromboembolism, and heart failure
What is the nurse's response when Mr. Griffin asks, "What is the biggest worry about having Atrial fibrillation?
the blood tends to pool in your heart's upper clamber, increasing the risk of developing a clot
Warm skin and brown pigmentation around the ankles is associated with
venous insufficiency
The medical record states that the patient's pulse is "small and weak". Which characteristic will the nurse examine to detect when performing a cardiovascular assessment on this patient?
-prolonged systolic peak -diminished pulse pressure -slow upstroke
The nurse is preparing a patient for a cardiovascular assessment. When providing the patient with info concerning the examination, which physical positions will the nurse indicate will be used during the examination?
-siting upright while leaning forward -supine -left lateral
palpation of the carotid artery is done to detect ______
a loss of elasticity that is associated with arteriosclerosis
When reviewing Mr. Griffin's medical record, the nurse recognizes what info as being a risk factor for Atrial fibrillation?
-history of hypertension -male over the age of 60
The life partner of a patient diagnosed with arial fibrillation (AF) demonstrates a need for instruction when asking the nurse, "Can you tell me why this is a problem?" What is the nurse's best response?
abnormal heartbeat results in poor blood flow to the heart
auscultation of the carotid artery is associated with
detection of a bruit, indicative of some degree of occulusion
Assessing Si and S2 heart sounds is done using the _______ of the stethoscope
diaphragm
When preparing a patient for an ECG the nurse will include which instructional information?
-sticky backed electrodes will be attached directly to the skin on the patient's arms, legs and chest -the patient will be asked to lie on his or her back for the length of the test, which is 5-10 mins -test is painless -Its important that the patient remain as still and relaxed as possible during the test
Which point on the heart will the nurse use to auscultate an apical pulse?
apex
which race have lower mean PRPs than another race?
black and Mexicans (especially females) have lower mean RPRs than non-Hispanic white females
Which example of nursing documentation best indicates that the patient has peripheral perfusion that reflects adequate cardiac output?
capillary refill noted in less than 2 seconds