4th Semester Test 1

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Analysis 20. An elderly patient with a 40-pack-year history of smoking and a recent myocardial infarction is admitted to the medical unit with acute shortness of breath; the nurse need to rule out pneumonia versus heart failure. The diagnostic test that the nurse will monitor to help in determining whether the patient has heart failure is a. 12-lead electrocardiogram (ECG). b. arterial blood gases (ABGs). c. B-type natriuretic peptide (BNP). d. serum creatine kinase (CK).

C Rationale: BNP is secreted when ventricular pressures increase, as with heart failure, and elevated BNP indicates a probable or very probable diagnosis of heart failure. 12-lead ECGs, ABGs, and CK may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP. Cognitive Level: Application Text Reference: p. 827 Nursing Process: Assessment

Physiological Integrity 17. While admitting a patient with an AMI, which action should the nurse carry out first? a. Assess peripheral pulses. b. Check the oxygen saturation. c. Attach the cardiac monitor. d. Obtain the BP.

C Rationale: Because dysrhythmias are the most common complication of MI, the first action should be to place the patient on a cardiac monitor. The other actions are also important and should be accomplished as quickly as possible. Cognitive Level: Application Text Reference: pp. 799, 806 Nursing Process: Implementation

Physiological Integrity 16. A patient with a non-ST segment elevation myocardial infarction (NSTEMI) is receiving heparin. What is the purpose of the heparin? a. Heparin will dissolve the clot that is blocking blood flow to the heart. b. Coronary artery plaque size and adherence are decreased with heparin. c. Heparin will prevent the development of clots in the coronary arteries. d. Platelet aggregation is enhanced by IV heparin infusion.

C Rationale: Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation. Cognitive Level: Comprehension Text Reference: p. 800 Nursing Process: Implementation

Physiological Integrity 15. During change-of-shift report, the nurse learns that a patient with a large myocardial infarction has been having frequent PVCs. When monitoring the patient for the effects of PVCs, the nurse will check the patient's a. medications. b. recent electrolyte values. c. apical radial heart rate. d. oxygen saturation.

C Rationale: It is important to assess the patient's apical-radial pulse rate because PVCs often do not generate a sufficient ventricular contraction to result in a peripheral pulse, which can lead to a pulse deficit. Electrolyte imbalances, hypoxia, and certain medications may precipitate PVCs. Cognitive Level: Comprehension Text Reference: p. 854 Nursing Process: Assessment

A patient who has had severe chest pain for several hours is admitted with a diagnosis of possible acute myocardial infarction (AMI). Which of these ordered laboratory tests should the nurse monitor to help determine whether the patient has had an AMI? A) a. Homocysteine B) b. C-reactive protein C) c. Cardiac-specific troponin I and troponin T D) d. High-density lipoprotein (HDL) cholesterol

C Cardiac-specific troponin I and troponin T

A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that A) a. electrocardiographic (ECG) monitoring will be required for 24 hours after the test. B) b. it will be important to lie completely still during the procedure. C) c. a warm feeling may be noted when the contrast dye is injected. D) d. monitored anesthesia care will be provided during the procedure.

C a warm feeling may be noted when the contrast dye is injected

A patient has received instruction on the management of a new permanent pacemaker before discharge from the hospital. The nurse recognizes that teaching has been effective when the patient tells the nurse, A) a. "It will be 6 weeks before I can take a bath or return to my usual activities." B) b. "I will notify the airlines when I make a reservation that I have a pacemaker." C) c. "I won't lift the arm on the pacemaker side up very high until I see the doctor." D) d. "I must avoid cooking with a microwave oven or being near a microwave in use."

C) c. "I won't lift the arm on the pacemaker side up very high until I see the doctor."

A patient who was admitted with a myocardial infarction experiences a 50-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute. Which action should the nurse take next? A) a. Notify the health care provider. B) b. Perform synchronized cardioversion. C) c. Administer the PRN IV lidocaine (Xylocaine). D) d. Document the rhythm and monitor the patient.

C) c. Administer the PRN IV lidocaine (Xylocaine).

During the administration of the fibrinolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences A) a. bleeding from the gums. B) b. surface bleeding from the IV site. C) c. a decrease in level of consciousness. D) d. a nonsustained episode of ventricular tachycardia.

C) c. a decrease in level of consciousness.

A nurse is performing discharge teaching with a client who has an implantable cardioverter defibrillator (ICD) placed. Which client statement indicates effective teaching?

"I'll keep a log of each time my ICD discharges."

Two nursing students are reading EKG strips. One of the students asks the instructor what the P-R interval represents. The correct response should be which of the following?

"It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node."

Which PR interval presents a first-degree heart block?

0.24 seconds

A client has developed atrial fibrillation, which a ventricular rate of 150 beats per minute. A nurse assesses the client for: 1. Hypotension and dizziness 2. Nausea and vomiting 3. Hypertension and headache 4. Flat neck veins

1. The client with uncontrolled atrial fibrillation with a ventricular rate more than 150 beats a 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.

A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs the client to do which of the following, if prescribed, during an episode of ventricular tachycardia? 1. Breathe deeply, regularly, and easily. 2. Inhale deeply and cough forcefully every 1 to 3 seconds. 3. Lie down flat in bed 4. Remove any metal jewelry

2. Cough cardiopulmonary resuscitation (CPR) sometimes is used in the client with unstable ventricular tachycardia. The nurse tells the client to use cough CPR, if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds. Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented.

When ventricular fibrillation occurs in a CCU, the first person reaching the client should: 1. Administer oxygen 2. Defibrillate the client 3. Initiate CPR 4. Administer sodium bicarbonate intravenously

2. Ventricular fibrillation is a death-producing dysrhythmia and, once identified, must be terminated immediately by precordial shock (defibrillation). This is usually a standing physician's order in a CCU.

Physiological Integrity 12. A patient with myocardial infarction develops symptomatic hypotension. The monitor shows a type 1, second-degree AV block with a heart rate of 30. The nurse administers IV atropine as prescribed. The nurse determines that the drug has been effective on finding a(n) a. increase in the patient's heart rate. b. increase in peripheral pulse volume. c. decrease in ventricular response. d. decrease in premature contractions.

A Rationale: Atropine will increase the heart rate and conduction through the AV node. Because the medication increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. Ventricular response will be increased by atropine because of the improvement in AV conduction. Atropine will not decrease PVCs, and the patient does not have PVCs. Cognitive Level: Application Text Reference: p. 853 Nursing Process: Evaluation

9) How does a nurse assess for dysrhythmias? A. 12 lead EKG B. Listen to lung sounds C. blood test D. Urine sample

A. 12 lead EKG

Which of these nursing interventions included in the plan of care for a patient who had an AMI 3 days ago is most appropriate for the RN to delegate to an experienced LPN/LVN?

Administration of the ordered metoprolol (Lopressor) and aspirin

The nurse is in the mall and observes a client slump to the floor. The nurse assesses the client and notes no pulse. The nurse calls for assistance to others in the mall and requests which piece of equipment?

An automatic external defibrillator

The nurse is caring for a patient who has just undergone catheter ablation therapy. The nurse in the step-down unit should prioritize what assessment? A) Cardiac monitoring B) Monitoring the implanted device signal C) Pain assessment D) Monitoring the patient's level of consciousness (LOC)

Ans: Cardiac monitoring Feedback: Following catheter ablation therapy, the patient is closely monitored to ensure the dysrhythmia does not reemerge. This is a priority over monitoring of LOC and pain, although these are valid and important assessments. Ablation does not involve the implantation of a device.

The nurse is caring for a patient who is in the recovery room following the implantation of an ICD. The patient has developed ventricular tachycardia (VT). What should the nurse assess and document? A) ECG to compare time of onset of VT and onset of device's shock B) ECG so physician can see what type of dysrhythmia the patient has C) Patient's level of consciousness (LOC) at the time of the dysrhythmia D) Patient's activity at time of dysrhythmia

Ans: ECG to compare time of onset of VT and onset of device's shock Feedback: If the patient has an ICD implanted and develops VT or ventricular fibrillation, the ECG should be recorded to note the time between the onset of the dysrhythmia and the onset of the device's shock or antitachycardia pacing. This is a priority over LOC or activity at the time of onset.

The nursing educator is presenting a case study of an adult patient who has abnormal ventricular depolarization. This pathologic change would be most evident in what component of the ECG? A) P wave B) T wave C) QRS complex D) U wave

Ans: QRS complex Feedback: The QRS complex represents the depolarization of the ventricles and, as such, the electrical activity of that ventricle.

The nurse is analyzing a rhythm strip. What component of the ECG corresponds to the resting state of the patient's heart? A) P wave B) T wave C) U wave D) QRS complex

Ans: T wave Feedback: The T wave specifically represents ventricular muscle depolarization, also referred to as the resting state. Ventricular muscle depolarization does not result in the P wave, U wave, or QRS complex.

Which of the following medication classifications is more likely to be expected when the nurse is caring for a client with atrial fibrillation?

Anticoagulant

Which medication is the drug of choice for sinus bradycardia?

Atropine

A patient with ST segment elevation in several electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for fibrinolytic therapy? A) a. "Do you take aspirin on a daily basis?" B) b. "What time did your chest pain begin?" C) c. "Is there any family history of heart disease?" D) d. "Can you describe the quality of your chest pain?"

B "What time did your chest pain begin?"

Which information collected by the nurse who is admitting a patient with chest pain suggests that the pain is caused by an acute myocardial infarction (AMI)? A) a. The pain increases with deep breathing. B) b. The pain has persisted longer than 30 minutes. C) c. The pain worsens when the patient raises the arms. D) d. The pain is relieved after the patient takes nitroglycerin.

B The pain has persisted longer than 30 minutes.

Which of the following may cause changes in ECG rhythms? A. Na is 136 mEq/L B. K is 2.8 mEq/L C. Ca is 8.5 mg/dL D. Creatine 1.0 mg/dL

B. K is 2.8 mEq/L Normal K is 3.5-5.0

Physiological Integrity 9. A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that a. a catheter will be inserted into a vein in the arm or leg and advanced to the heart. b. ECG monitoring will be required for 24 hours following the test to detect any dysrhythmias. c. a feeling of warmth may be experienced as the contrast material is injected into the catheter. d. it will be important to lie completely still during the coronary angiography procedure.

C Rationale: A sensation of warmth or flushing is common when the iodine-based contrast material is injected, which can be anxiety-producing unless it has been discussed with the patient. The catheter is inserted in an artery (typically the femoral artery) and advanced to the openings for the coronary arteries at the aortic root. Dysrhythmias may occur during the procedure, but most patients are discharged a few hours after the coronary arteriogram or angiogram is completed. The patient is not required to be completely immobile during the procedure. Cognitive Level: Application Text Reference: pp. 755, 759 Nursing Process: Implementation

Physiological Integrity 27. The nurse is taking a health history from a 24-year-old patient with hypertrophic cardiomyopathy (HC); which information obtained by the nurse is most relevant? a. The patient reports using cocaine once at age 16. b. The patient has a history of a recent upper respiratory infection. c. The patient's 29-year-old brother has had a sudden cardiac arrest. d. The patient has a family history of coronary artery disease (CAD).

C Rationale: About half of all cases of HC have a genetic basis, and HC is the most common cause of sudden cardiac death in otherwise healthy young people; the information about the patient's brother will be helpful in planning care (such as an automatic implantable cardioverter-defibrillator [AICD]) for the patient and in counseling other family members. The patient should be counseled against use of stimulant drugs, but the one-time use indicates that the patient is not at current risk for cocaine use. Viral infections and CAD are risk factors for dilated cardiomyopathy, but not for HC. Cognitive Level: Application Text Reference: pp. 886, 888 Nursing Process: Assessment

Physiological Integrity 37. The nurse has just received change-of-shift report about these four patients. Which patient should the nurse assess first? a. A 38-year-old who has pericarditis and is complaining of sharp, stabbing chest pain b. A 45-year-old who had an MI 4 days ago and is anxious about the planned discharge c. A 51-year-old who has just returned to the unit after a coronary arteriogram and PCI d. A 60-year-old who has a scheduled dose of atenolol (Tenormin) 25 mg PO due

C Rationale: After PCI, the patient is at risk for bleeding from the arterial access site for the PCI, so the nurse should assess the patient immediately. The other patients also should be assessed as quickly as possible, but assessment of this patient has the highest priority. Cognitive Level: Application Text Reference: p. 807 Nursing Process: Assessment

Which of the following is correct about ECG? A. it is an invasive procedure in which the patient receive electrical signals. B. ECG is used to evaluate the structure and function of valves. C. it is a non-invasive test done at the bedside used to rule out MI. D. ECG is only indicated for patients with chest pain.

C. it is a non-invasive test done at the bedside used to rule out MI.

When caring for a patient with ACS who has returned to the coronary care unit after having a PCI, the nurse obtains these assessment data. Which data indicate the need for immediate intervention by the nurse?

Chest pain level 8 on a 10-point scale

You are caring for a client who has been admitted to have a cardioverter defibrillator implanted. You would know that implanted cardioverter defibrillators are used in what clients?

Clients with recurrent life-threatening tachydysrhythmias

Which electrocardiographic (ECG) change will be of most concern to the nurse when admitting a patient with chest pain? a. Sinus tachycardia b. Inverted T wave c. ST-segment elevation d. Frequent PACs

Correct Answer: C Rationale: The patient is likely to be experiencing an ST-segment-elevation myocardial infarction (STEMI) and immediate therapy with PCI or fibrinolytic medications is indicated to minimize the amount of myocardial damage. The other ECG changes also suggest a need for therapy, but not as rapidly.

A patient with ST-segment elevation in several ECG leads is admitted to the ED and diagnosed as having an AMI. Which question should the nurse ask to determine whether the patient is a candidate for fibrinolytic therapy? a. "Is there any family history of heart disease?" b. "Do you take aspirin on a daily basis?" c. "Can you describe the quality of your chest pain?" d. "What time did your chest pain begin?"

Correct Answer: D Rationale: Fibrinolytic therapy should be started within 6 hours of the onset of the MI, so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information will also be needed, but it will not be a factor in the decision about fibrinolytic therapy. Cognitive Level: Application Text Reference: p. 807 Nursing Process: Assessment NCLEX: Physiological Integrity

Physiological Integrity 32. A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 123. Based on this information, which nursing diagnosis is a priority for the patient? a. Acute pain related to myocardial infarction b. Anxiety related to perceived threat of death c. Stress overload related to acute change in health d. Decreased cardiac output related to cardiogenic shock

D All the nursing diagnoses may be appropriate for this patient, but the hypotension and tachycardia indicate decreased cardiac output and shock from the damaged myocardium. This will result in decreased perfusion to all vital organs (e.g., brain, kidney, heart) and is a priority. DIF: Cognitive Level: Apply (application) REF: 746-747 OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis MSC:

Physiological Integrity 15. 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. b. P-R interval of 0.18 second. c. Q-T interval of 0.38 second. d. QRS interval of 0.14 second.

D Because the normal QRS interval is 0.04 to 0.10 seconds, the patient's QRS interval of 0.14 seconds indicates that the conduction through the ventricular conduction system is prolonged. The P-R interval and Q-T interval are within normal range, and ST segment should be isoelectric (flat). DIF: Cognitive Level: Apply (application) REF: 791 TOP: Nursing Process: Assessment MSC:

Physiological Integrity 19. A patient with ST-segment elevation in several ECG leads is admitted to the ED and diagnosed as having an AMI. Which question should the nurse ask to determine whether the patient is a candidate for fibrinolytic therapy? a. "Is there any family history of heart disease?" b. "Do you take aspirin on a daily basis?" c. "Can you describe the quality of your chest pain?" d. "What time did your chest pain begin?"

D Rationale: Fibrinolytic therapy should be started within 6 hours of the onset of the MI, so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information will also be needed, but it will not be a factor in the decision about fibrinolytic therapy. Cognitive Level: Application Text Reference: p. 807 Nursing Process: Assessment

Physiological Integrity 30. After having an AMI, a 62-year-old patient tells the nurse, "I guess having sex again will be too hard on my heart." The nurse's best response is a. "Sexual intercourse may be too strenuous on your heart, but closeness and intimacy can be maintained with holding and cuddling." b. "You should discuss your questions about your sexual activity with your doctor because the activity it requires is a medical concern." c. "Sexual activity can be resumed whenever you feel like you are ready. Most sexual response is emotional rather than physical." d. "Sexual activity can be gradually resumed like other activity. A good comparison of energy expenditure is climbing two flights of stairs."

D Rationale: Sexual activity places about as much physical stress on the cardiovascular system as climbing two flights of stairs. The answer beginning "Sexual intercourse may be too strenuous" may be true; however there are no data in the stem to indicate that intercourse will be too stressful to the heart for this patient. The answer beginning, "You should discuss your questions" implies that there are serious medical concerns about sexual activity. And the answer beginning "Sexual activity can be resumed whenever" is incorrect because physiologic parameters such as heart rate and BP do increase during sexual activity. Cognitive Level: Application Text Reference: p. 817 Nursing Process: Implementation

Physiological Integrity 33. A patient who has chest pain is admitted to the ED, and all the following diagnostic tests are ordered. Which one will the nurse arrange to be completed first? a. Chest x-ray b. Troponin level c. CT scan d. ECG

D Rationale: The priority for the patient is to determine whether an AMI is occurring so that reperfusion therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion. Troponin levels will increase after about 3 hours. Data from the CT scan and chest x-ray may impact the patient's care but are not helpful in determining whether the patient is experiencing an MI. Cognitive Level: Application Text Reference: p. 805 Nursing Process: Implementation

Physiological Integrity 2. When needing to estimate the ventricular rate quickly for a patient with a regular heart rhythm using an ECG strip, the nurse will a. print a 1-minute ECG strip and count the number of QRS complexes. b. count the number of large squares in the R-R interval and divide by 300. c. calculate the number of small squares between one QRS complex and the next and divide into 1500. d. use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.

D Rationale: This is the quickest way to determine the ventricular rate for a patient with a regular rhythm. All the other methods take longer. Cognitive Level: Comprehension Text Reference: pp. 843, 845 Nursing Process: Assessment

Physiological Integrity 31. When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse? a. Heart rate 102 beats/min b. Pedal pulses 1+ bilaterally c. Blood pressure 103/54 mm Hg d. Chest pain level 7 on a 0 to 10 point scale

D The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse. DIF: Cognitive Level: Apply (application) REF: 746 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:

After the nurse teaches a patient with chronic stable angina about how to use the prescribed short-acting and long-acting nitrates, which statement by the patient indicates that the teaching has been effective? A) a. "I will put on the nitroglycerin patch as soon as I develop any chest pain." B) b. "I will check the pulse rate in my wrist just before I take any nitroglycerin." C) c. "I will be sure to remove the nitroglycerin patch before using any sublingual nitroglycerin." D) d. "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue."

D) d. "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue."

The nurse has received change-of-shift report about the following patients on the telemetry unit. Which patient should the nurse see first? A. A patient with atrial fibrillation, rate 88, who has a new order for warfarin (Coumadin) B. A patient with type 1 second-degree atrioventricular (AV) block, rate 60, who is dizzy when ambulating C. A patient who is in a sinus rhythm, rate 98, after having electrical cardioversion 2 hours ago D. A patient whose implantable cardioverter-defibrillator (ICD) fired three times today who has a dose of amiodarone (Cordarone) due

D. A patient whose implantable cardioverter-defibrillator (ICD) fired three times today who has a dose of amiodarone (Cordarone) due The frequent firing of the ICD indicates that the patient's ventricles are very irritable, and the priority is to assess the patient and administer the amiodarone. The other patients may be seen after the amiodarone is administered.

When analyzing the waveforms of a patient's electrocardiogram (ECG), the nurse will need to investigate further upon finding a A. T wave of 0.16 second. B. P-R interval of 0.18 second. C. Q-T interval of 0.34 second. D. QRS interval of 0.14 second.

D. QRS interval of 0.14 second. Because the normal QRS interval is 0.04 to 0.10 seconds, the patient's QRS interval of 0.14 seconds indicates that the conduction through the ventricular conduction system is prolonged. The P-R interval, Q-T interval, and T wave interval are within the normal range.

A patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. The nurse should notify the health care provider and: A. elevate the left leg on a pillow. B. apply an elastic wrap to the leg. C. assist the patient in gently exercising the leg. D. keep the patient in bed in the supine position.

D. keep the patient in bed in the supine position. Sounds like an acute arterial ischemia. The six Ps: pain, pallor, paralysis, pulselessness, paresthesia, and poikilothermic (most often cool). Without immediate intervention it could lead to tissue necrosis and gangrene.

A patient is prescribed Quinidex for treatment of moderate depression of depolarization. The nurse knows to assess for the drugs' effectiveness, which can be evidenced by which of the following?

Decrease in cardiac contractility

The nurse is caring for a client who is displaying a third-degree AV block on the EKG monitor. The client is symptomatic due to the slow heart rate. The most appropriate nursing diagnosis for this client would be which of the following?

Decreased cardiac output

After observing a code blue situation, a nursing student asks a member of the code team what the treatment of choice is for witnessed ventricular fibrillation. The best response by the nurse is which of the following?

Defibrillation

Cardioversion is used to terminate dysrhythmias. With cardioversion, the:

Defibrillator should be set to deliver a shock during the QRS complex.

You are caring for a client who has premature ventricular contractions. What sign or symptom is observed in this client?

Fluttering/heart skipping

A patient with hyperlipidemia has a new order for the bile-acid sequestrant medication colesevelam (Welchol). Which nursing action is appropriate when giving the medication?

Give the patient's other medications 2 hours after the Welchol.

Heart rate increases from 66 to 90 beats/min.

A patient experiences a faster-than-normal heart rate when she drinks more than two cups of coffee in the morning. The nurse knows that an indicator of sinus tachycardia on an ECG would be which of the following?

Heart rate of 118 bpm

Sam, a retired professional NFL player, visits his cardiologist for his annual physical. The nurse takes an ECG and notices an abnormal finding. However, the nurse realizes that this result can be normal when present without symptoms. This finding is a:

Heart rate of 42 beats per minute (bpm).

A patient's sinus rhythm rate is 62. The PR interval is 0.18 seconds at 1:00 AM, 0.20 seconds at 12:30 PM, and 0.23 seconds at 4:00 PM. Which action should the nurse take?

Hold the ordered metoprolol (Lopressor) and call the health care provider.

Which of the following is a potential cause of premature ventricular complexes (PVCs)?

Hypokalemia

While assessing a client, the nurse finds a heart rate of 120 beats per minute. The nurse recalls that causes of sinus tachycardia include which of the following?

Hypovolemia and fever

A client has a medical diagnosis of an advanced AV block and is symptomatic due to a slow heart rate. With what initial treatment(s) should the nurse be prepared to assist?

IV bolus of atropine or temporary pacing

The nurse is aware that parasympathetic stimulation and certain medications can cause first-degree AV block. Choose the medication that should be evaluated.

Inderal

A 63-year-old client is in the cardiac step-down unit where you practice nursing. In your discussions about his condition, the client is puzzled as to what causes the heart to be an effective pump. Which of the following statements would you include in your response?

Inherent rhythmicity of cardiac muscle tissue

Which of the following nursing interventions is required to prepare a patient with cardiac dysrhythmia for an elective electrical cardioversion?

Instruct the patient to restrict food and oral intake

The staff educator is teaching a class in dysrhythmias. What statement is correct for defibrillation?

It is used to eliminate ventricular dysrhythmias.

A nurse is assessing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats per minute. The nurse assesses the cardiac rhythm as: A. Normal sinus rhythm B. Sinus bradycardia C. Sick sinus syndrome D. First-degree heart block.

NORMAL SINUS RHYTHM 1. measurements are normal, measuring 0.12 to 0.20 second and 0.4 to 0.10 second, respectively.

The nurse is analyzing a 6-second electrocardiogram (ECG) tracing. The P waves and QRS complexes are regular. The PR interval is 0.18 seconds long, and the QRS complexes are 0.08 seconds long. The heart rate is calculated at 70 bpm. The nurse correctly identifies this rhythm as which of the following?

Normal sinus rhythm

A patient develops sinus bradycardia at a rate of 32 beats/min, has a BP of 80/36 mm Hg, and is complaining of feeling faint. Which action should the nurse take?

Obtain and apply the transcutaneous pacemaker (TCP).

A patient who is complaining of a "racing" heart and nervousness comes to the emergency department. The patient's blood pressure (BP) is 102/68. The nurse places the patient on a cardiac monitor and obtains the following ECG tracing. Which action should the nurse take next?

Obtain further information about possible causes for the heart rate.

To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform?

P wave

Which of the following tends to be prolonged on the electrocardiogram (ECG) during a first-degree atrioventricular (AV) block?

PR interval

Two days after discharge following a permanent pacemaker insertion, the client returns to the clinic for a follow-up appointment. He reports tenderness and throbbing around the incision. The nurse observes mild swelling, erythema, and warmth at the site and suspects which of the following:

Pacemaker site infection

The nurse is assessing vital signs in a patient with a permanent pacemaker. What should the nurse document about the pacemaker?

Pacer rate

Which electrocardiographic (ECG) change will be of most concern to the nurse when admitting a patient with chest pain?

ST-segment elevation

A patient comes to the emergency department with complaints of chest pain after using cocaine. The nurse assesses the patient and obtains vital signs with results as follows: blood pressure 140/92, heart rate 128, respiratory rate 26, and an oxygen saturation of 98%. What rhythm on the monitor does the nurse anticipate viewing?

Sinus tachycardia

John, an 82-year-old retired librarian is brought into the ED where you practice nursing. The client's heart rate is greater than 155 beats/minute. As you connect him to the ECG, you notice that his rhythm is regular, rate is 162 beats/minute, and diastole is shortened. He is intermittently alert and reports chest pain. P waves cannot be identified. What condition would you expect the physician to diagnose?

Supraventricular tachycardia

The nurse is taking a health history from a 24-year-old patient with hypertrophic cardiomyopathy (HC); which information obtained by the nurse is most relevant?

The patient's 29-year-old brother has had a sudden cardiac arrest.

The nurse has obtained this rhythm strip from her patient's monitor: rate 110, normal PQRS. Which description of this ECG is correct? A. Sinus tachycardia B. Sinus bradycardia C. Ventricular fibrillation D. Ventricular tachycardia

This rhythm strip shows sinus tachycardia because the rate on this strip is above 101, and it displays normal P wave, PR interval, and QRS complex. Sinus bradycardia would look similar to sinus tachycardia but with a rate less than 60 beats per minute. Ventricular fibrillation does not have a measureable heart rate, PR interval, or QRS, and the P wave is not visible and the rhythm is irregular and chaotic. Ventricular tachycardia has a rate of 150 to 250 beats/minutes, with a regular or irregular rhythm and P waves occurring independently of the QRS complex.

Your patient is experiencing asymptomatic sinus tachycardia with a rate of 118. The nurse understands that the treatment of this condition includes:

Treating the underlying cause

Troponin levels

A patient with hypertension has a newly diagnosed atrial fibrillation. What medication does the nurse anticipate administering to prevent the complication of atrial thrombi?

Warfarin (Coumadin)

When caring for a patient who has survived a sudden cardiac death (SCD) event and has no evidence of an AMI, the nurse will anticipate teaching the patient _______________

about the purpose of outpatient Holter monitoring.

A patient admitted to the coronary care unit (CCU) with an MI and frequent premature ventricular contractions (PVCs) has health care provider orders for continuous amiodarone infusion, IV nitroglycerin infusion, and morphine sulfate 2 mg IV every 10 minutes until there is relief of pain. The patient says, "This is the worst pain I have ever had. Am I going to die?" Based on these data, the nurse identifies a priority nursing diagnosis of ___________________

acute pain related to myocardial ischemia.

The nurse reviews data from the cardiac monitor indicating that a patient with a myocardial infarction experienced a 50-second episode of ventricular tachycardia before a sinus rhythm and a heart rate of 98 were re-established. The most appropriate initial action by the nurse is to ________________

administer IV antidysrhythmic drugs per protocol.

A client with second-degree atrioventricular heart block is admitted to the coronary care unit. The nurse closely monitors the client's heart rate and rhythm. When interpreting the client's electrocardiogram (ECG) strip, the nurse knows that the QRS complex represents:

ventricular depolarization.

visualize any coronary artery blockages and dilate any obstructed arteries.

The nurse is monitoring the ECGs of several patients on a cardiac telemetry unit. The patients are directly visible to the nurse, and all of the patients are observed to be sitting up and talking with visitors. Which patient's rhythm would require the nurse to take immediate action? A. A 62-year-old man with a fever and sinus tachycardia with a rate of 110 beats/minute B. A 72-year-old woman with atrial fibrillation with 60 to 80 QRS complexes per minute C. A 52-year-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute D. A 42-year-old woman with first-degree AV block and sinus bradycardia at a rate of 56 beats/minute

C. Frequent premature ventricular contractions (PVCs) (greater than 1 every 10 beats) may reduce the cardiac output and precipitate angina and heart failure, depending on their frequency. Because PVCs in CAD or acute MI indicate ventricular irritability, the patient's physiologic response to PVCs must be monitored. Frequent PVCs most likely must be treated with oxygen therapy, electrolyte replacement, or antidysrhythmic agents.

When computing a heart rate from the ECG tracing, the nurse counts 15 of the small blocks between the R waves of a patient whose rhythm is regular. From these data, the nurse calculates the patient's heart rate to be A. 60 beats/min. B. 75 beats/min. C. 100 beats/min. D. 150 beats/min.

C. Since each small block on the ECG paper represents 0.04 seconds, 1500 of these blocks represents 1 minute. By dividing the number of small blocks (15, in this case) into 1500, the nurse can calculate the heart rate in a patient whose rhythm is regular (in this case, 100).

Safe and Effective Care Environment 23. A patient who is on the progressive care unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first? a. Obtain a 12-lead electrocardiogram (ECG). b. Notify the health care provider of the change in rhythm. c. Give supplemental O2 at 2 to 3 L/min via nasal cannula. d. Assess the patient's vital signs including oxygen saturation.

C Because this patient has dyspnea and chest pain in association with the new rhythm, the nurse's initial actions should be to address the patient's airway, breathing, and circulation (ABC) by starting with oxygen administration. The other actions also are important and should be implemented rapidly. DIF: Cognitive Level: Apply (application) REF: 793 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

A patient is admitted to the ED after an episode of severe chest pain, and the physician schedules the patient for coronary angiography and possible percutaneous coronary intervention (PCI). The nurse prepares the patient for the procedure by explaining that it is used to a. determine whether there are any structural defects in the chambers of the heart. b. locate any coronary artery obstructions and administer thrombolytic agents. c. measure the amount of blood being pumped from the heart with each contraction. d. visualize any coronary artery blockages and dilate any obstructed arteries.

Correct Answer: D Rationale: Visualization of the coronary arteries and possible balloon dilation are scheduled for this patient. Thrombolytic therapy is an alternative treatment if the patient is experiencing acute coronary syndrome (ACS) but is not the ordered therapy for this patient. Although angiography might help to detect structural defects or changes in cardiac output, it is not the reason for the procedure in this patient with symptoms of CAD. Cognitive Level: Application Text Reference: p. 807 Nursing Process: Implementation NCLEX: Physiological Integrity

Which statement best describes the electrical activity of the heart represented by measuring the PR interval on the ECG? A. The length of time it takes to depolarize the atrium B. The length of time it takes for the atria to depolarize and repolarize C. The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers D. The length of time it takes for the electrical impulse to travel from the SA node to the AV node

C. The electrical impulse in the heart must travel from the SA node through the AV node and into the Purkinje fibers in order for synchronous atrial and ventricular contraction to occur. When measuring the PR interval (the time from the beginning of the P wave to the beginning of the QRS), the nurse is identifying the length of time it takes for the electrical impulse to travel from the SA node to the Purkinje fibers. The P wave represents the length of time it takes for the impulse to travel from the SA node through the atrium causing depolarization of the atria (atrial contraction). Atrial repolarization occurs during ventricular depolarization and is hidden by the QRS complex. The length of time it takes for the electrical impulse to travel from the SA node to the AV node is the flat line between the end of the P wave and the beginning of the Q wave on the ECG and is not usually measured.

Which ECG characteristic is consistent with a diagnosis of ventricular tachycardia (VT)? A. Unmeasurable rate and rhythm B. Rate 150 beats/min; inverted P wave C. Rate 200 beats/min; P wave not visible D. Rate 125 beats/min; normal QRS complex

C. VT is associated with a rate of 150 to 250 beats/min; the P wave is not normally visible. Rate and rhythm are not measurable in ventricular fibrillation. P wave inversion and a normal QRS complex are not associated with VT.

Physiological Integrity 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 will prevent or minimize the risk for sudden cardiac death. b. The procedure will use cold therapy to stop the formation of the flutter waves. c. The procedure will use electrical energy to destroy areas of the conduction system. d. The procedure will stimulate the growth of new conduction pathways between the atria.

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. DIF: Cognitive Level: Apply (application) REF: 805 TOP: Nursing Process: Implementation MSC:

Physiological Integrity 6. The nurse obtains a monitor strip on a patient admitted to the coronary care unit with a myocardial infarction and makes the following analysis: P wave not apparent; ventricular rate 162, R-R interval regular; PR interval not measurable; and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as a. sinus tachycardia. b. atrial fibrillation. c. ventricular tachycardia. d. ventricular fibrillation.

C Rationale: The absence of P waves, wide QRS, rate >150, and the regularity of the rhythm indicate ventricular tachycardia. Atrial fibrillation is grossly irregular, has a narrow QRS configuration, and has fibrillatory P waves. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration. Cognitive Level: Application Text Reference: pp. 854-855 Nursing Process: Assessment

Physiological Integrity 21. During the administration of the fibrinolytic agent to a patient with an AMI, the nurse should stop the drug infusion if the patient experiences a. bleeding from the gums. b. surface bleeding from the IV site. c. a decrease in level of consciousness. d. a nonsustained episode of ventricular tachycardia.

C Rationale: The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of fibrinolytic therapy. Bleeding of the gums and prolonged bleeding from IV sites are expected side effects of the therapy. The nurse should address these by avoiding any further injuries, but they are not an indication to stop infusion of the fibrinolytic medication. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective. Cognitive Level: Application Text Reference: p. 808 Nursing Process: Evaluation

Physiological Integrity 16. When admitting a patient for a coronary arteriogram and angiogram, the assessment information that will be most important for the nurse to communicate to the health care provider is that the a. patient had an arteriogram a year ago. b. patient has not eaten anything yet today. c. patient is allergic to shellfish. d. patient's pedal pulses are +1.

C Rationale: The contrast dye used for the procedure is iodine based, so patients who have shellfish allergies will require treatment with medications such as corticosteroids and antihistamines before the arteriogram. The other information is also communicated to the health care provider but will not require a change in the usual pre-arteriogram orders or medications. Cognitive Level: Application Text Reference: p. 755 Nursing Process: Assessment

Physiological Integrity 3. During assessment of a 72-year-old with ankle swelling, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates a. decreased fluid volume. b. incompetent jugular vein valves. c. elevated right atrial pressure. d. jugular vein atherosclerosis.

C Rationale: The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects elevated right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume; it is not caused by incompetent jugular vein valves or atherosclerosis. Cognitive Level: Comprehension Text Reference: p. 825 Nursing Process: Assessment

Physiological Integrity 36. A patient who is being admitted to the emergency department with severe chest pain gives the following list of medications taken at home to the nurse. Which of the medications has the most immediate implications for the patient's care? a. captopril (Capoten) b. furosemide (Lasix) c. sildenafil (Viagra) d. diazepam (Valium)

C Rationale: The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using Viagra because of the risk of sudden death caused by vasodilation. The other home medications should also be documented and reported to the health care provider but do not have as immediate an impact on decisions about the patient's treatment. Cognitive Level: Application Text Reference: p. 817 Nursing Process: Assessment

Physiological Integrity 21. A patient's sinus rhythm rate is 62. The PR interval is 0.18 seconds at 1:00 AM, 0.20 seconds at 12:30 PM, and 0.23 seconds at 4:00 PM. Which action should the nurse take? a. Document the patient's rhythm and continue to monitor. b. Prepare for possible pacemaker insertion. c. Hold the ordered metoprolol (Lopressor) and call the health care provider. d. Give the PRN dose of lidocaine (Xylocaine).

C Rationale: The patient has progressive first-degree AV block, and the -blocker should be held until discussing the medication with the health care provider. Documentation and continued monitoring are not adequate responses because the block is progressively longer. The patient with first-degree AV block is asymptomatic, and a pacemaker is not indicated. Lidocaine is used to suppress ventricular dysrhythmias and is not appropriate to treat heart block. Cognitive Level: Application Text Reference: p. 853 Nursing Process: Implementation

Physiological Integrity 11. The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to a. remove the electrodes when taking a shower or tub bath. b. exercise more than usual while the monitor is in place. c. keep a diary of daily activities while the monitor is worn. d. connect the recorder to a telephone transmitter once daily.

C Rationale: The patient is instructed to keep a diary describing daily activities while Holter monitoring is being accomplished to help correlate any rhythm disturbances with patient activities. Patients are taught that they should not take a shower or bath during Holter monitoring and that they should continue with their usual daily activities. The recorder stores the information about the patient's rhythm until the end of the testing, when it is removed and the data are analyzed. Cognitive Level: Application Text Reference: pp. 753, 757 Nursing Process: Implementation

Physiological Integrity 6. Which electrocardiographic (ECG) change will be of most concern to the nurse when admitting a patient with chest pain? a. Sinus tachycardia b. Inverted T wave c. ST-segment elevation d. Frequent PACs

C Rationale: The patient is likely to be experiencing an ST-segment-elevation myocardial infarction (STEMI) and immediate therapy with PCI or fibrinolytic medications is indicated to minimize the amount of myocardial damage. The other ECG changes also suggest a need for therapy, but not as rapidly. Cognitive Level: Application Text Reference: p. 802 Nursing Process: Assessment

Physiological Integrity 23. Three days after an MI, the patient develops chest pain that radiates to the back and left arm and is relieved by sitting in a forward position. On auscultation of the patient's chest, the nurse would expect to hear a a. splitting of the S1 heart sound. b. S3 or S4 gallop rhythm. c. pericardial friction rub. d. holosystolic apical murmur.

C Rationale: The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient's symptoms. Cognitive Level: Application Text Reference: p. 805 Nursing Process: Assessment

Psychosocial Integrity 16. A patient who has been successfully resuscitated after developing ventricular fibrillation asks the nurse about what happened. The most appropriate response by the nurse is, a. "You almost died, but we were able to save you with electrical therapy." b. "You had an episode of some cardiac dysrhythmias that are common after a heart attack." c. "You had a serious abnormal heart rhythm, which treatment was able to reverse." d. "Your heart stopped beating, and we shocked you to get it started again."

C Rationale: This response honestly describes what happened to the patient while avoiding unnecessarily increasing the patient's anxiety level. More information may be given by the nurse if the patient asks further questions. The response "You had an episode of some cardiac dysrhythmias that are common after a heart attack" is not as honest and might lead to distrust of the nurse or health care system. The remaining two responses are accurate but would increase the anxiety level for many patients. Cognitive Level: Application Text Reference: p.855 Nursing Process: Implementation

Physiological Integrity 20. A patient with supraventricular tachycardia (SVT) is hemodynamically stable and requires cardioversion. The nurse will plan to a. turn the synchronizer switch to the "off" position. b. set the level of joules to 300 to convert the SVT. c. administer a sedative before the procedure is begun. d. check the incision for bleeding after the procedure.

C Rationale: When a patient has a non-emergency cardioversion, sedation is used just before the procedure. The synchronizer switch is turned on for cardioversion. A low level of joules (e.g., 50) is first selected for cardioversion. There is no incision after cardioversion. Cognitive Level: Application Text Reference: p. 857 Nursing Process: Implementation

Cardioversion is attempted for a 64-year-old man with atrial flutter and a rapid ventricular response. After the nurse delivers 50 joules by synchronized cardioversion, the patient develops ventricular fibrillation. Which action should the nurse take immediately? A. Administer 250 mL of 0.9% saline solution IV by rapid bolus. B. Assess the apical pulse, blood pressure, and bilateral neck vein distention. C. Turn the synchronizer switch to the "off" position and recharge the device. D. Tell the patient to report any chest pain or discomfort and administer morphine sulfate.

C. Ventricular fibrillation produces no effective cardiac contractions or cardiac output. If during synchronized cardioversion the patient becomes pulseless or the rhythm deteriorates to ventricular fibrillation, the nurse should turn the synchronizer switch off and initiate defibrillation. Fluids, additional assessment, or treatment of pain alone will not restore an effective heart rhythm.

A patient with dilated cardiomyopathy has an atrial fibrillation that has been unresponsive to drug therapy for several days. The nurse anticipates that the patient may need teaching about A. electrical cardioversion. B. IV adenosine (Adenocard). C. anticoagulant therapy with warfarin (Coumadin). D. Incorrect insertion of an implantable cardioverter-defibrillator (ICD).

C. anticoagulant therapy with warfarin (Coumadin). 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. Adenosine is not used to treat atrial fibrillation. Cardioversion may be done after several weeks of Coumadin therapy. ICDs are used for patients with recurrent ventricular fibrillation.

Physiological Integrity 16. During the administration of the thrombolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences a. bleeding from the gums. b. increase in blood pressure. c. a decrease in level of consciousness. d. a nonsustained episode of ventricular tachycardia.

C The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of thrombolytic therapy. Some bleeding of the gums is an expected side effect of the therapy but not an indication to stop infusion of the thrombolytic medication. A decrease in blood pressure could indicate internal bleeding. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective. DIF: Cognitive Level: Apply (application) REF: 752 TOP: Nursing Process: Evaluation MSC:

A patient has had an implantable cardioverter defibrillator inserted. What should the nurse be sure to include in the education of this patient prior to discharge? (Select all that apply.)

Call for emergency assistance if feeling dizzy. Avoid magnetic fields such as metal detection booths. Record events that trigger a shock sensation.

The nurse administers IV nitroglycerin to a patient with an MI. In evaluating the effect of this intervention, the nurse should monitor for a. relief of chest discomfort. b. a decreased heart rate. c. an increase in BP. d. fewer cardiac dysrhythmias.

Correct Answer: A Rationale: The goal of IV nitroglycerin administration in AMI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. Increases in heart rate and a drop in BP are common side effects of nitroglycerin. Nitroglycerin does not directly impact cardiac dysrhythmias. Cognitive Level: Application Text Reference: pp. 806, 808 Nursing Process: Evaluation NCLEX: Physiological Integrity

A patient is receiving fibrinolytic therapy 2 hours after developing an AMI. Which assessment information will be of most concern to the nurse? a. No change in the patient's chest pain b. A large bruise at the patient's IV insertion site c. A decrease in ST-segment elevation on the ECG d. An increase in cardiac enzyme levels since admission

Correct Answer: A Rationale: The ongoing chest pain indicates continued myocardial injury and necrosis. The nurse should notify the physician. Bruising is a possible side effect of fibrinolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST-segment elevation indicates that fibrinolysis is occurring and perfusion is returning to the injured myocardium. An increase in cardiac enzyme levels is expected even with reperfusion. Cognitive Level: Application Text Reference: p. 808 Nursing Process: Evaluation NCLEX: Physiological Integrity

Physiological Integrity 35. The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? a. The troponin level is elevated. b. The patient denies ever having a heart attack. c. Bilateral crackles are auscultated in the mid-lower lobes. d. The patient has occasional premature atrial contractions (PACs).

C The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors for the patient. Elevation in troponin level at this time is expected. PACs are not life-threatening dysrhythmias. Denial is a common response in the immediate period after the MI. DIF: Cognitive Level: Apply (application) REF: 748 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:

Safe and Effective Care Environment 28. A patient reports dizziness and shortness of breath for several days. During cardiac 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).

C The inconsistency between the atrial and ventricular rates and the variable P-R interval indicate that the rhythm is third-degree AV block. Sinus rhythm with PACs will have a normal rate and consistent P-R intervals with occasional PACs. An accelerated idioventricular rhythm will not have visible P waves. DIF: Cognitive Level: Apply (application) REF: 798 TOP: Nursing Process: Assessment MSC:

An outpatient who has developed heart failure after having an acute myocardial infarction has a new prescription for carvedilol (Coreg). After 2 weeks, the patient returns to the clinic. The assessment finding that will be of most concern to the nurse is that the patient a. has BP of 88/42. b. has an apical pulse rate of 56. c. complains of feeling tired. d. has 2+ pedal edema.

Correct Answer: A Rationale: The patient's BP indicates that the dose of carvedilol may need to be decreased because the mean arterial pressure is only 57. Bradycardia is a frequent adverse effect of β-Adrenergic blockade, but the rate of 56 is not as great a concern as the hypotension. β-adrenergic blockade will initially worsen symptoms of heart failure in many patients, and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs. Cognitive Level: Application Text Reference: p. 832 Nursing Process: Assessment NCLEX: Analysis

A patient who has had severe chest pain for the last 4 hours is admitted with a diagnosis of possible AMI. Which of these ordered laboratory tests should the nurse monitor to help determine whether the patient has had an MI? a. Troponin levels b. C-reactive protein c. High-density lipoprotein (HDL) cholesterol d. Homocysteine

Correct Answer: A Rationale: Troponin levels increase about 3 hours after the onset of MI. The other laboratory data are useful in determining the patient's risk for developing CAD but are not helpful in determining whether an acute MI is in progress. Cognitive Level: Application Text Reference: pp. 805-806 Nursing Process: Assessment NCLEX: Physiological Integrity

Two days after having an MI, a patient tells the nurse, "I wish I had died when I had this heart attack. I won't be able to do anything now." The most appropriate nursing diagnosis is a. ineffective coping related to depression and anxiety. b. situational low self-esteem related to perceived role changes. c. impaired adjustment related to unwillingness to alter lifestyle. d. ineffective health maintenance related to lack of knowledge.

Correct Answer: B Rationale: The patient's statements indicate that the perceived change in role is the major concern. The patient is experiencing progression through the normal stages of loss and grief that often occur after an MI, so ineffective coping is not an appropriate diagnosis. There is no evidence to support an unwillingness to alter lifestyle or ineffective health maintenance.

Physiological Integrity 29. 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 oxygen saturation. d. Prepare to give a -blocker medication to slow the heart rate.

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 -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. DIF: Cognitive Level: Analyze (analysis) REF: 793 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Safe and Effective Care Environment 30. Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain? a. Inverted P wave b. Sinus tachycardia c. ST-segment elevation d. First-degree atrioventricular block

C The patient is likely to be experiencing an ST-segment-elevation myocardial infarction (STEMI). Immediate therapy with percutaneous coronary intervention (PCI) or thrombolytic medication is indicated to minimize myocardial damage. The other ECG changes may also suggest a need for therapy, but not as rapidly. DIF: Cognitive Level: Apply (application) REF: 747-748 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:

The nurse has just received change-of-shift report about these four patients. Which patient should the nurse assess first? a. A 38-year-old who has pericarditis and is complaining of sharp, stabbing chest pain b. A 45-year-old who had an MI 4 days ago and is anxious about the planned discharge c. A 51-year-old who has just returned to the unit after a coronary arteriogram and PCI d. A 60-year-old who has a scheduled dose of atenolol (Tenormin) 25 mg PO due

Correct Answer: C Rationale: After PCI, the patient is at risk for bleeding from the arterial access site for the PCI, so the nurse should assess the patient immediately. The other patients also should be assessed as quickly as possible, but assessment of this patient has the highest priority. Cognitive Level: Application Text Reference: p. 807 Nursing Process: Assessment NCLEX: Physiological Integrity

While admitting a patient with an AMI, which action should the nurse carry out first? a. Assess peripheral pulses. b. Check the oxygen saturation. c. Attach the cardiac monitor. d. Obtain the BP.

Correct Answer: C Rationale: Because dysrhythmias are the most common complication of MI, the first action should be to place the patient on a cardiac monitor. The other actions are also important and should be accomplished as quickly as possible. Cognitive Level: Application Text Reference: pp. 799, 806 Nursing Process: Implementation NCLEX: Physiological Integrity

Physiological Integrity 17. A patient is recovering from a myocardial infarction (MI) and develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next? a. Assess the feet for pedal edema. b. Palpate the radial pulses bilaterally. c. Auscultate for a pericardial friction rub. d. Check the heart monitor for dysrhythmias.

C The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient's symptoms. DIF: Cognitive Level: Apply (application) REF: 749 TOP: Nursing Process: Implementation MSC:

A patient with a non-ST segment elevation myocardial infarction (NSTEMI) is receiving heparin. What is the purpose of the heparin? a. Heparin will dissolve the clot that is blocking blood flow to the heart. b. Coronary artery plaque size and adherence are decreased with heparin. c. Heparin will prevent the development of clots in the coronary arteries. d. Platelet aggregation is enhanced by IV heparin infusion.

Correct Answer: C Rationale: Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation. Cognitive Level: Comprehension Text Reference: p. 800 Nursing Process: Implementation NCLEX: Physiological Integrity

During the administration of the fibrinolytic agent to a patient with an AMI, the nurse should stop the drug infusion if the patient experiences a. bleeding from the gums. b. surface bleeding from the IV site. c. a decrease in level of consciousness. d. a nonsustained episode of ventricular tachycardia.

Correct Answer: C Rationale: The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of fibrinolytic therapy. Bleeding of the gums and prolonged bleeding from IV sites are expected side effects of the therapy. The nurse should address these by avoiding any further injuries, but they are not an indication to stop infusion of the fibrinolytic medication. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective. Cognitive Level: Application Text Reference: p. 808 Nursing Process: Evaluation NCLEX: Physiological Integrity

Three days after an MI, the patient develops chest pain that radiates to the back and left arm and is relieved by sitting in a forward position. On auscultation of the patient's chest, the nurse would expect to hear a a. splitting of the S1 heart sound. b. S3 or S4 gallop rhythm. c. pericardial friction rub. d. holosystolic apical murmur.

Correct Answer: C Rationale: The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient's symptoms. Cognitive Level: Application Text Reference: p. 805 Nursing Process: Assessment NCLEX: Physiological Integrity

Following an AMI, a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response, which of these assessment data would indicate that the exercise level should be decreased? a. BP rises from 118/60 to 126/68 mm Hg. b. Respiratory rate goes from 14 to 22 breaths/min. c. Oxygen saturation drops from 100% to 98%. d. Heart rate increases from 66 to 90 beats/min.

Correct Answer: D Rationale: A change in heart rate of more than 20 beats or more indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in oxygen saturation, are normal responses to exercise. Cognitive Level: Application Text Reference: pp. 815-816 Nursing Process: Evaluation NCLEX: Physiological Integrity

Physiological Integrity 14. A patient with ST-segment elevation in three contiguous electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? a. "Do you have any allergies?" b. "Do you take aspirin on a daily basis?" c. "What time did your chest pain begin?" d. "Can you rate your chest pain using a 0 to 10 scale?"

C Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction (MI), so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information will also be needed, but it will not be a factor in the decision about thrombolytic therapy. DIF: Cognitive Level: Apply (application) REF: 743 TOP: Nursing Process: Assessment MSC:

Physiological Integrity 26. Which nursing action can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) working as a telemetry technician on the cardiac care unit? a. Decide whether a patient's heart rate of 116 requires urgent treatment. b. Monitor a patient's level of consciousness during synchronized cardioversion. c. Observe cardiac rhythms for multiple patients who have telemetry monitoring. d. Select the best lead for monitoring a patient admitted with acute coronary syndrome.

C UAP serving as telemetry technicians can monitor cardiac 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. DIF: Cognitive Level: Analyze (analysis) REF: 15 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

Following an acute myocardial infarction, a previously healthy 67-year-old patient develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about a. digitalis preparations, such as digoxin (Lanoxin). b. calcium-channel blockers, such as diltiazem (Cardizem). c. β-adrenergic agonists, such as dobutamine (Dobutrex). d. angiotensin-converting enzyme (ACE) inhibitors, such as captopril (Capoten).

Correct Answer: D Rationale: ACE-inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other medications such as ACE-inhibitors, diuretics, and β-adrenergic blockers is insufficient. Calcium-channel blockers are not generally used in the treatment of heart failure. The β-adrenergic agonists such as dobutamine are administered through the IV route and are not used as initial therapy for heart failure. Cognitive Level: Application Text Reference: p. 832 Nursing Process: Implementation NCLEX: Physiological Integrity

the nurse is admitting a patient who is complaining of chest pain to the emergency department (ED). Which information collected by the nurse suggests that the pain is caused by an acute myocardial infarction (AMI)? a. The pain worsens when the patient raises the arms. b. The pain increases with deep breathing. c. The pain is relieved after the patient takes nitroglycerin. d. The pain has persisted longer than 30 minutes.

Correct Answer: D Rationale: Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of pericarditis or musculoskeletal pain. Stable angina is usually relieved when the patient takes nitroglycerin. Cognitive Level: Application Text Reference: p. 803 Nursing Process: Assessment NCLEX: Physiological Integrity

Heparin is prescribed for a patient who has dilated cardiomyopathy has been admitted to the hospital with fatigue and orthopnea. Which statement is appropriate for the nurse to use in patient teaching about anticoagulation therapy?

"Heparin will help prevent blood clots from forming in your heart chambers."

Which of these statements made by a patient after the nurse has completed teaching about the TLC diet indicates that further teaching is needed?

"I will miss being able to eat peanut butter sandwiches."

"I won't lift the arm on the pacemaker side up very high until I see the doctor."

A patient is being examined for medical management of atrial flutter. The nurse reviews the ECG strip. He expects to see which of the following?

"Sawtooth" pattern to the waveform

After having an AMI, a 62-year-old patient tells the nurse, "I guess having sex again will be too hard on my heart." The nurse's best response is ______________

"Sexual activity can be gradually resumed like other activity. A good comparison of energy expenditure is climbing two flights of stairs."

The nurse is caring for a client who had a permanent pacemaker surgically placed yesterday and is now ready for discharge. Which statement made by the client indicates the need for more education.

"We will be getting rid of our microwave oven so it will not affect my pacemaker."

A patient who has been successfully resuscitated after developing ventricular fibrillation asks the nurse about what happened. The most appropriate response by the nurse is, _____________

"You had a serious abnormal heart rhythm, which treatment was able to reverse."

The nurse is caring for a client who is being discharged after insertion of a permanent pacemaker. The client, an avid tennis player, is scheduled to play in a tournament in 1 week. What is the best advice the nurse can give related to this activity?

"You will need to cancel this activity; you must restrict arm movement above your head for 2 weeks."

The nurse is caring for a client with atrial fibrillation. The client's symptoms started about 1 week ago, but he is just now seeking medical attention. The client asks the nurse why he has to wait several weeks before the cardioversion takes place. The best answer by the nurse is which of the following?

"Your atrial chambers may contain blood clots now, so you must take an anticoagulant for a few weeks before the cardioversion."

After taking an ECG on a 38-year-old woman, the nurse reports that the PR interval reflects normal sinus rhythm. The nurse has made this interpretation based on the PR interval of:

0.12 and 0.2 seconds.

When a patient requires defibrillation, in which order will the nurse accomplish the following steps?

1 Turn the defibrillator on. 2 Select the appropriate energy level 3 Place the paddles on the patient's chest. 4 Check the location of other personnel and call out "all clear." 5 Deliver the electrical charge.

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Check all that apply. 1. The RR intervals are relatively consistent 2. One P wave precedes each QRS complex 3. Four to eight complexes occur in a 6 second strip 4. The ST segment is higher than the PR interval 5. The QRS complex ranges from 0.12 to 0.20 second.

1, 2. The consistency of the RR interval indicates regular rhythm. A normal P wave before each complex indicates the impulse originated in the SA node. The number of complexes in a 6 second strip is multiplied by 10 to approximate the heart rate; normal sinus rhythm is 60 to 100. Elevation of the ST segment is a sign of cardiac ischemia and is unrelated to the rhythm. The QRS duration should be less than 0.12 second; the PR interval should be 0.12 to 0.20 second.

A client with rapid rate atrial fibrillation asks a nurse why the physician is going to perform carotid massage. The nurse responds that this procedure may stimulate the: 1. Vagus nerve to slow the heart rate 2. Vagus nerve to increase the heart rate; overdriving the rhythm. 3. Diaphragmic nerve to slow the heart rate 4. Diaphragmic nerve to overdrive the rhythm

1. Carotid sinus massage is one of the maneuvers used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The others include inducing the gag reflex and asking the client to strain or bear down. Medication therapy often is needed as an adjunct to keep the rate down or maintain the normal rhythm.

A client is having frequent premature ventricular contractions. A nurse would place priority on assessment of which of the following items? 1. Blood pressure and peripheral perfusion 2. Sensation of palpitations 3. Causative factors such as caffeine 4. Precipitating factors such as infection

1. Premature ventricular contractions can cause hemodynamic compromise. The shortened ventricular filling time with the ectopic beats leads to decreased stroke volume and, if frequent enough, to decreased cardiac output. The client may be asymptomatic or may feel palpations. PVCs can be caused by cardiac disorders or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by the intake of caffeine, alcohol, or nicotine.

A nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead there are wavy lines. The QRS complexes measure 0.08 second, but they are irregular, with a rate of 120 beats a minute. The nurse interprets this rhythm as: 1. Sinus tachycardia 2. Atrial fibrillation 3. Ventricular tachycardia 4. Ventricular fibrillation

2. Atrial fibrillation is characterized by a loss of P waves; an undulating, wavy baseline; QRS duration that is often within normal limits; and an irregular ventricular rate, which can range from 60 to 100 beats per minute (when controlled with medications) to 100 to 160 beats per minute (when uncontrolled).

While caring for a client who has sustained an MI, the nurse notes eight PVCs in one minute on the cardiac monitor. The client is receiving an IV infusion of D5W and oxygen at 2 L/minute. The nurse's first course of action should be to: 1. Increase the IV infusion rate 2. Notify the physician promptly 3. Increase the oxygen concentration 4. Administer a prescribed analgesic

2. PVCs are often a precursor of life-threatening dysrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than 5 or 6 per minute in the post MI client, the physician should be notified immediately. More than 6 PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability.

A nurse notices frequent artifact on the ECG monitor for a client whose leads are connected by cable to a console at the bedside. The nurse examines the client to determine the cause. Which of the following items is unlikely to be responsible for the artifact? 1. Frequent movement of the client 2. Tightly secured cable connections 3. Leads applied over hairy areas 4. Leads applied to the limbs

2. Tightly secured cable connections. Motion artifact, or "noise," can be caused by frequent client movement, electrode placement on limbs, and insufficient adhesion to the skin, such as placing electrodes over hairy areas of the skin. Electrode placement over bony prominence's also should be avoided. Signal interference can also occur with electrode removal and cable disconnection.

A 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 or definable QRS complexes. Instead there are coarse wavy lines of varying amplitude. The nurse assesses this rhythm to be: 1. Ventricular tachycardia 2. Ventricular fibrillation 3. Atrial fibrillation 4. Asystole

2. 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.

A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but over 100. The nurse determines that the client is experiencing: 1. Premature ventricular contractions 2. Ventricular tachycardia 3. Ventricular fibrillation 4. Sinus tachycardia

2. Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (usually greater than 0.14 second), and a rate between 100 and 250 impulses per minute. The rhythm is usually regular.

A nurse is viewing the cardiac monitor in a client's room and notes that the client has just gone into ventricular tachycardia. The client is awake and alert and has good skin color. The nurse would prepare to do which of the following? 1. Immediately defibrillate 2. Prepare for pacemaker insertion 3. Administer amiodarone (Cordarone) intravenously 4. Administer epinephrine (Adrenaline) intravenously

3. First-line treatment of ventricular tachycardia in a client who is hemodynamically stable is the use of anti-dysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm (cardioversion is recommended for stable ventricular tachycardia). Defibrillation is used with pulseless ventricular tachycardia. Epinephrine would stimulate and already excitable ventricle and is contraindicated.

When auscultating the apical pulse of a client who has atrial fibrillation, the nurse would expect to hear a rhythm that is characterized by: 1. The presence of occasional coupled beats 2. Long pauses in an otherwise regular rhythm 3. A continuous and totally unpredictable irregularity 4. Slow but strong and regular beats

3. In atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions.

The adaptations of a client with complete heart block would most likely include: 1. Nausea and vertigo 2. Flushing and slurred speech 3. Cephalalgia and blurred vision 4. Syncope and low ventricular rate

4. In complete atrioventricular block, the ventricles take over the pacemaker function in the heart but at a much slower rate than that of the SA node. As a result there is decreased cerebral circulation, causing syncope.

Physiological Integrity COMPLETION 1. When analyzing an electrocardiographic (ECG) rhythm strip of a patient with a regular heart rhythm, the nurse counts 30 small blocks from one R wave to the next. The nurse calculates the patient's heart rate as ____.

50 There are 1500 small blocks in a minute, and the nurse will divide 1500 by 30. DIF: Cognitive Level: Remember (knowledge) REF: 789-790 TOP: Nursing Process: Assessment MSC:

When analyzing an ECG rhythm strip of a patient with a regular cardiac rhythm, the nurse finds there are 25 small blocks from one R wave to the next. The nurse calculates the patient's heart rate as ______.

Physiological Integrity COMPLETION 1. When analyzing an ECG rhythm strip of a patient with a regular cardiac rhythm, the nurse finds there are 25 small blocks from one R wave to the next. The nurse calculates the patient's heart rate as ______.

60 Rationale: There are 1500 small blocks in a minute, and the nurse will divide 1500 by 25. Cognitive Level: Comprehension Text Reference: p. 844 Nursing Process: Assessment

A patient is admitted to the emergency department (ED) with complaints of chest pain and shortness of breath. The nurse notes an irregular rhythm on the bedside electrocardiograph (ECG) monitor. The nurse counts 9 RR intervals on the patient's 6-second rhythm tracing. The nurse correctly identifies the patient's heart rate as which of the following?

90 bpm

90bpm

Physiological Integrity 25. Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin? a. Instruct the patient to call for assistance before getting out of bed. b. Explain the association between various dysrhythmias and syncope. c. Educate the patient about the need to avoid caffeine and other stimulants. d. Tell the patient about the benefits of implantable cardioverter-defibrillators.

A A patient with fainting episodes is at risk for falls. The nurse will plan to minimize the risk by having assistance whenever the patient 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. DIF: Cognitive Level: Apply (application) REF: 807 TOP: Nursing Process: Planning MSC:

Safe and Effective Care Environment 27. Which action by a new registered nurse (RN) who is orienting to the progressive care unit indicates a good understanding of the treatment of cardiac dysrhythmias? a. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia b. Obtains the defibrillator and quickly brings it to the bedside of a patient whose monitor shows asystole 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

A Adenosine must be given over 1 to 2 seconds to be effective. The other actions indicate a need for more education about treatment of cardiac dysrhythmias. The RN should hold the diltiazem until talking to the health care provider. The treatment for asystole is immediate CPR. The synchronizer switch should be "off" when defibrillating. DIF: Cognitive Level: Analyze (analysis) REF: 795 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 29. When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Give the scheduled aspirin and lipid-lowering medication. b. Perform the initial assessment of the catheter insertion site. c. Teach the patient about the usual postprocedure plan of care. d. Titrate the heparin infusion according to the agency protocol.

A Administration of oral medications is within the scope of practice for LPNs/LVNs. The initial assessment of the patient, patient teaching, and titration of IV anticoagulant medications should be done by the registered nurse (RN). DIF: Cognitive Level: Apply (application) REF: 758 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

Physiological Integrity 9. A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. The priority teaching needed for this patient would include information about a. anticoagulant therapy. b. permanent pacemakers. c. electrical cardioversion. d. IV adenosine (Adenocard).

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. DIF: Cognitive Level: Apply (application) REF: 796 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC:

Physiological Integrity 8. After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective? a. Increase in the patient's heart rate b. Increase in strength of peripheral pulses c. Decrease in premature atrial contractions d. Decrease in premature ventricular contractions

A Atropine will increase the heart rate and conduction through the AV node. Because the medication increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have premature atrial or ventricular contractions. DIF: Cognitive Level: Apply (application) REF: 798 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 34. Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care provider? a. No change in the patient's chest pain b. An increase in troponin levels from baseline c. A large bruise at the patient's IV insertion site d. A decrease in ST-segment elevation on the electrocardiogram

A Continued chest pain suggests that the thrombolytic therapy is not effective and that other interventions such as percutaneous coronary intervention (PCI) may be needed. Bruising is a possible side effect of thrombolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST-segment elevation indicates that thrombolysis is occurring and perfusion is returning to the injured myocardium. An increase in troponin levels is expected with reperfusion and is related to the washout of cardiac markers into the circulation as the blocked vessel is opened. DIF: Cognitive Level: Apply (application) REF: 752 OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 25. The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would include a. when cardiac rehabilitation will begin. b. the typical emotional responses to AMI. c. information regarding discharge medications. d. the pathophysiology of coronary artery disease.

A Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this time, the patient's anxiety level or denial will interfere with good understanding of complex information such as the pathophysiology of coronary artery disease (CAD). Teaching about discharge medications should be done closer to discharge. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional responses to myocardial infarction (MI). DIF: Cognitive Level: Apply (application) REF: 759-762 TOP: Nursing Process: Planning MSC:

Physiological Integrity 14. A 20-year-old 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, 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 diagnostic 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.

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. DIF: Cognitive Level: Apply (application) REF: 793 TOP: Nursing Process: Implementation MSC:

Physiological Integrity 15. A patient admitted to the coronary care unit (CCU) with an MI and frequent premature ventricular contractions (PVCs) has health care provider orders for continuous amiodarone infusion, IV nitroglycerin infusion, and morphine sulfate 2 mg IV every 10 minutes until there is relief of pain. The patient says, "This is the worst pain I have ever had. Am I going to die?" Based on these data, the nurse identifies a priority nursing diagnosis of a. acute pain related to myocardial ischemia. b. anxiety related to perceived threat of death. c. decreased cardiac output related to cardiogenic shock. d. activity intolerance related to decreased cardiac output.

A Rationale: All the nursing diagnoses may be appropriate for this patient, but the data indicate that the priority diagnosis is pain, a physiologic stressor. The patient's anxiety will also be reduced if the pain is resolved. There are no data indicating that the patient is experiencing cardiogenic shock or activity intolerance. Cognitive Level: Application Text Reference: pp. 806, 811, 813 Nursing Process: Diagnosis

Physiological Integrity 13. The nurse has received the laboratory results for a patient who developed chest pain 2 hours ago and may be having a myocardial infarction. The most important laboratory result to review will be a. troponins T and I. b. creatine kinase-MB. c. LDL cholesterol. d. C-reactive protein.

A Rationale: Cardiac troponins start to elevate 1 hour after myocardial injury and are specific to myocardium. Creatine kinase (CK-MB) is specific to myocardial injury and infarction, but it does not increase until 4 to 6 hours after the infarction occurs. LDL cholesterol and C-reactive protein are useful in assessing cardiovascular risk but are not helpful in determining whether a patient is having an acute myocardial infarction. Cognitive Level: Application Text Reference: pp. 751-752 Nursing Process: Assessment

Physiological Integrity 28. Heparin is prescribed for a patient who has dilated cardiomyopathy has been admitted to the hospital with fatigue and orthopnea. Which statement is appropriate for the nurse to use in patient teaching about anticoagulation therapy? a. "Heparin will help prevent blood clots from forming in your heart chambers." b. "Heparin is used to improve the circulation to the muscles in your arms and legs." c. "Heparin has been prescribed to stop blood clots from traveling to your lungs." d. "Heparin makes it easier for your heart to pump and will decrease your symptoms."

A Rationale: Decreased blood flow through the heart causes blood stasis and the formation of blood clots in the ventricles, which then may embolize. Anticoagulant therapy will not improve circulation to the skeletal muscles. The patient with dilated cardiomyopathy who is inactive may be at risk for deep-vein thrombosis and pulmonary emboli, but this is not the usual reason for anticoagulation. There is no indication in the stem that the patient is immobile. Heparin will not decrease cardiac workload or decrease the patient's fatigue or orthopnea. Cognitive Level: Application Text Reference: p. 886 Nursing Process: Implementation

Physiological Integrity 31. Which of these nursing interventions included in the plan of care for a patient who had an AMI 3 days ago is most appropriate for the RN to delegate to an experienced LPN/LVN? a. Administration of the ordered metoprolol (Lopressor) and aspirin b. Evaluating the patient's response to ambulation in the hallway c. Teaching the patient about the pathophysiology of heart disease d. Completing the documentation for a home health nurse referral

A Rationale: LPN/LVN education and scope of practice include safe administration of medications. Evaluating the patient response to exercise after an AMI requires more education and should be done by the RN. Teaching and discharge planning/documentation are higher level skills that require RN education and scope of practice. Cognitive Level: Application Text Reference: pp. 810-817 Nursing Process: Evaluation

Physiological Integrity 5. A patient has a dysrhythmia that requires careful monitoring of atrial activity. Which lead will be best to use for continuous monitoring? a. MCL1 b. AVF c. V6 d. I

A Rationale: Leads II and MCL1 are the best leads for visualization of P waves, which reflect atrial activity. The other leads are less commonly used for continuous monitoring, since they do not usually demonstrate the P wave and QRS activity as well. Cognitive Level: Application Text Reference: p. 843 Nursing Process: Implementation

Physiological Integrity 18. The nurse administers IV nitroglycerin to a patient with an MI. In evaluating the effect of this intervention, the nurse should monitor for a. relief of chest discomfort. b. a decreased heart rate. c. an increase in BP. d. fewer cardiac dysrhythmias.

A Rationale: The goal of IV nitroglycerin administration in AMI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. Increases in heart rate and a drop in BP are common side effects of nitroglycerin. Nitroglycerin does not directly impact cardiac dysrhythmias. Cognitive Level: Application Text Reference: pp. 806, 808 Nursing Process: Evaluation

Three days after a myocardial infarction (MI), the patient develops chest pain that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next? A) a. Palpate the radial pulses bilaterally. B) b. Assess the feet for peripheral edema. C) c. Auscultate for a pericardial friction rub. D) d. Check the cardiac monitor for dysrhythmias.

C) c. Auscultate for a pericardial friction rub.

Physiological Integrity 11. A patient experiences dizziness and shortness of breath for several days. During cardiac monitoring in the ED, the nurse obtains the following ECG tracing. The nurse interprets this cardiac rhythm as a. third-degree AV block. b. sinus rhythm with premature atrial contractions (PACs). c. sinus rhythm with PVCs. d. junctional escape rhythm.

A Rationale: 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 or PVCs will have a normal rate and consistent PR intervals with occasional PACs or PVCs. A junctional escape rhythm will not have P waves. Cognitive Level: Application Text Reference: p. 854 Nursing Process: Assessment

Physiological Integrity 22. A patient is receiving fibrinolytic therapy 2 hours after developing an AMI. Which assessment information will be of most concern to the nurse? a. No change in the patient's chest pain b. A large bruise at the patient's IV insertion site c. A decrease in ST-segment elevation on the ECG d. An increase in cardiac enzyme levels since admission

A Rationale: The ongoing chest pain indicates continued myocardial injury and necrosis. The nurse should notify the physician. Bruising is a possible side effect of fibrinolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST-segment elevation indicates that fibrinolysis is occurring and perfusion is returning to the injured myocardium. An increase in cardiac enzyme levels is expected even with reperfusion. Cognitive Level: Application Text Reference: p. 808 Nursing Process: Evaluation

Psychosocial Integrity 18. A patient has received instruction on the management of a new permanent pacemaker before discharge from the hospital. The nurse recognizes that teaching has been effective when the patient tells the nurse, a. "I won't lift the arm on the pacemaker side up very high until I see the doctor." b. "I will notify the airlines when I make a reservation that I have a pacemaker." c. "I must avoid cooking with a microwave oven or being near a microwave in use." d. "It will be 6 weeks before I can take a bath or return to my usual activities."

A Rationale: The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The pacemaker rarely sets off an airport security alarm and there is no need to notify the airlines when making a reservation. Microwave oven use does not affect the pacemaker. The insertion procedure involves minor surgery that will have a short recovery period. Cognitive Level: Application Text Reference: p. 861 Nursing Process: Evaluation

Health Promotion and Maintenance 19. An outpatient who has developed heart failure after having an acute myocardial infarction has a new prescription for carvedilol (Coreg). After 2 weeks, the patient returns to the clinic. The assessment finding that will be of most concern to the nurse is that the patient a. has BP of 88/42. b. has an apical pulse rate of 56. c. complains of feeling tired. d. has 2+ pedal edema.

A Rationale: The patient's BP indicates that the dose of carvedilol may need to be decreased because the mean arterial pressure is only 57. Bradycardia is a frequent adverse effect of -Adrenergic blockade, but the rate of 56 is not as great a concern as the hypotension. -adrenergic blockade will initially worsen symptoms of heart failure in many patients, and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs. Cognitive Level: Application Text Reference: p. 832 Nursing Process: Assessment

Physiological Integrity 14. The nurse hears the cardiac monitor alarm and notes that the patient has a cardiac pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious with no pulse or respirations. After calling for assistance, the nurse should a. start basic cardiopulmonary resuscitation (CPR). b. administer an IV bolus dose of epinephrine. c. prepare the patient for endotracheal intubation. d. wait for the defibrillator to arrive.

A Rationale: The patient's rhythm and assessment indicate ventricular fibrillation and cardiac arrest; therefore, the initial actions include calling for help, and initiating CPR until defibrillation is possible. If a defibrillator is not immediately available or is unsuccessful in converting the patient to a better rhythm, CPR should be continued and IV medications and endotracheal intubation should be initiated. Cognitive Level: Application Text Reference: p. 855 Nursing Process: Implementation

Physiological Integrity 11. A patient who has had severe chest pain for the last 4 hours is admitted with a diagnosis of possible AMI. Which of these ordered laboratory tests should the nurse monitor to help determine whether the patient has had an MI? a. Troponin levels b. C-reactive protein c. High-density lipoprotein (HDL) cholesterol d. Homocysteine

A Rationale: Troponin levels increase about 3 hours after the onset of MI. The other laboratory data are useful in determining the patient's risk for developing CAD but are not helpful in determining whether an acute MI is in progress. Cognitive Level: Application Text Reference: pp. 805-806 Nursing Process: Assessment

Physiological Integrity Lewis: Medical-Surgical Nursing, 7th Edition Test Bank Chapter 35: Nursing Management: Heart Failure MULTIPLE CHOICE 1. A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. The patient has pitting edema in both ankles, blood pressure (BP) of 170/100, an apical pulse rate of 92, and respirations 28. The most important assessment for the nurse to accomplish next is to a. auscultate the lung sounds. b. assess the orientation. c. check the capillary refill. d. palpate the abdomen.

A Rationale: When caring for a patient with severe dyspnea, the nurse should use the ABCs to guide initial care. This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patient's volume status and should also be accomplished rapidly, but detection (and treatment) of fluid-filled alveoli is the priority. Cognitive Level: Application Text Reference: pp. 824-825 Nursing Process: Assessment

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

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

A patient with dilated cardiomyopathy has an atrial fibrillation that has been unresponsive to drug therapy for several days. The nurse anticipates that the patient may need teaching about A) a. electrical cardioversion. B) b. IV adenosine (Adenocard). C) c. anticoagulant therapy with warfarin (Coumadin). D) d. insertion of an implantable cardioverter-defibrillator (ICD).

C) c. anticoagulant therapy with warfarin (Coumadin).

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

A The P wave represents the depolarization of the atria. The P-R interval represents depolarization of the atria, atrioventricular (AV) node, bundle of His, bundle branches, and the Purkinje fibers. The QRS represents ventricular depolarization. The Q wave is the first negative deflection following the P wave and should be narrow and short. DIF: Cognitive Level: Understand (comprehension) REF: 791 TOP: Nursing Process: Assessment MSC:

1. Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take immediate action? a. The right hand is cooler than the left hand. b. The mean arterial pressure (MAP) is 77 mm Hg. c. The system is delivering 3 mL of flush solution per hour. d. The flush bag and tubing were last changed 3 days previously.

A The change in temperature of the left hand suggests that blood flow to the left hand is impaired. The flush system needs to be changed every 96 hours. A mean arterial pressure (MAP) of 75 mm Hg is normal. Flush systems for hemodynamic monitoring are set up to deliver 3 to 6 mL/hour of flush solution.

Physiological Integrity 19. Three days after experiencing a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with hygiene activities, saying, "I am too nervous to take care of myself." Based on this information, which nursing diagnosis is appropriate? a. Ineffective coping related to anxiety b. Activity intolerance related to weakness c. Denial related to lack of acceptance of the MI d. Disturbed personal identity related to understanding of illness

A The patient data indicate that ineffective coping after the MI caused by anxiety about the impact of the MI is a concern. The other nursing diagnoses may be appropriate for some patients after an MI, but the data for this patient do not support denial, activity intolerance, or disturbed personal identity. DIF: Cognitive Level: Apply (application) REF: 757 TOP: Nursing Process: Diagnosis MSC:

Physiological Integrity 12. 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 education about care of patients with ICDs? a. The nurse assists the patient to do active range of motion exercises for all extremities. b. The nurse assists the patient to fill out the application for obtaining a Medic Alert ID. c. The nurse gives amiodarone (Cordarone) to the patient without first consulting with the health care provider. d. The nurse teaches the patient that sexual activity usually can be resumed once the surgical incision is healed.

A The patient should avoid moving the arm on the ICD insertion site until healing has occurred in order to prevent displacement of the ICD leads. The other actions by the new nurse are appropriate for this patient. DIF: Cognitive Level: Apply (application) REF: 803 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 18. A patient's cardiac monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious and pulseless. Which action should the nurse take first? a. Perform immediate defibrillation. b. Give epinephrine (Adrenalin) IV. c. Prepare for endotracheal intubation. d. Give ventilations with a bag-valve-mask device.

A 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, the other actions may be appropriate. DIF: Cognitive Level: Apply (application) REF: 801 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Physiological Integrity 21. A few days after experiencing a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, "I just had a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which reply would be most appropriate for the nurse to make? a. "What do you think caused your chest pain?" b. "Where are you planning to go for your vacation?" c. "Sometimes plans need to change after a heart attack." d. "Recovery from a heart attack takes at least a few weeks."

A When the patient is experiencing denial, the nurse should assist the patient in testing reality until the patient has progressed beyond this step of the emotional adjustment to MI. Asking the patient about vacation plans reinforces the patient's plan, which is not appropriate in the immediate post-MI period. Reminding the patient in denial about the MI is likely to make the patient angry and lead to distrust of the nursing staff. DIF: Cognitive Level: Apply (application) REF: 757 TOP: Nursing Process: Implementation MSC:

When reviewing the 12-lead electrocardiograph (ECG) for a healthy 86-year-old patient who is having an annual physical examination, which of the following will be of most concern to the nurse? A) a. The heart rate (HR) is 43 beats/minute. B) b. The PR interval is 0.21 seconds. C) c. There is a right bundle-branch block. D) d. The QRS duration is 0.13 seconds.

A The heart rate (HR) is 43 beats/minute.

The nurse has received change-of-shift report about all of these patients on the telemetry unit. Which patient should the nurse see first?

A patient whose ICD fired three times today who is scheduled for a dose of amiodarone (Cordarone)

The nurse is assigned to care for the following patients admitted to a telemetry unit. Which patient should the nurse assess first?

A patient whose implantable cardioverter defibrillator (ICD) fired twice on the prior shift requiring amiodarone IV

A 19-year-old has a mandatory electrocardiogram (ECG) before participating on a college swim team and is found to have sinus bradycardia, rate 52. BP is 114/54, and the student denies any health problems. What action by the nurse is appropriate? A) a. Allow the student to participate on the swim team. B) b. Refer the student to a cardiologist for further assessment. C) c. Obtain more detailed information about the student's health history. D) d. Tell the student to stop swimming immediately if any dyspnea occurs.

A) a. Allow the student to participate on the swim team.

. A patient's cardiac monitor has a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious and pulseless. Which action should the nurse take first? A) a. Defibrillate at 360 joules. B) b. Give O2 per bag-valve-mask. C) c. Give epinephrine (Adrenalin) IV. D) d. Prepare for endotracheal intubation.

A) a. Defibrillate at 360 joules.

After the nurse administers IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective? A) a. Increase in the patient's heart rate B) b. Decrease in premature contractions C) c. Increase in peripheral pulse volume D) d. Decrease in ventricular ectopic beats

A) a. Increase in the patient's heart rate

To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the length of the patient's A) a. P wave. B) b. PR interval. C) c. QT interval. D) d. QRS complex.

A) a. P wave.

Which action 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 education about care of patients with ICDs? A) a. The nurse assists the patient to do active range of motion exercises for all extremities. B) b. The nurse assists the patient to fill out the application for obtaining a Medic Alert ID and bracelet. C) c. The nurse gives atenolol (Tenormin) to the patient without consulting first with the health care provider. D) d. The nurse teaches the patient that sexual activity usually can be resumed once the surgical incision is healed.

A) a. The nurse assists the patient to do active range of motion exercises for all extremities.

Following an acute myocardial infarction, a previously healthy 67-year-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about A) a. angiotensin-converting enzyme (ACE) inhibitors. B) b. digitalis preparations. C) c. b-adrenergic agonists. D) d. calcium channel blockers.

A) a. angiotensin-converting enzyme (ACE) inhibitors.

After the nurse has finished teaching a patient about use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective? A. "I can expect indigestion as a side effect of nitroglycerin." B. "I can only take the nitroglycerin if I start to have chest pain." C. "I will call an ambulance if I still have pain 5 minutes after taking the nitroglycerin." D. "I will help slow down the progress of the plaque formation by taking nitroglycerin."

C. "I will call an ambulance if I still have pain 5 minutes after taking the nitroglycerin." Indigestion is not a side effect It can be taken as a preventative - before exercise It will not slow plaque formation

Physiological Integrity OTHER 1. 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 paddles on the patient's chest. e. Check the location of other staff and call out "all clear."

A, C, D, E, B This order will result in rapid defibrillation without endangering hospital staff. DIF: Cognitive Level: Analyze (analysis) REF: 802 TOP: Nursing Process: Implementation MSC:

A patient has sought care following a syncopal episode of unknown etiology. Which nursing action should the nurse prioritize in the patient's subsequent diagnostic workup? A. Preparing to assist with a head-up tilt-test B. Preparing an IV dose of a β-adrenergic blocker C. Assessing the patient's knowledge of pacemakers D. Teaching the patient about the role of antiplatelet aggregators

A, In patients without structural heart disease, the head-up tilt-test is a common component of the diagnostic workup following episodes of syncope. IV β-blockers are not indicated although an IV infusion of low-dose isoproterenol may be started in an attempt to provoke a response if the head-up tilt-test did not have a response. Addressing pacemakers is premature and inappropriate at this stage of diagnosis. Patient teaching surrounding antiplatelet aggregators is not directly relevant to the patient's syncope at this time.

A 19-year-old has a mandatory electrocardiogram (ECG) before participating on a college swim team and is found to have sinus bradycardia, rate 52. BP is 114/54, and the student denies any health problems. What action by the nurse is appropriate? A. Allow the student to participate on the swim team. B. Refer the student to a cardiologist for further assessment. C. Obtain more detailed information about the student's health history. D. Tell the student to stop swimming immediately if any dyspnea occurs.

A. Allow the student to participate on the swim team. 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 health history. Dyspnea during an aerobic activity such as swimming is normal.

A few days after an acute myocardial infarction (MI), a patient complains of stabbing chest pain that increases with deep breathing. Which action will the nurse take first? A. Auscultate the heart sounds. B. Check the patient's oral temperature. C. Notify the patient's health care provider. D. Give the ordered acetaminophen (Tylenol).

A. Auscultate the heart sounds. To check for suspected pericarditis

A patient's cardiac monitor has a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious and pulseless. Which action should the nurse take first? A. Defibrillate at 200 joules. B. Give O2 per bag-valve-mask. C. Give epinephrine (Adrenalin) IV. D. Prepare for endotracheal intubation.

A. Defibrillate at 200 joules. 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, the other actions may be appropriate.

For which dysrhythmia is defibrillation primarily indicated? A. Ventricular fibrillation B. Third-degree AV block C. Uncontrolled atrial fibrillation D. Ventricular tachycardia with a pulse

A. Defibrillation is always indicated in the treatment of ventricular fibrillation. Drug treatments are normally used in the treatment of uncontrolled atrial fibrillation and for ventricular tachycardia with a pulse (if the patient is stable). Otherwise, synchronized cardioversion is used (as long as the patient has a pulse). Pacemakers are the treatment of choice for third-degree heart block.

A patient who has chest pain is admitted to the emergency department (ED), and all the following diagnostic tests are ordered. Which one will the nurse arrange to be completed first? A. Electrocardiogram (ECG) B. Computed tomography (CT) scan C. Chest x-ray D. Troponin level

A. Electrocardiogram (ECG)

The patient has hypokalemia, and the nurse obtains the following measurements on the rhythm strip: Heart rate of 86 with a regular rhythm; the P wave is 0.06 seconds (sec) and normal shape; the PR interval is 0.24 sec; the QRS is 0.09 sec. How should the nurse document this rhythm? A. First-degree AV block B. Second-degree AV block C. Premature atrial contraction (PAC) D. Premature ventricular contraction (PVC)

A. In first-degree AV block there is prolonged duration of AV conduction that lengthens the PR interval above 0.20 sec. In type I second-degree AV block the PR interval continues to increase in duration until a QRS complex is blocked. In Type II the PR interval may be normal or prolonged, the ventricular rhythm may be irregular, and the QRS is usually greater than 0.12 sec. PACs cause an irregular rhythm with a different-shaped P wave than the rest of the beats, and the PR interval may be shorter or longer. PVCs cause an irregular rhythm, and the QRS complex is wide and distorted in shape.

After the nurse administers IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective? A. Increase in the patient's heart rate B. Decrease in premature contractions C. Increase in peripheral pulse volume D. Decrease in ventricular ectopic beats

A. Increase in the patient's heart rate Atropine will increase the heart rate and conduction through the AV node. Because the medication increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have ventricular ectopy or premature contractions.

A patient in asystole is likely to receive which drug treatment? A. Epinephrine and atropine B. Lidocaine and amiodarone C. Digoxin and procainamide D. β-adrenergic blockers and dopamine

A. Normally the patient in asystole cannot be successfully resuscitated. However, administration of epinephrine and atropine may prompt the return of depolarization and ventricular contraction. Lidocaine and amiodarone are used for PVCs. Digoxin and procainamide are used for ventricular rate control. β-adrenergic blockers are used to slow heart rate, and dopamine is used to increase heart rate.

To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the length of the patient's A. P wave. B. PR interval. C. QT interval. D. QRS complex.

A. P wave. The P wave represents the depolarization of the atria. The P-R interval represents depolarization of the atria, atrioventricular (AV) node, bundle of His, bundle branches, and the Purkinje fibers. The QRS represents ventricular depolarization. The Q-T interval represents depolarization and repolarization of the entire conduction system.

A patient whose cardiac monitor shows sinus tachycardia, rate 102, is apneic and no pulses are palpable by the nurse. What is the first action that the nurse should take? A. Start CPR. B. Defibrillate. C. Administer atropine per hospital protocol. D. Give 100% oxygen per non-rebreather mask.

A. Start CPR. 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.

Which action 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 education about care of patients with ICDs? A. The nurse assists the patient to do active range of motion exercises for all extremities. B. The nurse assists the patient to fill out the application for obtaining a Medic Alert ID and bracelet. C. The nurse gives atenolol (Tenormin) to the patient without consulting first with the health care provider. D. The nurse teaches the patient that sexual activity usually can be resumed once the surgical incision is healed.

A. The nurse assists the patient to do active range of motion exercises for all extremities. The patient should avoid moving the arm on the ICD insertion site until healing has occurred in order to prevent displacement of the ICD leads. The other actions by the new nurse are appropriate for this patient.

A patient has received instruction on the management of a new permanent pacemaker before discharge from the hospital. The nurse recognizes that teaching has been effective when the patient tells the nurse, A. "It will be 6 weeks before I can take a bath or return to my usual activities." B. Incorrect "I will notify the airlines when I make a reservation that I have a pacemaker." C. "I won't lift the arm on the pacemaker side up very high until I see the doctor." D. "I must avoid cooking with a microwave oven or being near a microwave in use."

C. "I won't lift the arm on the pacemaker side up very high until I see the doctor." The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The patient should notify airport security about the presence of a pacemaker before going through the metal detector, but there is no need to notify the airlines when making a reservation. Microwave oven use does not affect the pacemaker. The insertion procedure involves minor surgery that will have a short recovery period.

A patient who was admitted with a myocardial infarction experiences a 50-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute. Which action should the nurse take next? A. Notify the health care provider. B. Perform synchronized cardioversion. C. Administer the PRN IV lidocaine (Xylocaine). D. Document the rhythm and monitor the patient.

C. Administer the PRN IV lidocaine (Xylocaine). 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 medications are administered. Defibrillation is not indicated given that the patient is currently in a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation.

The nurse is caring for a patient who is 24 hours postpacemaker insertion. Which nursing intervention is most appropriate at this time? A. Reinforcing the pressure dressing as needed B. Encouraging range-of-motion exercises of the involved arm C. Assessing the incision for any redness, swelling, or discharge D. Applying wet-to-dry dressings every 4 hours to the insertion site

C. After pacemaker insertion, it is important for the nurse to observe signs of infection by assessing for any redness, swelling, or discharge from the incision site. The nonpressure dressing is kept dry until removed, usually 24 hours postoperatively. It is important for the patient to limit activity of the involved arm to minimize pacemaker lead displacement.

The nurse is seeing artifact on the telemetry monitor. Which factors could contribute to this artifact? A. Disabled automaticity B. Electrodes in the wrong lead C. Too much hair under the electrodes D. Stimulation of the vagus nerve fibers

C. Artifact is caused by muscle activity, electrical interference, or insecure leads and electrodes that could be caused by excessive chest wall hair. Disabled automaticity would cause an atrial dysrhythmia. Electrodes in the wrong lead will measure electricity in a different plane of the heart and may have a different wave form than expected. Stimulation of the vagus nerve fibers causes a decrease in heart rate, not artifact.

2. The nurse is caring for a patient who has an intraortic balloon pump (IABP) following a massive heart attack. When assessing the patient, the nurse notices blood backing up into the IABP catheter. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Ensure that the IABP console has turned off. b. Assess the patient's vital signs and orientation. c. Obtain supplies for insertion of a new IABP catheter. d. Notify the health care provider of the IABP malfunction.

ANS: A, B, D, C Blood in the IABP catheter indicates a possible tear in the balloon. The console will shut off automatically to prevent complications such as air embolism. Next, the nurse will assess the patient and communicate with the health care provider about the patient's assessment and the IABP problem. Finally, supplies for insertion of a new IABP catheter may be needed, based on the patient assessment and the decision of the health care provider.

1. When assisting with oral intubation of a patient who is having respiratory distress, in which order will the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Obtain a portable chest-x-ray. b. Position the patient in the supine position. c. Inflate the cuff of the endotracheal tube after insertion. d. Attach an end-tidal CO2 detector to the endotracheal tube. e. Oxygenate the patient with a bag-valve-mask device for several minutes.

ANS: E, B, C, D, A The patient is pre-oxygenated with a bag-valve-mask system for 3 to 5 minutes before intubation and then placed in a supine position. Following the intubation, the cuff on the endotracheal tube is inflated to occlude and protect the airway. Tube placement is assessed first with an end-tidal CO2 sensor, then with a chest x-ray.

25. The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would include a. when cardiac rehabilitation will begin. b. the typical emotional responses to AMI. c. information regarding discharge medications. d. the pathophysiology of coronary artery disease.

ANS: A Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this time, the patient's anxiety level or denial will interfere with good understanding of complex information such as the pathophysiology of coronary artery disease (CAD). Teaching about discharge medications should be done closer to discharge. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional responses to myocardial infarction (MI).

19. Three days after experiencing a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with hygiene activities, saying, "I am too nervous to take care of myself." Based on this information, which nursing diagnosis is appropriate? a. Ineffective coping related to anxiety b. Activity intolerance related to weakness c. Denial related to lack of acceptance of the MI d. Disturbed personal identity related to understanding of illness

ANS: A The patient data indicate that ineffective coping after the MI caused by anxiety about the impact of the MI is a concern. The other nursing diagnoses may be appropriate for some patients after an MI, but the data for this patient do not support denial, activity intolerance, or disturbed personal identity.

29. When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Give the scheduled aspirin and lipid-lowering medication. b. Perform the initial assessment of the catheter insertion site. c. Teach the patient about the usual postprocedure plan of care. d. Titrate the heparin infusion according to the agency protocol.

ANS: A Administration of oral medications is within the scope of practice for LPNs/LVNs. The initial assessment of the patient, patient teaching, and titration of IV anticoagulant medications should be done by the registered nurse (RN).

34. Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care provider? a. No change in the patient's chest pain b. An increase in troponin levels from baseline c. A large bruise at the patient's IV insertion site d. A decrease in ST-segment elevation on the electrocardiogram

ANS: A Continued chest pain suggests that the thrombolytic therapy is not effective and that other interventions such as percutaneous coronary intervention (PCI) may be needed. Bruising is a possible side effect of thrombolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST-segment elevation indicates that thrombolysis is occurring and perfusion is returning to the injured myocardium. An increase in troponin levels is expected with reperfusion and is related to the washout of cardiac markers into the circulation as the blocked vessel is opened.

36. A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most important to discuss with the health care provider before starting the SBT? a. New ST segment elevation is noted on the cardiac monitor. b. Enteral feedings are being given through an orogastric tube. c. Scattered rhonchi are heard when auscultating breath sounds. d. HYDROmorphone (Dilaudid) is being used to treat postoperative pain.

ANS: A Myocardial ischemia is a contraindication for ventilator weaning. The ST segment elevation is an indication that weaning should be postponed until further investigation and/or treatment for myocardial ischemia can be done. The other information will also be shared with the health care provider, but ventilator weaning can proceed when opioids are used for pain management, abnormal lung sounds are present, or enteral feedings are being used.

22. A patient with respiratory failure has arterial pressure-based cardiac output (APCO) monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 12 cm H2O. Which information indicates that a change in the ventilator settings may be required? a. The arterial pressure is 90/46. b. The heart rate is 58 beats/minute. c. The stroke volume is increased. d. The stroke volume variation is 12%.

ANS: A The hypotension suggests that the high intrathoracic pressure caused by the PEEP may be decreasing venous return and (potentially) cardiac output. The other assessment data would not be a direct result of PEEP and mechanical ventilation.

33. A patient who is orally intubated and receiving mechanical ventilation is anxious and is "fighting" the ventilator. Which action should the nurse take next? a. Verbally coach the patient to breathe with the ventilator. b. Sedate the patient with the ordered PRN lorazepam (Ativan). c. Manually ventilate the patient with a bag-valve-mask device. d. Increase the rate for the ordered propofol (Diprivan) infusion.

ANS: A The initial response by the nurse should be to try to decrease the patient's anxiety by coaching the patient about how to coordinate respirations with the ventilator. The other actions may also be helpful if the verbal coaching is ineffective in reducing the patient's anxiety.

27. A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of medications to the nurse. Which medication has the most immediate implications for the patient's care? a. Sildenafil b. Furosemide c. Captopril d. Warfarin

ANS: A The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using sildenafil because of the risk of severe hypotension caused by vasodilation. The other home medications also should be documented and reported to the health care provider but do not have as immediate an impact on decisions about the patient's treatment.

21. A few days after experiencing a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, "I just had a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which reply would be most appropriate for the nurse to make? a. "What do you think caused your chest pain?" b. "Where are you planning to go for your vacation?" c. "Sometimes plans need to change after a heart attack." d. "Recovery from a heart attack takes at least a few weeks."

ANS: A When the patient is experiencing denial, the nurse should assist the patient in testing reality until the patient has progressed beyond this step of the emotional adjustment to MI. Asking the patient about vacation plans reinforces the patient's plan, which is not appropriate in the immediate post-MI period. Reminding the patient in denial about the MI is likely to make the patient angry and lead to distrust of the nursing staff.

20. When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that a. sudden cardiac death events rarely reoccur. b. additional diagnostic testing will be required. c. long-term anticoagulation therapy will be needed. d. limited physical activity after discharge will be needed to prevent future events. .

ANS: B Diagnostic testing (e.g., stress test, Holter monitor, electrophysiologic studies, cardiac catheterization) is used to determine the possible cause of the SCD and treatment options. SCD is likely to recur. Anticoagulation therapy will not have any effect on the incidence of SCD, and SCD can occur even when the patient is resting.

28. Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider? a. Complaints of incisional chest pain b. Pallor and weakness of the right hand c. Fine crackles heard at both lung bases d. Redness on both sides of the sternal incision

ANS: B The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions such as prescribed calcium channel blockers or surgery. The other changes are expected and/or require nursing interventions.

4. Following surgery for an abdominal aortic aneurysm, a patient's central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take? a. Administer IV diuretic medications. b. Increase the IV fluid infusion per protocol. c. Document the CVP and continue to monitor. d. Elevate the head of the patient's bed to 45 degrees.

ANS: B A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Diuretic administration will contribute to hypovolemia and elevation of the head may decrease cerebral perfusion. Documentation and continued monitoring is an inadequate response to the low CVP.

39. To improve the physical activity level for a mildly obese 71-year-old patient, which action should the nurse plan to take? a. Stress that weight loss is a major benefit of increased exercise. b. Determine what kind of physical activities the patient usually enjoys. c. Tell the patient that older adults should exercise for no more than 20 minutes at a time. d. Teach the patient to include a short warm-up period at the beginning of physical activity.

ANS: B Because patients are more likely to continue physical activities that they already enjoy, the nurse will plan to ask the patient about preferred activities. The goal for older adults is 30 minutes of moderate activity on most days. Older adults should plan for a longer warm-up period. Benefits of exercises, such as improved activity tolerance, should be emphasized rather than aiming for significant weight loss in older mildly obese adults.

3. Which assessment data collected by the nurse who is admitting a patient with chest pain suggest that the pain is caused by an acute myocardial infarction (AMI)? a. The pain increases with deep breathing. b. The pain has lasted longer than 30 minutes. c. The pain is relieved after the patient takes nitroglycerin. d. The pain is reproducible when the patient raises the arms.

ANS: B Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of musculoskeletal pain or pericarditis. Stable angina is usually relieved when the patient takes nitroglycerin.

1. A 68-year-old patient has been in the intensive care unit for 4 days and has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action should the nurse include in the plan of care? a. Administer prescribed sedatives or opioids at bedtime to promote sleep. b. Cluster nursing activities so that the patient has uninterrupted rest periods. c. Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps. d. Eliminate assessments between 0100 and 0600 to allow uninterrupted sleep. Integrity

ANS: B Clustering nursing activities and providing uninterrupted rest periods will minimize sleep-cycle disruption. Sedative and opioid medications tend to decrease the amount of rapid eye movement (REM) sleep and can contribute to sleep disturbance and disturbed sensory perception. Silencing the alarms on the cardiac monitors would be unsafe in a critically ill patient, as would discontinuing assessments during the night.

12. The central venous oxygen saturation (ScvO2) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased ScvO2, the nurse assesses the patient's a. lipase. b. temperature. c. urinary output. d. body mass index.

ANS: B Elevated temperature increases metabolic demands and oxygen use by tissues, resulting in a drop in oxygen saturation of central venous blood. Information about the patient's body mass index, urinary output, and lipase will not help in determining the cause of the patient's drop in ScvO2.

. When caring for a patient who has an arterial catheter in the left radial artery for arterial pressure-based cardiac output (APCO) monitoring, which information obtained by the nurse is most important to report to the health care provider? a. The patient has a positive Allen test. b. There is redness at the catheter insertion site. c. The mean arterial pressure (MAP) is 86 mm Hg. d. The dicrotic notch is visible in the arterial waveform.

ANS: B Redness at the catheter insertion site indicates possible infection. The Allen test is performed before arterial line insertion, and a positive test indicates normal ulnar artery perfusion. A MAP of 86 is normal and the dicrotic notch is normally present on the arterial waveform.

3. While family members are visiting, a patient has a respiratory arrest and is being resuscitated. Which action by the nurse is best? a. Tell the family members that watching the resuscitation will be very stressful. b. Ask family members if they wish to remain in the room during the resuscitation. c. Take the family members quickly out of the patient room and remain with them. d. Assign a staff member to wait with family members just outside the patient room.

ANS: B Research indicates that family members want the option of remaining in the room during procedures such as cardiopulmonary resuscitation (CPR) and that this decreases anxiety and facilitates grieving. The other options may be appropriate if the family decides not to remain with the patient.

23. A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about when sexual intercourse can be resumed. Which response by the nurse is best? a. "Most patients are able to enjoy intercourse without any complications." b. "Sexual activity uses about as much energy as climbing two flights of stairs." c. "The doctor will provide sexual guidelines when your heart is strong enough." d. "Holding and cuddling are good ways to maintain intimacy after a heart attack."

ANS: B Sexual activity places about as much physical stress on the cardiovascular system as most moderate-energy activities such as climbing two flights of stairs. The other responses do not directly address the patient's question or may not be accurate for this patient.

2. Which hemodynamic parameter is most appropriate for the nurse to monitor to determine the effectiveness of medications given to a patient to reduce left ventricular afterload? a. Mean arterial pressure (MAP) b. Systemic vascular resistance (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP)

ANS: B Systemic vascular resistance reflects the resistance to ventricular ejection, or afterload. The other parameters will be monitored, but do not reflect afterload as directly.

34. The nurse educator is evaluating the performance of a new registered nurse (RN) who is providing care to a patient who is receiving mechanical ventilation with 15 cm H2O of peak end-expiratory pressure (PEEP). Which action indicates that the new RN is safe? a. The RN plans to suction the patient every 1 to 2 hours. b. The RN uses a closed-suction technique to suction the patient. c. The RN tapes connection between the ventilator tubing and the ET. d. The RN changes the ventilator circuit tubing routinely every 48 hours.

ANS: B The closed-suction technique is used when patients require high levels of PEEP (>10 cm H2O) to prevent the loss of PEEP that occurs when disconnecting the patient from the ventilator. Suctioning should not be scheduled routinely, but it should be done only when patient assessment data indicate the need for suctioning. Taping connections between the ET and the ventilator tubing would restrict the ability of the tubing to swivel in response to patient repositioning. Ventilator tubing changes increase the risk for ventilator-associated pneumonia (VAP) and are not indicated routinely.

13. When titrating IV nitroglycerin for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication? a. Monitor heart rate. b. Ask about chest pain. c. Check blood pressure. d. Observe for dysrhythmias.

ANS: B The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse also will monitor heart rate and blood pressure (BP) and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective.

26. When evaluating a patient with a central venous catheter, the nurse observes that the insertion site is red and tender to touch and the patient's temperature is 101.8° F. What should the nurse plan to do next? a. Give analgesics and antibiotics as ordered. b. Discontinue the catheter and culture the tip. c. Change the flush system and monitor the site. d. Check the site more frequently for any swelling.

ANS: B The information indicates that the patient has a local and systemic infection caused by the catheter, and the catheter should be discontinued. Changing the flush system, giving analgesics, and continued monitoring will not help prevent or treat the infection. Administration of antibiotics is appropriate, but the line should still be discontinued to avoid further complications such as endocarditis.

27. An 81-year-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. The nurse will plan to a. give PRN lorazepam (Ativan) and cancel the transfer. b. inform the receiving nurse and then transfer the patient. c. notify the health care provider and postpone the transfer. d. obtain an order for restraints as needed and transfer the patient.

ANS: B The patient's history and symptoms most likely indicate delirium associated with the sleep deprivation and sensory overload in the ICU environment. Informing the receiving nurse and transferring the patient is appropriate. Postponing the transfer is likely to prolong the delirium. Benzodiazepines and restraints contribute to delirium and agitation.

32. A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 123. Based on this information, which nursing diagnosis is a priority for the patient? a. Acute pain related to myocardial infarction b. Anxiety related to perceived threat of death c. Stress overload related to acute change in health d. Decreased cardiac output related to cardiogenic shock

ANS: C All the nursing diagnoses may be appropriate for this patient, but the hypotension and tachycardia indicate decreased cardiac output and shock from the damaged myocardium. This will result in decreased perfusion to all vital organs (e.g., brain, kidney, heart) and is a priority.

35. The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? a. The troponin level is elevated. b. The patient denies ever having a heart attack. c. Bilateral crackles are auscultated in the mid-lower lobes. d. The patient has occasional premature atrial contractions (PACs).

ANS: C The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin- converting enzyme (ACE) inhibitors for the patient. Elevation in troponin level at this time is expected. PACs are not life-threatening dysrhythmias. Denial is a common response in the immediate period after the MI.

13. An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which assessment data indicate to the nurse that the goals of treatment with the IABP are being met? a. Urine output of 25 mL/hr b. Heart rate of 110 beats/minute c. Cardiac output (CO) of 5 L/min d. Stroke volume (SV) of 40 mL/beat

ANS: C A CO of 5 L/min is normal and indicates that the IABP has been successful in treating the shock. The low SV signifies continued cardiogenic shock. The tachycardia and low urine output also suggest continued cardiogenic shock.

20. The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will be most effective in addressing this problem? a. Increase suctioning to every hour. b. Reposition the patient every 1 to 2 hours. c. Add additional water to the patient's enteral feedings. d. Instill 5 mL of sterile saline into the ET before suctioning.

ANS: C Because the patient's secretions are thick, better hydration is indicated. Suctioning every hour without any specific evidence for the need will increase the incidence of mucosal trauma and would not address the etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may decrease the SpO2. Repositioning the patient is appropriate but will not decrease the thickness of secretions.

28. The family members of a patient who has just been admitted to the intensive care unit (ICU) with multiple traumatic injuries have just arrived in the ICU waiting room. Which action should the nurse take next? a. Explain ICU visitation policies and encourage family visits. b. Immediately take the family members to the patient's bedside. c. Describe the patient's injuries and the care that is being provided. d. Invite the family to participate in a multidisciplinary care conference.

ANS: C Lack of information is a major source of anxiety for family members and should be addressed first. Family members should be prepared for the patient's appearance and the ICU environment before visiting the patient for the first time. ICU visiting should be individualized to each patient and family rather than being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial action by the nurse.

14. The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be included in the plan of care? a. Position the patient supine at all times. b. Avoid the use of anticoagulant medications. c. Measure the patient's urinary output every hour. d. Provide passive range of motion for all extremities.

ANS: C Monitoring urine output will help determine whether the patient's cardiac output has improved and also help monitor for balloon displacement. The head of the bed can be elevated up to 30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the extremity with the balloon insertion site to prevent displacement of the balloon.

5. When caring for a patient with pulmonary hypertension, which parameter is most appropriate for the nurse to monitor to evaluate the effectiveness of the treatment? a. Central venous pressure (CVP) b. Systemic vascular resistance (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP)

ANS: C PVR is a major contributor to pulmonary hypertension, and a decrease would indicate that pulmonary hypertension was improving. The other parameters also may be monitored but do not directly assess for pulmonary hypertension.

23. A nurse is weaning a 68-kg male patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped? a. The patient's heart rate is 97 beats/min. b. The patient's oxygen saturation is 93%. c. The patient respiratory rate is 32 breaths/min. d. The patient's spontaneous tidal volume is 450 mL.

ANS: C Tachypnea is a sign that the patient's work of breathing is too high to allow weaning to proceed. The patient's heart rate is within normal limits, although the nurse should continue to monitor it. An oxygen saturation of 93% is acceptable for a patient with COPD. A spontaneous tidal volume of 450 mL is within the acceptable range.

16. During the administration of the thrombolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences a. bleeding from the gums. b. increase in blood pressure. c. a decrease in level of consciousness. d. a nonsustained episode of ventricular tachycardia.

ANS: C The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of thrombolytic therapy. Some bleeding of the gums is an expected side effect of the therapy but not an indication to stop infusion of the thrombolytic medication. A decrease in blood pressure could indicate internal bleeding. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective.

ANS: C The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors for the patient. Elevation in troponin level at this time is expected. A normal heart rate is 60-100 bpm. Denial is a common response in the immediate period after the MI.

8. Which action is a priority for the nurse to take when the low pressure alarm sounds for a patient who has an arterial line in the left radial artery? a. Fast flush the arterial line. b. Check the left hand for pallor. c. Assess for cardiac dysrhythmias. d. Rezero the monitoring equipment.

ANS: C The low pressure alarm indicates a drop in the patient's blood pressure, which may be caused by cardiac dysrhythmias. There is no indication to rezero the equipment. Pallor of the left hand would be caused by occlusion of the radial artery by the arterial catheter, not by low pressure. There is no indication of a need for flushing the line.

31. The nurse notes that a patient's endotracheal tube (ET), which was at the 22-cm mark, is now at the 25-cm mark and the patient is anxious and restless. Which action should the nurse take next? a. Offer reassurance to the patient. b. Bag the patient at an FIO2 of 100%. c. Listen to the patient's breath sounds. d. Notify the patient's health care provider.

ANS: C The nurse should first determine whether the ET tube has been displaced into the right mainstem bronchus by listening for unilateral breath sounds. If so, assistance will be needed to reposition the tube immediately. The other actions are also appropriate, but detection and correction of tube malposition are the most critical actions.

30. Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain? a. Inverted P wave b. Sinus tachycardia c. ST-segment elevation d. First-degree atrioventricular block

ANS: C The patient is likely to be experiencing an ST-segment-elevation myocardial infarction (STEMI). Immediate therapy with percutaneous coronary intervention (PCI) or thrombolytic medication is indicated to minimize myocardial damage. The other ECG changes may also suggest a need for therapy, but not as rapidly.

17. A patient is recovering from a myocardial infarction (MI) and develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next? a. Assess the feet for pedal edema. b. Palpate the radial pulses bilaterally. c. Auscultate for a pericardial friction rub. d. Check the heart monitor for dysrhythmias.

ANS: C The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient's symptoms.

14. A patient with ST-segment elevation in three contiguous electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? a. "Do you have any allergies?" b. "Do you take aspirin on a daily basis?" c. "What time did your chest pain begin?" d. "Can you rate your chest pain using a 0 to 10 scale?"

ANS: C Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction (MI), so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information will also be needed, but it will not be a factor in the decision about thrombolytic therapy.

24. The nurse is caring for a patient receiving a continuous norepinephrine (Levophed) IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted? a. Heart rate is 58 beats/minute. b. Mean arterial pressure (MAP) is 56 mm Hg. c. Systemic vascular resistance (SVR) is elevated. d. Pulmonary artery wedge pressure (PAWP) is low.

ANS: C Vasoconstrictors such as norepinephrine (Levophed) will increase SVR, and this will increase the work of the heart and decrease peripheral perfusion. The infusion rate may need to be decreased. Bradycardia, hypotension (MAP of 56 mm Hg), and low PAWP are not associated with norepinephrine infusion.

9. Which action will the nurse need to do when preparing to assist with the insertion of a pulmonary artery catheter? a. Determine if the cardiac troponin level is elevated. b. Auscultate heart and breath sounds during insertion. c. Place the patient on NPO status before the procedure. d. Attach cardiac monitoring leads before the procedure.

ANS: D Dysrhythmias can occur as the catheter is floated through the right atrium and ventricle, and it is important for the nurse to monitor for these during insertion. Pulmonary artery catheter insertion does not require anesthesia, and the patient will not need to be NPO. Changes in cardiac troponin or heart and breath sounds are not expected during pulmonary artery catheter insertion.

16. To verify the correct placement of an oral endotracheal tube (ET) after insertion, the best initial action by the nurse is to a. auscultate for the presence of bilateral breath sounds. b. obtain a portable chest x-ray to check tube placement. c. observe the chest for symmetric chest movement with ventilation. d. use an end-tidal CO2 monitor to check for placement in the trachea.

ANS: D End-tidal CO2 monitors are currently recommended for rapid verification of ET placement. Auscultation for bilateral breath sounds and checking chest expansion are also used, but they are not as accurate as end-tidal CO2 monitoring. A chest x-ray confirms the placement but is done after the tube is secured.

35. The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the health care provider immediately if the patient develops a. oxygen saturation of 93%. b. respirations of 20 breaths/minute. c. green nasogastric tube drainage. d. increased jugular venous distention.

ANS: D Increases in jugular venous distention in a patient with a subarachnoid hemorrhage may indicate an increase in intracranial pressure (ICP) and that the PEEP setting is too high for this patient. A respiratory rate of 20, O2 saturation of 93%, and green nasogastric tube drainage are within normal limits.

36. A patient had a non-ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention included in the plan of care is most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Evaluation of the patient's response to walking in the hallway b. Completion of the referral form for a home health nurse follow-up c. Education of the patient about the pathophysiology of heart disease d. Reinforcement of teaching about the purpose of prescribed medications

ANS: D LPN/LVN education and scope of practice include reinforcing education that has previously been done by the RN. Evaluating the patient response to exercise after a NSTEMI requires more education and should be done by the RN. Teaching and discharge planning/ documentation are higher level skills that require RN education and scope of practice.

7. When monitoring for the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, the most important information for the nurse to obtain is a. central venous pressure (CVP). b. systemic vascular resistance (SVR). c. pulmonary vascular resistance (PVR). d. pulmonary artery wedge pressure (PAWP).

ANS: D PAWP reflects left ventricular end diastolic pressure (or left ventricular preload) and is a sensitive indicator of cardiac function. Because the patient is high risk for left ventricular failure, the PAWP must be monitored. An increase will indicate left ventricular failure. The other values would also provide useful information, but the most definitive measurement of changes in cardiac function is the PAWP.

37. After change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first? a. Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the ventilator b. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoring c. Patient with a central venous oxygen saturation (ScvO2) of 69% while on bilevel positive airway pressure (BiPAP) d. Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours

ANS: D The decreased urine output may indicate acute kidney injury or that the patient's cardiac output and perfusion of vital organs have decreased. Any of these causes would require rapid action. The data about the other patients indicate that their conditions are stable and do not require immediate assessment or changes in their care. Continuous PETCO2 monitoring is frequently used when patients are intubated. The rest mode should be used to allow patient recovery after a failed SBT, and an ScvO2 of 69% is within normal limits.

38. After change-of-shift report, which patient should the progressive care nurse assess first? a. Patient who was extubated in the morning and has a temperature of 101.4° F (38.6° C) b. Patient with bilevel positive airway pressure (BiPAP) for sleep apnea whose respiratory rate is 16 c. Patient with arterial pressure monitoring who is 2 hours post-percutaneous coronary intervention who needs to void d. Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 98 sec

ANS: D The findings for this patient indicate high risk for bleeding from an elevated (nontherapeutic) PTT. The nurse needs to adjust the rate of the infusion (dose) per the health care provider's parameters. The patient with BiPAP for sleep apnea has a normal respiratory rate. The patient recovering from the percutaneous coronary intervention will need to be assisted with voiding and this task could be delegated to unlicensed assistive personnel. The patient with a fever may be developing ventilator-associated pneumonia, but addressing the bleeding risk is a higher priority.

32. The nurse educator is evaluating the care that a new registered nurse (RN) provides to a patient receiving mechanical ventilation. Which action by the new RN indicates the need for more education? a. The RN increases the FIO2 to 100% before suctioning. b. The RN secures a bite block in place using adhesive tape. c. The RN asks for assistance to reposition the endotracheal tube. d. The RN positions the patient with the head of bed at 10 degrees.

ANS: D The head of the patient's bed should be positioned at 30 to 45 degrees to prevent ventilator-associated pneumonia. The other actions by the new RN are appropriate.

15. While waiting for cardiac transplantation, a patient with severe cardiomyopathy has a ventricular assist device (VAD) implanted. When planning care for this patient, the nurse should anticipate a. giving immunosuppressive medications. b. preparing the patient for a permanent VAD. c. teaching the patient the reason for complete bed rest. d. monitoring the surgical incision for signs of infection.

ANS: D The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patient's with VADs are able to have some mobility and may not be on bed rest. The VAD is a bridge to transplantation, not a permanent device. Immunosuppression is not necessary for nonbiologic devices like the VAD.

17. To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should a. inflate the cuff with a minimum of 10 mL of air. b. inflate the cuff until the pilot balloon is firm on palpation. c. inject air into the cuff until a manometer shows 15 mm Hg pressure. d. inject air into the cuff until a slight leak is heard only at peak inflation.

ANS: D The minimal occluding volume technique involves injecting air into the cuff until an air leak is present only at peak inflation. The volume to inflate the cuff varies with the ET and the patient's size. Cuff pressure should be maintained at 20 to 25 mm Hg. An accurate assessment of cuff pressure cannot be obtained by palpating the pilot balloon.

30. The nurse responds to a ventilator alarm and finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take next? a. Activate the rapid response team. b. Provide reassurance to the patient. c. Call the health care provider to reinsert the tube. d. Manually ventilate the patient with 100% oxygen.

ANS: D The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system. Offering reassurance to the patient, notifying the health care provider about the need to reinsert the tube, and activating the rapid response team are also appropriate after the nurse has stabilized the patient's oxygenation.

21. Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patient's arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3- of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to a. increase the FIO2. b. increase the tidal volume. c. increase the respiratory rate. d. decrease the respiratory rate.

ANS: D The patient's PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD and increasing the respiratory rate and tidal volume would further lower the PaCO2.

31. When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse? a. Heart rate 102 beats/min b. Pedal pulses 1+ bilaterally c. Blood pressure 103/54 mm Hg d. Chest pain level 7 on a 0 to 10 point scale

ANS: D The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse.

38. After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? a. 39-year-old with pericarditis who is complaining of sharp, stabbing chest pain b. 56-year-old with variant angina who is to receive a dose of nifedipine c. 65-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned discharge d. 59-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI)

ANS: D This patient is at risk for bleeding from the arterial access site for the PCI, so the nurse should assess the patient's blood pressure, pulse, and the access site immediately. The other patients should also be assessed as quickly as possible, but assessment of this patient has the highest priority.

8. A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to help determine whether the patient has had an AMI? a. Myoglobin b. Homocysteine c. C-reactive protein d. Cardiac-specific troponin

ANS: D Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI) and are highly specific indicators for MI. Myoglobin is released within 2 hours of MI, but it lacks specificity and its use is limited. The other laboratory data are useful in determining the patient's risk for developing coronary artery disease (CAD) but are not helpful in determining whether an acute MI is in progress.

25. When caring for the patient with a pulmonary artery (PA) pressure catheter, the nurse observes that the PA waveform indicates that the catheter is in the wedged position. Which action should the nurse take next? a. Zero balance the transducer. b. Activate the fast flush system. c. Notify the health care provider. d. Deflate and reinflate the PA balloon.

ANS: D When the catheter is in the wedge position, blood flow past the catheter is obstructed, placing the patient at risk for pulmonary infarction. A health care provider or advanced practice nurse should be called to reposition the catheter. The other actions will not correct the wedging of the PA catheter.

A 26-year-old Air Force staff sergeant is returning for diagnostic follow-up to the cardiologist's office where you practice nursing. Her Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minute. What other conditions can cause this response in a healthy heart?

All options are correct (Strenuous exercise, shock and elevated temperature)

A 19-year-old student has a mandatory ECG before participating on a college swim team and is found to have sinus bradycardia, rate 52. BP is 114/54, and the student denies any health problems. What action by the nurse is appropriate?

Allow the student to participate on the swim team.

A few days after experiencing an MI, the patient states, "I just had a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which nursing intervention is appropriate to include in the nursing care plan?

Allow the use of denial as a coping mechanism until the patient begins asking questions about the MI.

The nurse is caring for clients on a telemetry unit. Which nursing consideration best represents concerns of altered rhythmic patterns of the heart?

Altered patterns frequently affect the heart's ability to pump blood effectively.

New nurses on the telemetry unit have been paired with preceptors. One new nurse asks her preceptor to explain depolarization. What would be the best answer by the preceptor? A) "Depolarization is the mechanical contraction of the heart muscles." B) "Depolarization is the electrical stimulation of the heart muscles." C) "Depolarization is the electrical relaxation of the heart muscles." D) "Depolarization is the mechanical relaxation of the heart muscles."

Ans: "Depolarization is the electrical stimulation of the heart muscles." Feedback: The electrical stimulation of the heart is called depolarization, and the mechanical contraction is called systole. Electrical relaxation is called repolarization, and mechanical relaxation is called diastole.

During a CPR class, a participant asks about the difference between cardioversion and defibrillation. What would be the instructor's best response? A) "Cardioversion is done on a beating heart; defibrillation is not." B) "The difference is the timing of the delivery of the electric current." C) "Defibrillation is synchronized with the electrical activity of the heart, but cardioversion is not." D) "Cardioversion is always attempted before defibrillation because it has fewer risks."

Ans: "The difference is the timing of the delivery of the electric current." Feedback: One major difference between cardioversion and defibrillation is the timing of the delivery of electrical current. In cardioversion, the delivery of the electrical current is synchronized with the patient's electrical events; in defibrillation, the delivery of the current is immediate and unsynchronized. Both can be done on beating heart (i.e., in a dysrhythmia). Cardioversion is not necessarily attempted first.

The nurse is providing care to a patient who has just undergone an electrophysiologic (EP) study. The patient states that she is nervous about "things going wrong" during the procedure. What is the nurse's best response? A) "This is basically a risk-free procedure." B) "Thousands of patients undergo EP every year." C) "Remember that this is a step that will bring you closer to enjoying good health." D) "The whole team will be monitoring you very closely for the entire procedure."

Ans: "The whole team will be monitoring you very closely for the entire procedure." Feedback: Patients who are to undergo an EP study may be anxious about the procedure and its outcome. A detailed discussion involving the patient, the family, and the electrophysiologist usually occurs to ensure that the patient can give informed consent and to reduce the patient's anxiety about the procedure. It is inaccurate to state that EP is "risk-free" and stating that it is common does not necessarily relieve the patient's anxiety. Characterizing EP as a step toward good health does not directly address the patient's anxiety.

A patient who is a candidate for an implantable cardioverter defibrillator (ICD) asks the nurse about the purpose of this device. What would be the nurse's best response? A) "To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia" B) "To detect and treat bradycardia, which is an excessively slow heart rate" C) "To detect and treat atrial fibrillation, in which your heart beats too quickly and inefficiently" D) "To shock your heart if you have a heart attack at home"

Ans: "To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia" Feedback: The ICD is a device that detects and terminates life-threatening episodes of ventricular tachycardia and ventricular fibrillation. It does not treat atrial fibrillation, MI, or bradycardia.

A patient is brought to the ED and determined to be experiencing symptomatic sinus bradycardia. The nurse caring for this patient is aware the medication of choice for treatment of this dysrhythmia is the administration of atropine. What guidelines will the nurse follow when administering atropine? A) Administer atropine 0.5 mg as an IV bolus every 3 to 5 minutes to a maximum of 3.0 mg. B) Administer atropine as a continuous infusion until symptoms resolve. C) Administer atropine as a continuous infusion to a maximum of 30 mg in 24 hours. D) Administer atropine 1.0 mg sublingually.

Ans: Administer atropine 0.5 mg as an IV bolus every 3 to 5 minutes to a maximum of 3.0 mg. Feedback: Atropine 0.5 mg given rapidly as an intravenous (IV) bolus every 3 to 5 minutes to a maximum total dose of 3.0 mg is the medication of choice in treating symptomatic sinus bradycardia. By this guideline, the other listed options are inappropriate.

During a patient's care conference, the team is discussing whether the patient is a candidate for cardiac conduction surgery. What would be the most important criterion for a patient to have this surgery? A) Angina pectoris not responsive to other treatments B) Decreased activity tolerance related to decreased cardiac output C) Atrial and ventricular tachycardias not responsive to other treatments D) Ventricular fibrillation not responsive to other treatments

Ans: Atrial and ventricular tachycardias not responsive to other treatments Feedback: Cardiac conduction surgery is considered in patients who do not respond to medications and antitachycardia pacing. Angina, reduced activity tolerance, and ventricular fibrillation are not criteria.

The nurse is planning discharge teaching for a patient with a newly inserted permanent pacemaker. What is the priority teaching point for this patient? A) Start lifting the arm above the shoulder right away to prevent chest wall adhesion. B) Avoid cooking with a microwave oven. C) Avoid exposure to high-voltage electrical generators. D) Avoid walking through store and library antitheft devices.

Ans: Avoid exposure to high-voltage electrical generators. Feedback: High-output electrical generators can reprogram pacemakers and should be avoided. Recent pacemaker technology allows patients to safely use most household electronic appliances and devices (e.g., microwave ovens). The affected arm should not be raised above the shoulder for 1 week following placement of the pacemaker. Antitheft alarms may be triggered so patients should be taught to walk through them quickly and avoid standing in or near these devices. These alarms generally do not interfere with pacemaker function.

A patient has returned to the cardiac care unit after having a permanent pacemaker implantation. For which potential complication should the nurse most closely assess this patient? A) Chest pain B) Bleeding at the implantation site C) Malignant hyperthermia D) Bradycardia

Ans: Bleeding at the implantation site Feedback: Bleeding, hematomas, local infections, perforation of the myocardium, and tachycardia are complications of pacemaker implantations. The nurse should monitor for chest pain and bradycardia, but bleeding is a more common immediate complication. Malignant hyperthermia is unlikely because it is a response to anesthesia administration.

The nurse is caring for a patient who has had a dysrhythmic event. The nurse is aware of the need to assess for signs of diminished cardiac output (CO). What change in status may signal to the nurse a decrease in cardiac output? A) Increased blood pressure B) Bounding peripheral pulses C) Changes in level of consciousness D) Skin flushing

Ans: Changes in level of consciousness Feedback: The nurse conducts a physical assessment to confirm the data obtained from the history and to observe for signs of diminished cardiac output (CO) during the dysrhythmic event, especially changes in level of consciousness. Blood pressure tends to decrease with lowered CO and bounding peripheral pulses are inconsistent with this problem. Pallor, not skin flushing, is expected.

A patient converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin and Cardizem are given. The nurse caring for the patient understands that the main goal of treatment is what? treatment is what? A) Decrease SA node conduction B) Control ventricular heart rate C) Improve oxygenation D) Maintain anticoagulation

Ans: Control ventricular heart rate Feedback: Treatment for atrial fibrillation is to terminate the rhythm or to control ventricular rate. This is a priority because it directly affects cardiac output. A rapid ventricular response reduces the time for ventricular filling, resulting in a smaller stroke volume. Control of rhythm is the initial treatment of choice, followed by anticoagulation with heparin and then Coumadin.

A nurse is caring for a patient who is exhibiting ventricular tachycardia (VT). Because the patient is pulseless, the nurse should prepare for what intervention? A) Defibrillation B) ECG monitoring C) Implantation of a cardioverter defibrillator D) Angioplasty

Ans: Defibrillation Feedback: Any type of VT in a patient who is unconscious and without a pulse is treated in the same manner as ventricular fibrillation: Immediate defibrillation is the action of choice. ECG monitoring is appropriate, but this is an assessment, not an intervention, and will not resolve the problem. An ICD and angioplasty do not address the dysrhythmia.

A patient is scheduled for catheter ablation therapy. When describing this procedure to the patient's family, the nurse should address what aspect of the treatment? A) Resetting of the heart's contractility B) Destruction of specific cardiac cells C) Correction of structural cardiac abnormalities D) Clearance of partially occluded coronary arteries

Ans: Destruction of specific cardiac cells Feedback: Catheter ablation destroys specific cells that are the cause or central conduction route of a tachydysrhythmia. It does not "reset" the heart's contractility and it does not address structural or vascular abnormalities.

A patient is admitted to the cardiac care unit for an electrophysiology (EP) study. What goal should guide the planning and execution of the patient's care? A) Ablate the area causing the dysrhythmia. B) Freeze hypersensitive cells. C) Diagnose the dysrhythmia. D) Determine the nursing plan of care.

Ans: Diagnose the dysrhythmia. Feedback: A patient may undergo an EP study in which electrodes are placed inside the heart to obtain an intracardiac ECG. This is used not only to diagnose the dysrhythmia but also to determine the most effective treatment plan. However, because an EP study is invasive, it is performed in the hospital and may require that the patient be admitted.

Following cardiac resuscitation, a patient has been placed in a state of mild hypothermia before being transferred to the cardiac intensive care unit. The nurse's assessment reveals that the patient is experiencing neuromuscular paralysis. How should the nurse best respond? A) Administer hypertonic IV solution. B) Administer a bolus of warned normal saline. C) Reassess the patient in 15 minutes. D) Document this as an expected assessment finding

Ans: Document this as an expected assessment finding. Feedback: The nurse caring for a patient with hypothermia (passive or induced) needs to monitor for appropriate level of cooling, sedation, and neuromuscular paralysis to prevent seizures; myoclonus; and shivering. Neuromuscular paralysis is an expected finding and does not necessitate further interventions.

The ED nurse is caring for a patient who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform? A) Place gel pads over the apex and posterior chest for better conduction. B) Ensure no one is touching the patient at the time shock is delivered. C) Continue to ventilate the patient via endotracheal tube during the procedure. D) Allow at least 3 minutes between shocks.

Ans: Ensure no one is touching the patient at the time shock is delivered. Feedback: In external defibrillation, both paddles may be placed on the front of the chest, which is the standard paddle placement. Whether using pads, or paddles, the nurse must observe two safety measures. First, maintain good contact between the pads or paddles and the patient's skin to prevent leaking. Second, ensure that no one is in contact with the patient or with anything that is touching the patient when the defibrillator is discharged, to minimize the chance that electrical current will be conducted to anyone other than the patient. Ventilation should be stopped during defibrillation.

The nurse and the other members of the team are caring for a patient who converted to ventricular fibrillation (VF). The patient was defibrillated unsuccessfully and the patient remains in VF. According to national standards, the nurse should anticipate the administration of what medication? treatment is what? A) Decrease SA node conduction B) Control ventricular heart rate C) Improve oxygenation D) Maintain anticoagulation

Ans: Epinephrine 1 mg IV push Feedback: Epinephrine should be administered as soon as possible after the first unsuccessful defibrillation and then every 3 to 5 minutes. Antiarrhythmic medications such as amiodarone and licocaine are given if ventricular dysrhythmia persists.

An adult patient with third-degree AV block is admitted to the cardiac care unit and placed on continuous cardiac monitoring. What rhythm characteristic will the ECG most likely show? A) PP interval and RR interval are irregular. B) PP interval is equal to RR interval. C) Fewer QRS complexes than P waves D) PR interval is constant.

Ans: Fewer QRS complexes than P waves Feedback: In third-degree AV block, no atrial impulse is conducted through the AV node into the ventricles. As a result, there are impulses stimulating the atria and impulses stimulating the ventricles. Therefore, there are more P waves than QRS complexes due to the difference in the natural pacemaker (nodes) rates of the heart. The other listed ECG changes are not consistent with this diagnosis.

An ECG has been ordered for a newly admitted patient. What should the nurse do prior to electrode placement? A) Clean the skin with providone-iodine solution. B) Ensure that the area for electrode placement is dry. C) Apply tincture of benzoin to the electrode sites and wait for it to become "tacky." D) Gently abrade the skin by rubbing the electrode sites with dry gauze or cloth.

Ans: Gently abrade the skin by rubbing the electrode sites with dry gauze or cloth. Feedback: An ECG is obtained by slightly abrading the skin with a clean dry gauze pad and placing electrodes on the body at specific areas. The abrading of skin will enhance signal transmission. Disinfecting the skin is unnecessary and conduction gel is used.

When planning the care of a patient with an implanted pacemaker, what assessment should the nurse prioritize? A) Core body temperature B) Heart rate and rhythm C) Blood pressure D) Oxygen saturation level

Ans: Heart rate and rhythm Feedback: For patients with pacemakers, close monitoring of the heart rate and rhythm is a priority, even though each of the other listed vital signs must be assessed.

The nurse is assessing a patient who had a pacemaker implanted 4 weeks ago. During the patient's most recent follow-up appointment, the nurse identifies data that suggest the patient may be socially isolated and depressed. What nursing diagnosis is suggested by these data? A) Decisional conflict related to pacemaker implantation B) Deficient knowledge related to pacemaker implantation C) Spiritual distress related to pacemaker implantation D) Ineffective coping related to pacemaker implantation

Ans: Ineffective coping related to pacemaker implantation Feedback: Depression and isolation may be symptoms of ineffective coping with the implantation. These psychosocial symptoms are not necessarily indicative of issues related to knowledge or decisions. Further data would be needed to determine a spiritual component to the patient's challenges.

The nurse is writing a plan of care for a patient with a cardiac dysrhythmia. What would be the most appropriate goal for the patient? A) Maintain a resting heart rate below 70 bpm. B) Maintain adequate control of chest pain. C) Maintain adequate cardiac output. D) Maintain normal cardiac structure.

Ans: Maintain adequate cardiac output. Feedback: For patient safety, the most appropriate goal is to maintain cardiac output to prevent worsening complications as a result of decreased cardiac output. A resting rate of less than 70 bpm is not appropriate for every patient. Chest pain is more closely associated with acute coronary syndrome than with dysrhythmias. Nursing actions cannot normally influence the physical structure of the heart.

The nurse is caring for an adult patient who has gone into ventricular fibrillation. When assisting with defibrillating the patient, what must the nurse do? A) Maintain firm contact between paddles and patient skin. B) Apply a layer of water as a conducting agent. C) Call "all clear" once before discharging the defibrillator. D) Ensure the defibrillator is in the sync mode.

Ans: Maintain firm contact between paddles and patient skin. Feedback: When defibrillating an adult patient, the nurse should maintain good contact between the paddles and the patient's skin to prevent arcing, apply an appropriate conducting agent (not water) between the skin and the paddles, and ensure the defibrillator is in the nonsync mode. "Clear" should be called three times before discharging the paddles.

A patient is undergoing preoperative teaching before his cardiac surgery and the nurse is aware that a temporary pacemaker will be placed later that day. What is the nurse's responsibility in the care of the patient's pacemaker? A) Monitoring for pacemaker malfunction or battery failure B) Determining when it is appropriate to remove the pacemaker C) Making necessary changes to the pacemaker settings D) Selecting alternatives to future pacemaker use

Ans: Monitoring for pacemaker malfunction or battery failure Feedback: Monitoring for pacemaker malfunctioning and battery failure is a nursing responsibility. The other listed actions are physician responsibilities.

A patient calls his cardiologist's office and talks to the nurse. He is concerned because he feels he is being defibrillated too often. The nurse tells the patient to come to the office to be evaluated because the nurse knows that the most frequent complication of ICD therapy is what? A) Infection B) Failure to capture C) Premature battery depletion D) Oversensing of dysrhythmias

Ans: Oversensing of dysrhythmias Feedback: Inappropriate delivery of ICD therapy, usually due to oversensing of atrial and sinus tachycardias with a rapid ventricular rate response, is the most frequent complication of ICD. Infections, failure to capture, and premature battery failure are less common.

The nurse is caring for a patient who has had an ECG. The nurse notes that leads I, II, and III differ from one another on the cardiac rhythm strip. How should the nurse best respond? A) Recognize that the view of the electrical current changes in relation to the lead placement. B) Recognize that the electrophysiological conduction of the heart differs with lead placement. C) Inform the technician that the ECG equipment has malfunctioned. D) Inform the physician that the patient is experiencing a new onset of dysrhythmia.

Ans: Recognize that the view of the electrical current changes in relation to the lead placement. Feedback: Each lead offers a different reference point to view the electrical activity of the heart. The lead displays the configuration of electrical activity of the heart. Differences between leads are not necessarily attributable to equipment malfunction or dysrhythmias.

The nurse is caring for a patient with refractory atrial fibrillation who underwent the maze procedure several months ago. The nurse reviews the result of the patient's most recent cardiac imaging, which notes the presence of scarring on the atria. How should the nurse best respond to this finding? A) Recognize that the procedure was unsuccessful. B) Recognize this as a therapeutic goal of the procedure. C) Liaise with the care team in preparation for repeating the maze procedure. D) Prepare the patient for pacemaker implantation.

Ans: Recognize this as a therapeutic goal of the procedure. Feedback: The maze procedure is an open heart surgical procedure for refractory atrial fibrillation. Small transmural incisions are made throughout the atria. The resulting formation of scar tissue prevents reentry conduction of the electrical impulse. Consequently, scar formation would constitute a successful procedure. There is no indication for repeating the procedure or implanting a pacemaker.

The nurse is caring for a patient who has had a biventricular pacemaker implanted. When planning the patient's care, the nurse should recognize what goal of this intervention? A) Resynchronization B) Defibrillation C) Angioplasty D) Ablation

Ans: Resynchronization Feedback: Biventricular (both ventricles) pacing, also called resynchronization therapy, may be used to treat advanced heart failure that does not respond to medication. This type of pacing therapy is not called defibrillation, angioplasty, or ablation therapy.

A patient has undergone diagnostic testing and received a diagnosis of sinus bradycardia attributable to sinus node dysfunction. When planning this patient's care, what nursing diagnosis is most appropriate? A) Acute pain B) Risk for unilateral neglect C) Risk for activity intolerance D) Risk for fluid volume excess

Ans: Risk for activity intolerance Feedback: Sinus bradycardia causes decreased cardiac output that is likely to cause activity intolerance. It does not typically cause pain, fluid imbalances, or neglect of a unilateral nature.

A group of nurses are participating in orientation to a telemetry unit. What should the staff educator tell this class about ST segments? A) They are the part of an ECG that reflects systole. B) They are the part of an ECG used to calculate ventricular rate and rhythm. C) They are the part of an ECG that reflects the time from ventricular depolarization through repolarization. D) They are the part of an ECG that represents early ventricular repolarization.

Ans: They are the part of an ECG that represents early ventricular repolarization. Feedback: ST segment is the part of an ECG that reflects the end of the QRS complex to the beginning of the T wave. The part of an ECG that reflects repolarization of the ventricles is the T wave. The part of an ECG used to calculate ventricular rate and rhythm is the RR interval. The part of an ECG that reflects the time from ventricular depolarization through repolarization is the QT interval.

The nurse caring for a patient whose sudden onset of sinus bradycardia is not responding adequately to atropine. What might be the treatment of choice for this patient? A) Implanted pacemaker B) Trancutaneous pacemaker C) ICD D) Asynchronous defibrillator

Ans: Trancutaneous pacemaker Feedback: If a patient suddenly develops a bradycardia, is symptomatic but has a pulse, and is unresponsive to atropine, emergency pacing may be started with transcutaneous pacing, which most defibrillators are now equipped to perform. An implanted pacemaker is not a time-appropriate option. An asynchronous defibrillator or ICD would not provide relief.

The staff educator is teaching a CPR class. Which of the following aspects of defibrillation should the educator stress to the class? A) Apply the paddles directly to the patient's skin. B) Use a conducting medium between the paddles and the skin. C) Always use a petroleum-based gel between the paddles and the skin. D) Any available liquid can be used between the paddles and the skin.

Ans: Use a conducting medium between the paddles and the skin. Feedback: Use multifunction conductor pads or paddles with a conducting medium between the paddles and the skin (the conducting medium is available as a sheet, gel, or paste). Do not use gels or pastes with poor electrical conductivity.

A nurse is providing health education to a patient scheduled for cryoablation therapy. The nurse should describe what aspect of this treatment? A) Peeling away the area of endocardium responsible for the dysrhythmia B) Using electrical shocks directly to the endocarduim to eliminate the source of dysrhythmia C) Using high-frequency sound waves to eliminate the source of dysrhythmia D) Using a cooled probe to eliminate the source of dysrhythmia

Ans: Using a cooled probe to eliminate the source of dysrhythmia Feedback: Cryoablation therapy involves using a cooled probe to create a small scar on the endocardium to eliminate the source of the dysrhythmias. Endocardium resection involves peeling away a specified area of the endocardium. Electrical ablation involves using shocks to eliminate the area causing the dysrhythmias. Radio frequency ablation uses high-frequency sound waves to destroy the area causing the dysrhythmias.

The nurse is caring for a patient who has just had an implantable cardioverter defibrillator (ICD) placed. What is the priority area for the nurse's assessment? A) Assessing the patient's activity level B) Facilitating transthoracic echocardiography C) Vigilant monitoring of the patient's ECG D) Close monitoring of the patient's peripheral perfusion

Ans: Vigilant monitoring of the patient's ECG Feedback: After a permanent electronic device (pacemaker or ICD) is inserted, the patient's heart rate and rhythm are monitored by ECG. This is a priority over peripheral circulation and activity. Echocardiography is not indicated.

The nurse is caring for a patient on telemetry. The patient's ECG shows a shortened PR interval, slurring of the initial QRS deflection, and prolonged QRS duration. What does this ECG show? A) Sinus bradycardia B) Myocardial infarction C) Lupus-like syndrome D) Wolf-Parkinson-White (WPW) syndrome

Ans: Wolf-Parkinson-White (WPW) syndrome Feedback: In WPW syndrome there is a shortened PR interval, slurring (called a delta wave) of the initial QRS deflection, and prolonged QRS duration. These characteristics are not typical of the other listed cardiac anomalies.

The nurse caring for a patient with a dysrhythmia understands that the P wave on an electrocardiogram (ECG) represents what phase of the cardiac cycle?

Atrial depolarization

A client presents to the emergency department via ambulance with a heart rate of 210 beats/minute and a sawtooth waveform pattern per cardiac monitor. The nurse is most correct to alert the medical team of the presence of a client with which disorder?

Atrial flutter

A nurse is caring for a client who's experiencing sinus bradycardia with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mm Hg and he complains of dizziness. Which medication does the nurse anticpate administering to treat his bradycardia?

Atropine

A nurse is completing a shift assessment on a patient admitted to the telemetry unit with a diagnosis of syncope. The patient's heart rate is 55 bpm with a blood pressure of 90/66 mm Hg. The patient is also experiencing dizziness and shortness of breath. Which of the following medications will the nurse anticipate administering to the patient based on these clinical findings?

Atropine

The patient is told that she has second-degree AV block with symptomatic bradycardia. The patient will be treated with an anticholinergic that blocks the effects of the vagal nerve. Choose the most likely drug that will be prescribed.

Atropine sulfate

A few days after an acute MI, a patient complains of stabbing chest pain that increases with deep breathing. Which action will the nurse take first?

Auscultate the heart sounds.

A patient tells the nurse "my heart is skipping beats again; I'm having palpitations." After completing a physical assessment, the nurse concludes the patient is experiencing occasional premature atrial complexes (PACs). The nurse should instruct the patient to complete which of the following?

Avoid caffeinated beverages.

Physiological Integrity 39. To improve the physical activity level for a mildly obese 71-year-old patient, which action should the nurse plan to take? a. Stress that weight loss is a major benefit of increased exercise. b. Determine what kind of physical activities the patient usually enjoys. c. Tell the patient that older adults should exercise for no more than 20 minutes at a time. d. Teach the patient to include a short warm-up period at the beginning of physical activity.

B Because patients are more likely to continue physical activities that they already enjoy, the nurse will plan to ask the patient about preferred activities. The goal for older adults is 30 minutes of moderate activity on most days. Older adults should plan for a longer warm-up period. Benefits of exercises, such as improved activity tolerance, should be emphasized rather than aiming for significant weight loss in older mildly obese adults. DIF: Cognitive Level: Apply (application) REF: 761 TOP: Nursing Process: Planning MSC:

Psychosocial Integrity 20. When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that a. sudden cardiac death events rarely reoccur. b. additional diagnostic testing will be required. c. long-term anticoagulation therapy will be needed. d. limited physical activity after discharge will be needed to prevent future events.

B Diagnostic testing (e.g., stress test, Holter monitor, electrophysiologic studies, cardiac catheterization) is used to determine the possible cause of the SCD and treatment options. SCD is likely to recur. Anticoagulation therapy will not have any effect on the incidence of SCD, and SCD can occur even when the patient is resting. DIF: Cognitive Level: Apply (application) REF: 762 TOP: Nursing Process: Planning MSC:

Physiological Integrity 21. A 19-year-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 premature ventricular contractions (PVCs). What action should the nurse take next? a. Start supplemental O2 at 2 to 3 L/min via nasal cannula. b. Ask the patient about current stress level and caffeine use. c. Ask the patient about any history of coronary artery disease. d. Have the patient taken to the hospital emergency department (ED).

B In a patient with a normal heart, occasional PVCs are a benign finding. The timing of the PVCs suggests stress or caffeine as possible etiologic factors. It is unlikely that the patient has coronary artery disease, and this should not be the first question the nurse asks. The patient is hemodynamically stable, so there is no indication that the patient needs to be seen in the ED or that oxygen needs to be administered. DIF: Cognitive Level: Apply (application) REF: 799 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Physiological Integrity 34. For a patient who has been admitted the previous day to the coronary care unit with an AMI, the nurse will anticipate teaching the patient about a. the pathophysiology of coronary artery disease. b. when patient cardiac rehabilitation will begin. c. home-discharge drugs such as aspirin and -blockers. d. typical emotional responses to MI.

B Rationale: At this time, the patient's anxiety level or denial will prevent good understanding of complex information such as CAD pathophysiology. Teaching about discharge medications should be done when the time for discharge is closer. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional response to MI. Cognitive Level: Application Text Reference: p. 813 Nursing Process: Planning

Safe and Effective Care Environment 26. When analyzing the waveforms of a patient's ECG, the nurse will need to investigate further upon finding a a. PR interval of 0.18 second. b. QRS interval of 0.14 second. c. T wave of 0.16 second. d. QT interval of 0.34 second.

B Rationale: Because the normal QRS interval is 0.04 to 0.10 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 the normal range. T-wave intervals are not measured when monitoring ECGs. Cognitive Level: Application Text Reference: p. 847 Nursing Process: Assessment

Physiological Integrity 28. A few days after experiencing an MI, the patient states, "I just had a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which nursing intervention is appropriate to include in the nursing care plan? a. Have the family members encourage the patient to continue planning for the vacation. b. Allow the use of denial as a coping mechanism until the patient begins asking questions about the MI. c. Implement reality orientation by reminding the patient several times a day about the MI. d. Begin teaching the patient about the normal functions of the heart to improve understanding of the MI.

B Rationale: Denial is a normal coping mechanism after an acute episode like an MI; waiting until the patient asks questions will improve the patient's ability to take in needed information. The patient should not be encouraged to leave for a vacation during the MI recovery period. Reminding the patient about the MI is likely to make the patient angry and lead to distrust of the nursing staff. The patient in denial will not be interested in learning about the normal functions of the heart. Cognitive Level: Application Text Reference: p. 814 Nursing Process: Planning

Physiological Integrity 8. A patient has a normal cardiac rhythm strip except that the PR interval is 0.34 seconds. The appropriate intervention by the nurse is to a. prepare the patient for temporary pacemaker insertion. b. document the finding and continue to monitor the patient. c. notify the health care provider immediately. d. administer atropine per protocol.

B Rationale: First-degree atrioventricular (AV) block is asymptomatic and requires ongoing monitoring because it may progress to more serious forms of heart block. The rate is normal, so there is no indication that atropine or a pacemaker is needed. Immediate notification of the health care provider about an asymptomatic rhythm is not necessary. Cognitive Level: Application Text Reference: p. 853 Nursing Process: Implementation

Physiological Integrity 27. When caring for a patient who has survived a sudden cardiac death (SCD) event and has no evidence of an AMI, the nurse will anticipate teaching the patient a. that sudden cardiac death events rarely reoccur. b. about the purpose of outpatient Holter monitoring. c. how to self-administer low-molecular-weight heparin. d. to limit activities after discharge to prevent future events.

B Rationale: Holter monitoring is used to determine whether the patient is experiencing dysrhythmias such as ventricular tachycardia during normal daily activities. SCD is likely to recur. Heparin will not have any effect on the incidence of SCD, which can occur even when the patient is resting. Cognitive Level: Application Text Reference: p. 818 Nursing Process: Planning

Physiological Integrity 7. A nursing action that is indicated for the collaborative problem of potential complication: cardiac dysrhythmia in a patient who has had a repair of a descending thoracic aortic aneurysm is to a. assess level of consciousness and orientation hourly. b. titrate oxygen to keep O2 saturation greater than 90%. c. turn the patient every 1 to 2 hours while on bed rest. d. monitor hourly fluid intake and urine output levels.

B Rationale: Hypoxemia may precipitate dysrhythmias in patients after aneurysm repair. Neurologic assessments, turning the patient, and monitoring intake and output are also appropriate nursing actions after aneurysm repair but will not have an effect on dysrhythmias. Cognitive Level: Application Text Reference: p. 897 Nursing Process: Implementation

Physiological Integrity 19. A patient who has a history of sudden cardiac death has an ICD inserted. When performing discharge teaching with the patient, it is important for the nurse to instruct the patient and family that a. medications will no longer be needed to control dysrhythmias. b. if the ICD fires and the patient loses consciousness, 911 should be called. c. CPR may displace the ICD leads and should not be performed. d. the ICD rarely triggers airport security alarms and travel without restrictions is allowed.

B Rationale: If the ICD fires and the patient continues to have symptoms of cardiac arrest, activation of the emergency response system is indicated. The patient is likely to continue on medications to control dysrhythmias. If the patient experiences cardiac arrest, CPR should be performed. ICDs do trigger airport security alarms, and the patient will need to notify airport personnel about the presence of the device. Cognitive Level: Application Text Reference: p. 858 Nursing Process: Implementation

Physiological Integrity 23. A 21-year-old college student arrives at the student health center at the end of the quarter complaining, "My heart is skipping beats." The nurse obtains an ECG and notes the presence of occasional PVCs. What action should the nurse take first? a. Ask the patient about any history of coronary artery disease. b. Question the patient about current stress level and coffee use. c. Have the patient transported to the hospital ED. d. Administer O2 to the patient at 2 to 3 L/min using nasal prongs.

B Rationale: In a patient with a normal heart, occasional PVCs are a benign finding. The timing of the PVCs suggests stress or caffeine as possible etiologic factors. It is unlikely that the patient has coronary artery disease, and this should not be the first question the nurse asks. There is no indication that the patient needs to be seen in the ED or that oxygen needs to be administered. Cognitive Level: Application Text Reference: pp. 847, 854 Nursing Process: Implementation

Physiological Integrity 24. A 19-year-old student has a mandatory ECG before participating on a college swim team and is found to have sinus bradycardia, rate 52. BP is 114/54, and the student denies any health problems. What action by the nurse is appropriate? a. Refer the student to a cardiologist for further assessment. b. Allow the student to participate on the swim team. c. Obtain more detailed information about the student's health history. d. Tell the student to stop swimming immediately if any dyspnea occurs.

B Rationale: 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 health history. Dyspnea during an aerobic activity such as swimming is normal. Cognitive Level: Application Text Reference: p. 849 Nursing Process: Implementation

Physiological Integrity 12. Nifedipine (Procardia) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that Procardia will a. help to prevent clotting in the coronary arteries. b. decrease spasm of the coronary arteries. c. increase the force of myocardial contraction. d. reduce the "fight or flight" response.

B Rationale: Prinzmetal's angina is caused by coronary artery spasm. Calcium-channel blockers (e.g., nifedipine) are a first-line therapy for this type of angina. Platelet inhibitors, such as aspirin, help to prevent coronary artery thrombosis, and -blockers decrease sympathetic stimulation of the heart. Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing oxygen demand. Cognitive Level: Application Text Reference: p. 801 Nursing Process: Implementation

Physiological Integrity Lewis: Medical-Surgical Nursing, 7th Edition Test Bank Chapter 36: Nursing Management: Dysrhythmias MULTIPLE CHOICE 1. In analyzing a patient's electrocardiographic (ECG) rhythm strip, the nurse uses the knowledge that the time of the conduction of an impulse through the Purkinje fibers is represented by the a. P wave. b. PR interval. c. QRS complex. d. QT interval.

B Rationale: The PR interval represents depolarization of the atria, AV node, bundle of His, bundle branches, and the Purkinje fibers, up to the point of depolarization of the ventricular cells. The P wave represents atrial depolarization. The QRS represents ventricular depolarization. The QT interval represents depolarization of the depolarization and repolarization of the entire conduction system. Cognitive Level: Comprehension Text Reference: pp. 846-847 Nursing Process: Assessment

Physiological Integrity 10. The nurse reviews data from the cardiac monitor indicating that a patient with a myocardial infarction experienced a 50-second episode of ventricular tachycardia before a sinus rhythm and a heart rate of 98 were re-established. The most appropriate initial action by the nurse is to a. notify the health care provider. b. administer IV antidysrhythmic drugs per protocol. c. defibrillate the patient. d. document the rhythm and continue to monitor the patient.

B Rationale: 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 medications are administered. Defibrillation is not indicated given that the patient is currently in a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation. Cognitive Level: Application Text Reference: p. 855 Nursing Process: Implementation

Physiological Integrity 22. A patient develops sinus bradycardia at a rate of 32 beats/min, has a BP of 80/36 mm Hg, and is complaining of feeling faint. Which action should the nurse take? a. Continue to monitor the rhythm and BP. b. Obtain and apply the transcutaneous pacemaker (TCP). c. Give the scheduled dose of diltiazem (Cardizem). d. Have the patient perform the Valsalva maneuver.

B Rationale: 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. Cognitive Level: Application Text Reference: p. 859 Nursing Process: Implementation

Physiological Integrity 26. A patient who has developed acute pulmonary edema is hospitalized and diagnosed with dilated cardiomyopathy. Which information will the nurse plan to include when teaching the patient about management of this disorder? a. Careful compliance with diet and medications will control the patient's symptoms. b. Notify the doctor about any symptoms of heart failure such as shortness of breath. c. No more than one or two alcoholic drinks daily are permitted. d. Elevating the legs above the heart will help relieve angina.

B Rationale: The patient should be instructed to notify the health care provider about any worsening of heart failure symptoms. Because dilated cardiomyopathy does not respond well to therapy, even patients with good compliance with therapy may have recurrent episodes of heart failure. The patient is instructed to avoid alcoholic beverages. Elevation of the legs above the heart will worsen symptoms (although this approach is appropriate for a patient with hypertrophic cardiomyopathy). Cognitive Level: Application Text Reference: pp. 886, 888 Nursing Process: Planning

Physiological Integrity 7. When caring for a patient with ACS who has returned to the coronary care unit after having a PCI, the nurse obtains these assessment data. Which data indicate the need for immediate intervention by the nurse? a. Heart rate 100 beats/min b. Chest pain level 8 on a 10-point scale c. Blood pressure (BP) 104/56 mm Hg d. Pedal pulses 2+

B Rationale: The patient's chest pain may indicate that restenosis of the coronary artery is occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse. Cognitive Level: Application Text Reference: p. 807 Nursing Process: Assessment

Physiological Integrity 25. Two days after having an MI, a patient tells the nurse, "I wish I had died when I had this heart attack. I won't be able to do anything now." The most appropriate nursing diagnosis is a. ineffective coping related to depression and anxiety. b. situational low self-esteem related to perceived role changes. c. impaired adjustment related to unwillingness to alter lifestyle. d. ineffective health maintenance related to lack of knowledge.

B Rationale: The patient's statements indicate that the perceived change in role is the major concern. The patient is experiencing progression through the normal stages of loss and grief that often occur after an MI, so ineffective coping is not an appropriate diagnosis. There is no evidence to support an unwillingness to alter lifestyle or ineffective health maintenance. Cognitive Level: Application Text Reference: pp. 813-814 Nursing Process: Diagnosis

Physiological Integrity 4. When reviewing the 12-lead ECG for a healthy 86-year-old patient who is having an annual physical examination, which of these observations will be of most concern to the nurse? a. The PR interval is 0.21 seconds. b. The HR is 43 beats/min. c. There is a right bundle-branch block. d. There is a QRS duration of 0.13 seconds.

B Rationale: The resting HR does not change with aging, so the decrease in HR requires further investigation. Bundle-branch block and slight increases in PR interval or QRS duration are common in older individuals because of increases in conduction time through the AV node, the bundle of His, and the bundle branches. Cognitive Level: Application Text Reference: p. 744 Nursing Process: Assessment

Physiological Integrity 7. The nurse determines that a patient has ventricular bigeminy when the rhythm strip indicates that a. there are pairs of wide and distorted QRS complexes. b. every other QRS complex is wide and starts prematurely. c. all QRS complexes are wide and the rate is 150 to 250 beats/min. d. there are premature QRS complexes with two different shapes.

B Rationale: Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking. Pairs of wide QRS complexes are described as couplets. Wide QRS complexes at a rate of 150 to 250 indicate ventricular tachycardia. Wide QRS complexes with different shapes are described as multifocal premature ventricular contractions (PVCs). Cognitive Level: Comprehension Text Reference: p. 854 Nursing Process: Assessment

Physiological Integrity 23. A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about when sexual intercourse can be resumed. Which response by the nurse is best? a. "Most patients are able to enjoy intercourse without any complications." b. "Sexual activity uses about as much energy as climbing two flights of stairs." c. "The doctor will provide sexual guidelines when your heart is strong enough." d. "Holding and cuddling are good ways to maintain intimacy after a heart attack."

B Sexual activity places about as much physical stress on the cardiovascular system as most moderate-energy activities such as climbing two flights of stairs. The other responses do not directly address the patient's question or may not be accurate for this patient. DIF: Cognitive Level: Apply (application) REF: 761 TOP: Nursing Process: Implementation MSC:

Physiological Integrity 28. Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider? a. Complaints of incisional chest pain b. Pallor and weakness of the right hand c. Fine crackles heard at both lung bases d. Redness on both sides of the sternal incision

B The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions such as prescribed calcium channel blockers or surgery. The other changes are expected and/or require nursing interventions. DIF: Cognitive Level: Apply (application) REF: 752 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:

Physiological Integrity 13. When titrating IV nitroglycerin (Tridil) for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication? a. Monitor heart rate. b. Ask about chest pain. c. Check blood pressure. d. Observe for dysrhythmias.

B The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse also will monitor heart rate and blood pressure (BP) and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective. DIF: Cognitive Level: Apply (application) REF: 753 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 40. Which patient at the cardiovascular clinic requires the most immediate action by the nurse? a. Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL b. Patient with stable angina whose chest pain has recently increased in frequency c. Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL d. Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg

B The history of more frequent chest pain suggests that the patient may have unstable angina, which is part of the acute coronary syndrome spectrum. This will require rapid implementation of actions such as cardiac catheterization and possible percutaneous coronary intervention. The data about the other patients suggest that their conditions are stable. DIF: Cognitive Level: Analyze (analysis) REF: 743 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Planning MSC:

Physiological Integrity 24. A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic and has no palpable pulses. What is the first action that the nurse should take? a. Perform synchronized cardioversion. b. Start cardiopulmonary resuscitation (CPR). c. Administer atropine per agency dysrhythmia protocol. d. Provide supplemental oxygen via non-rebreather mask.

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. DIF: Cognitive Level: Apply (application) REF: 800 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Physiological Integrity 5. The nurse notes that a patient's cardiac monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm? a. Ventricular couplets b. Ventricular bigeminy c. Ventricular R-on-T phenomenon d. Multifocal premature ventricular contractions

B Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking. Pairs of wide QRS complexes are described as ventricular couplets. There is no indication that the premature ventricular contractions (PVCs) are multifocal or that the R-on-T phenomenon is occurring. DIF: Cognitive Level: Apply (application) REF: 799 TOP: Nursing Process: Assessment MSC:

Safe and Effective Care Environment 13. 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.

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. DIF: Cognitive Level: Apply (application) REF: 802 TOP: Nursing Process: Implementation MSC:

6. The intensive care unit (ICU) nurse educator will determine that teaching about arterial pressure monitoring for a new staff nurse has been effective when the nurse a. balances and calibrates the monitoring equipment every 2 hours. b. positions the zero-reference stopcock line level with the phlebostatic axis. c. ensures that the patient is supine with the head of the bed flat for all readings. d. rechecks the location of the phlebostatic axis when changing the patient's position.

B For accurate measurement of pressures, the zero-reference level should be at the phlebostatic axis. There is no need to rebalance and recalibrate monitoring equipment hourly. Accurate hemodynamic readings are possible with the patient's head raised to 45 degrees or in the prone position. The anatomic position of the phlebostatic axis does not change when patients are repositioned.

A patient develops sinus bradycardia at a rate of 32 beats/minute, has a BP of 80/36 mm Hg, and is complaining of feeling faint. Which action should the nurse take? A) a. Continue to monitor the rhythm and BP. B) b. Apply the transcutaneous pacemaker (TCP). C) c. Have the patient perform the Valsalva maneuver. D) d. Give the scheduled dose of diltiazem (Cardizem).

B) b. Apply the transcutaneous pacemaker (TCP).

When caring for a patient who has survived a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient A) a. that sudden cardiac death events rarely reoccur. B) b. about the purpose of outpatient Holter monitoring. C) c. how to self-administer low-molecular-weight heparin. D) d. to limit activities after discharge to prevent future events.

B) b. about the purpose of outpatient Holter monitoring.

Physiological Integrity OTHER 1. When a patient requires defibrillation, in which order will the nurse accomplish the following steps? a. Place the paddles on the patient's chest. b. Turn the defibrillator on. c. Check the location of other personnel and call out "all clear." d. Select the appropriate energy level. e. Deliver the electrical charge.

B, D, A, C, E Rationale: This order will result in rapid defibrillation without endangering hospital personnel. Cognitive Level: Application Text Reference: p. 857 Nursing Process: Implementation

An elderly patient with a 40-pack-year history of smoking and a recent myocardial infarction is admitted to the medical unit with acute shortness of breath; the nurse need to rule out pneumonia versus heart failure. The diagnostic test that the nurse will monitor to help in determining whether the patient has heart failure is ______________

B-type natriuretic peptide (BNP).

A patient develops sinus bradycardia at a rate of 32 beats/minute, has a BP of 80/36 mm Hg, and is complaining of feeling faint. Which action should the nurse take? A. Continue to monitor the rhythm and BP. B. Apply the transcutaneous pacemaker (TCP). C. Have the patient perform the Valsalva maneuver. D. Give the scheduled dose of diltiazem (Cardizem).

B. Apply the transcutaneous pacemaker (TCP). 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 nurse is watching the cardiac monitor, and a patient's rhythm suddenly changes. There are no P waves. Instead there are fine, wavy lines between the QRS complexes. The QRS complexes measure 0.08 sec (narrow), but they occur irregularly with a rate of 120 beats/min. The nurse correctly interprets this rhythm as what? A. Sinus tachycardia B. Atrial fibrillation C. Ventricular fibrillation D. Ventricular tachycardia

B. Atrial fibrillation is represented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atria are not truly contracting, just fibrillating. Sinus tachycardia is a sinus rate above 100 beats/minute with normal P waves. Ventricular fibrillation is seen on the ECG without a visible P wave; an unmeasurable heart rate, PR or QRS; and the rhythm is irregular and chaotic. Ventricular tachycardia is seen as three or more premature ventricular contractions (PVCs) that have distorted QRS complexes with regular or irregular rhythm, and the P wave is usually buried in the QRS complex without a measurable PR interval.

A patient who is on the telemetry unit develops atrial flutter, rate 150, with associated dyspnea and diaphoresis. Which of these actions that are included in the hospital dysrhythmia protocol should the nurse take first? A. Obtain a 12-lead electrocardiogram (ECG). B. Give O2 at 3 to 4 L/min. C. Take the patient's blood pressure and respiratory rate. D. Notify the health care provider of the change in rhythm.

B. Give O2 at 3 to 4 L/min. Since this patient has dyspnea in association with the new rhythm, the nurse's initial actions should be to address the patient's airway, breathing, and circulation (ABC) by oxygen

The patient has atrial fibrillation with a rapid ventricular response. The nurse knows to prepare for which treatment if an electrical treatment is planned for this patient? A. Defibrillation B. Synchronized cardioversion C. Automatic external defibrillator (AED) D. Implantable cardioverter-defibrillator (ICD)

B. Synchronized cardioversion is planned for a patient with supraventricular tachydysrhythmias (atrial fibrillation with a rapid ventricular response). Defibrillation or AEDs are the treatment of choice to end ventricular fibrillation and pulseless ventricular tachycardia (VT). An ICD is used with patients who have survived sudden cardiac death (SCD), have spontaneous sustained VT, and are at high risk for future life-threatening dysrhythmias.

The patient is admitted with acute coronary syndrome (ACS). The ECG shows ST-segment depression and T-wave inversion. What should the nurse know that this indicates? A. Myocardia injury B. Myocardial ischemia C. Myocardial infarction D. A pacemaker is present

B. The ST depression and T wave inversion on the ECG of a patient diagnosed with ACS indicate myocardial ischemia from inadequate supply of blood and oxygen to the heart. Myocardial injury is identified with ST-segment elevation. Myocardial infarction is identified with ST-segment elevation and a widened and deep Q wave. A pacemaker's presence is evident on the ECG by a spike leading to depolarization and contraction.

Which information collected by the nurse who is admitting a patient with chest pain suggests that the pain is caused by an acute myocardial infarction (AMI)? A. The pain increases with deep breathing. B. The pain has persisted longer than 30 minutes. C. The pain worsens when the patient raises the arms. D. The pain is relieved after the patient takes nitroglycerin.

B. The pain has persisted longer than 30 minutes.

When admitting a patient for a coronary arteriogram and angiogram, which information about the patient is most important to communicate to the health care provider? A. The patient's pedal pulses are +1. B. The patient is allergic to shellfish. C. The patient has not eaten anything today. D. The patient had an arteriogram a year ago.

B. The patient is allergic to shellfish. The contrast is iodine

The nurse is doing discharge teaching with the patient and spouse of the patient who just received an implantable cardioverter-defibrillator (ICD) in the left side. Which statement by the patient indicates to the nurse that the patient needs more teaching? A. "I will call the cardiologist if my ICD fires." B. "I cannot fly because it will damage the ICD." C. "I cannot move my left arm until it is approved." D. "I cannot drive until my cardiologist says it is okay."

B. The patient statement that flying will damage the ICD indicates misunderstanding about flying. The patient should be taught that informing TSA about the ICD can be done because it may set off the metal detector and if a hand-held screening wand is used, it should not be placed directly over the ICD. The other options indicate the patient understands the teaching.

The nurse obtains a 6-second rhythm strip and charts the following analysis: Tab 1 Tab 2 Tab 3 Atrial data Ventricular data Additional data Rate: 70, regular Variable PR interval Independent beats Rate: 40, regular Isolated escape beats QRS: 0.04 sec P wave and QRS complexes unrelated What is the correct interpretation of this rhythm strip? A. Sinus arrhythmias B. Third-degree heart block C. Wenckebach phenomenon D. Premature ventricular contractions

B. Third-degree heart block represents a loss of communication between the atrium and ventricles from AV node dissociation. This is depicted on the rhythm strip as no relationship between the P waves (representing atrial contraction) and QRS complexes (representing ventricular contraction). The atria are beating totally on their own at 70 beats/min, whereas the ventricles are pacing themselves at 40 beats/min. Sinus dysrhythmia is seen with a slower heart rate with exhalation and an increased heart rate with inhalation. In Wenckebach heart block, there is a gradual lengthening of the PR interval until an atrial impulse is nonconducted and a QRS complex is blocked or missing. Premature ventricular contractions (PVCs) are the early occurrence of a wide, distorted QRS complex.

The nurse notes that a patient's cardiac monitor shows that every other beat is earlier than expected, has no P wave, and has a QRS complex with a wide and bizarre shape. How will the nurse document the rhythm? A. Ventricular couplets B. Ventricular bigeminy C. Ventricular R-on-T phenomenon D. Ventricular multifocal contractions

B. Ventricular bigeminy Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking. Pairs of wide QRS complexes are described as couplets. There is no indication that the premature ventricular contractions (PVCs) are multifocal or that the R-on-T phenomenon is occurring.

The nurse in the intensive care unit (ICU) hears an alarm sound in the patient's room. Arriving in the room, the patient is unresponsive, without a pulse, and a flat line on the monitor. What is the first action by the nurse?

Begin cardiopulmonary resuscitation (CPR)

A nurse is providing morning care for a patient in the ICU. Suddenly, the bedside monitor shows ventricular fibrillation and the patient becomes unresponsive. After calling for assistance, what action should the nurse take next?

Begin cardiopulmonary resuscitation.

Physiological Integrity 6. A patient has a normal cardiac rhythm and a heart rate of 72 beats/minute. The nurse determines that the P-R interval is 0.24 seconds. The most appropriate intervention by the nurse would be to a. notify the health care provider immediately. b. give atropine per agency dysrhythmia protocol. c. prepare the patient for temporary pacemaker insertion. d. document the finding and continue to monitor the patient.

D First-degree atrioventricular (AV) block is asymptomatic and requires ongoing monitoring because it may progress to more serious forms of heart block. The rate is normal, so there is no indication that atropine is needed. Immediate notification of the health care provider about an asymptomatic rhythm is not necessary. DIF: Cognitive Level: Apply (application) REF: 798 TOP: Nursing Process: Implementation MSC:

Physiological Integrity 17. 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 243 mg/dL b. Serum chloride 92 mEq/L c. Serum sodium 134 mEq/L d. Serum potassium 2.9 mEq/L

D Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation. The health care provider will need to prescribe a potassium infusion to correct this abnormality. Although the other laboratory values also are abnormal, they are not likely to be the etiology of the patient's PVCs and do not require immediate correction. DIF: Cognitive Level: Apply (application) REF: 799 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:

Physiological Integrity 36. A patient had a non-ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention included in the plan of care is most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Evaluation of the patient's response to walking in the hallway b. Completion of the referral form for a home health nurse follow-up c. Education of the patient about the pathophysiology of heart disease d. Reinforcement of teaching about the purpose of prescribed medications

D LPN/LVN education and scope of practice include reinforcing education that has previously been done by the RN. Evaluating the patient response to exercise after a NSTEMI requires more education and should be done by the RN. Teaching and discharge planning/ documentation are higher level skills that require RN education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 15-16 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

Health Promotion and Maintenance 43. After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider? a. Q waves on ECG b. Elevated troponin levels c. Fever and hyperglycemia d. Tachypnea and crackles in lungs

D Pulmonary congestion and tachypnea suggest that the patient may be developing heart failure, a complication of myocardial infarction (MI). Mild fever and hyperglycemia are common after MI because of the inflammatory process that occurs with tissue necrosis. Troponin levels will be elevated for several days after MI. Q waves often develop with ST-segment-elevation MI. DIF: Cognitive Level: Analyze (analysis) REF: 737 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:

Physiological Integrity 17. Following an acute myocardial infarction, a previously healthy 67-year-old patient develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about a. digitalis preparations, such as digoxin (Lanoxin). b. calcium-channel blockers, such as diltiazem (Cardizem). c. -adrenergic agonists, such as dobutamine (Dobutrex). d. angiotensin-converting enzyme (ACE) inhibitors, such as captopril (Capoten).

D Rationale: ACE-inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other medications such as ACE-inhibitors, diuretics, and -adrenergic blockers is insufficient. Calcium-channel blockers are not generally used in the treatment of heart failure. The -adrenergic agonists such as dobutamine are administered through the IV route and are not used as initial therapy for heart failure. Cognitive Level: Application Text Reference: p. 832 Nursing Process: Implementation

Physiological Integrity 13. A patient with dilated cardiomyopathy has an atrial fibrillation that has been unresponsive to drug therapy for several days. The nurse anticipates that further treatment of the patient will require a. IV adenosine (Adenocard). b. electrical cardioversion. c. insertion of an implantable cardioverter-defibrillator (ICD). d. anticoagulant therapy with warfarin (Coumadin).

D Rationale: Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant treatment for 3 to 4 weeks before attempting cardioversion; this is done to prevent embolization of clots from the atria. Adenosine is not used to treat atrial fibrillation. Cardioversion may be done after several weeks of Coumadin therapy. ICDs are used for patients with recurrent ventricular fibrillation. Cognitive Level: Application Text Reference: p. 852 Nursing Process: Planning

Health Promotion and Maintenance 3. The nurse is admitting a patient who is complaining of chest pain to the emergency department (ED). Which information collected by the nurse suggests that the pain is caused by an acute myocardial infarction (AMI)? a. The pain worsens when the patient raises the arms. b. The pain increases with deep breathing. c. The pain is relieved after the patient takes nitroglycerin. d. The pain has persisted longer than 30 minutes.

D Rationale: Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of pericarditis or musculoskeletal pain. Stable angina is usually relieved when the patient takes nitroglycerin. Cognitive Level: Application Text Reference: p. 803 Nursing Process: Assessment

Physiological Integrity 9. A patient with diabetes mellitus is admitted unresponsive to the emergency department (ED). Initial laboratory findings are serum potassium 2.8 mEq/L (2.8 mmol/L), serum sodium 138 mEq/L (138 mmol/L), serum chloride 90 mEq/L (90 mmol/L), and blood glucose 628 mg/dl (34.9 mmol/L). Cardiac monitoring shows multifocal PVCs. The nurse understands that the patient's PVCs are most likely caused by a. hyperglycemia. b. hypoxemia. c. dehydration. d. hypokalemia.

D Rationale: Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation. Hyperglycemia and dehydration are not associated with increased PVC risk. There is no indication that the patient is hypoxemic. Cognitive Level: Analysis Text Reference: p. 854 Nursing Process: Assessment

Physiological Integrity 20. Which information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI) will be most important to report to the health care provider before the MRI? a. The patient has a history of coronary artery disease. b. The patient took all the prescribed cardiac medications today. c. The patient has an allergy to shellfish and iodine. d. The patient has a permanent ventricular pacemaker in place.

D Rationale: MRI is contraindicated for patients with implanted metallic devices such as pacemakers. The other information will also be reported to the health care provider but does not impact on whether or not the patient can have an MRI. Cognitive Level: Application Text Reference: p. 755 Nursing Process: Implementation

Health Promotion and Maintenance 10. After the nurse teaches the patient about the use of atenolol (Tenormin) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? a. "Atenolol will increase the strength of my heart muscle." b. "I can expect to feel short of breath when taking atenolol." c. "Atenolol will improve the blood flow to my coronary arteries." d. "It is important not to suddenly stop taking the atenolol."

D Rationale: Patients who have been taking -blockers can develop intense and frequent angina if the medication is suddenly discontinued. Atenolol (Tenormin) decreases myocardial contractility. Shortness of breath that occurs when taking -blockers for angina may be due to bronchospasm and should be reported to the health care provider. Atenolol is not a vasodilator and works by decreasing myocardial oxygen demand, not by increasing blood flow to the coronary arteries. Cognitive Level: Application Text Reference: p. 801 Nursing Process: Evaluation

Psychosocial Integrity 26. The nurse obtains the following data when caring for a patient who experienced an AMI 2 days previously. Which information is most important to report to the health care provider? a. The oral temperature is 100.8° F (38.2° C). b. The white blood cell count (WBC) is 12,000/l. c. The patient denies ever having a heart attack. d. The lungs have crackles audible to the midline.

D Rationale: The crackles indicate that the patient may be developing heart failure, a possible complication of MI. The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors for the patient. The fever and elevated WBC are normal occurrences after MI as a result of inflammation that occurs after tissue necrosis. Denial is a common response in the immediate period after the MI. Cognitive Level: Application Text Reference: p. 804 Nursing Process: Assessment

Physiological Integrity 25. The nurse has received change-of-shift report about all of these patients on the telemetry unit. Which patient should the nurse see first? a. A patient with atrial fibrillation, rate 88, who has a new warfarin (Coumadin) order b. A patient with type 1 second-degree AV block, rate 60, who is dizzy when ambulating c. A patient who is in a sinus rhythm, rate 98, after having electrical cardioversion 2 hours ago d. A patient whose ICD fired three times today who is scheduled for a dose of amiodarone (Cordarone)

D Rationale: The frequent firing of the ICD indicates that the patient's ventricles are very irritable, and the priority is to assess the patient and administer the amiodarone. The other patients may be seen after the amiodarone is administered. Cognitive Level: Application Text Reference: pp. 852, 857-858 Nursing Process: Implementation

Physiological Integrity 4. A patient who is complaining of a "racing" heart and nervousness comes to the emergency department. The patient's blood pressure (BP) is 102/68. The nurse places the patient on a cardiac monitor and obtains the following ECG tracing. Which action should the nurse take next? a. Have the patient perform the Valsalva maneuver. b. Prepare to administer -blocker medication to slow the heart rate. c. Get ready to perform electrical cardioversion. d. Obtain further information about possible causes for the heart rate.

D Rationale: The patient has sinus tachycardia, which may be caused by multiple stressors such as pain, dehydration, or myocardial ischemia; further assessment is needed before determining the treatment. Vagal stimulation and electrical cardioversion are not used to treat sinus tachycardia. -blockade may be used, but further assessment is needed first. Cognitive Level: Analysis Text Reference: p. 850 Nursing Process: Implementation

Physiological Integrity 17. A patient has a permanent pacemaker inserted for treatment of chronic atrial fibrillation with slow ventricular response. The nurse teaches the patient that the pacemaker will a. prevent or minimize ventricular irritability. b. discharge if ventricular fibrillation occurs and prevent cardiac arrest. c. depolarize the atria and generate a P wave. d. stimulate a heart beat if the patient's own heart rate drops too low.

D Rationale: The permanent pacemaker will discharge when the ventricular rate drops below the set rate. The pacemaker will not decrease ventricular irritability or discharge if the patient develops ventricular fibrillation. A P wave will not be generated even with a dual-chamber pacemaker because the atria are already depolarizing in atrial fibrillation. Cognitive Level: Application Text Reference: pp. 858-859 Nursing Process: Implementation

Physiological Integrity 4. A patient is admitted to the ED after an episode of severe chest pain, and the physician schedules the patient for coronary angiography and possible percutaneous coronary intervention (PCI). The nurse prepares the patient for the procedure by explaining that it is used to a. determine whether there are any structural defects in the chambers of the heart. b. locate any coronary artery obstructions and administer thrombolytic agents. c. measure the amount of blood being pumped from the heart with each contraction. d. visualize any coronary artery blockages and dilate any obstructed arteries.

D Rationale: Visualization of the coronary arteries and possible balloon dilation are scheduled for this patient. Thrombolytic therapy is an alternative treatment if the patient is experiencing acute coronary syndrome (ACS) but is not the ordered therapy for this patient. Although angiography might help to detect structural defects or changes in cardiac output, it is not the reason for the procedure in this patient with symptoms of CAD. Cognitive Level: Application Text Reference: p. 807 Nursing Process: Implementation

Physiological Integrity 10. While assessing a patient with heart failure, the nurse notes that the patient has jugular venous distension (JVD) when lying flat in bed. The nurse's next action will be to a. have the patient perform the Valsalva maneuver and observe the jugular veins. b. palpate the jugular veins and compare the volume and pressure on the both sides. c. use a centimeter ruler to measure and document accurately the level of the JVD. d. elevate the patient gradually to an upright position and examine for continued JVD.

D Rationale: When assessing for and documenting JVD, the nurse should document the angle at which the patient is positioned. When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but not clinically significant) finding. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant. The nurse may use a ruler to determine the level of JVD above the heart if the JVD persists when the patient is at 30 to 45 degree angle or more. JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure increases. Comparison of the volume and pressure of the jugular veins is not included in jugular vein assessment. Cognitive Level: Application Text Reference: pp. 748-749 Nursing Process: Assessment

**Physiological Integrity 4. The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, P-R interval not measurable, ventricular rate 162, R-R interval regular, and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as a. atrial flutter. b. sinus tachycardia. c. ventricular fibrillation. d. ventricular tachycardia.

D The absence of P waves, wide QRS, rate >150 beats/minute, 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. DIF: Cognitive Level: Apply (application) REF: 794 TOP: Nursing Process: Assessment MSC:

Physiological Integrity 7. 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/minute. Which of the following actions should the nurse take next? a. Immediately notify the health care provider. b. Document the rhythm and continue to monitor the patient. c. Perform synchronized cardioversion per agency dysrhythmia protocol. d. Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol.

D 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. Defibrillation is not indicated given that the patient is currently in a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation. DIF: Cognitive Level: Apply (application) REF: 799 TOP: Nursing Process: Implementation MSC:

Physiological Integrity 22. The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first? a. A patient who is in a sinus rhythm, rate 98, after having electrical cardioversion 2 hours ago b. A patient with new onset atrial fibrillation, rate 88, who has a first dose of warfarin (Coumadin) due c. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating d. A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due

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 administer the amiodarone. The other patients may be seen after the amiodarone is administered. DIF: Cognitive Level: Analyze (analysis) REF: 803 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Implementation MSC:

Physiological Integrity 20. A patient develops sinus bradycardia at a rate of 32 beats/minute, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which actions 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.

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. DIF: Cognitive Level: Apply (application) REF: 804 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Psychosocial Integrity 11. After providing a patient with discharge instructions on the management of a new permanent pacemaker, the nurse knows that teaching has been effective when the patient states a. "I will avoid cooking with a microwave oven or being near one in use." b. "It will be 1 month before I can take a bath or return to my usual activities." 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 up very high until I see the doctor."

D The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The patient should notify airport security about the presence of a pacemaker before going through the metal detector, but there is no need to notify the airlines when making a reservation. Microwave oven use does not affect the pacemaker. The insertion procedure involves minor surgery that will have a short recovery period. DIF: Cognitive Level: Apply (application) REF: 805 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 2. 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. Calculate the number of small squares between one QRS complex and the next and divide into 1500. d. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.

D This is the quickest way to determine the ventricular rate for a patient with a regular rhythm. All the other methods are accurate, but take longer. DIF: Cognitive Level: Apply (application) REF: 789-790 TOP: Nursing Process: Assessment MSC:

Physiological Integrity 38. After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? a. 39-year-old with pericarditis who is complaining of sharp, stabbing chest pain b. 56-year-old with variant angina who is to receive a dose of nifedipine (Procardia) c. 65-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned discharge d. 59-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI)

D This patient is at risk for bleeding from the arterial access site for the PCI, so the nurse should assess the patient's blood pressure, pulse, and the access site immediately. The other patients should also be assessed as quickly as possible, but assessment of this patient has the highest priority. DIF: Cognitive Level: Analyze (analysis) REF: 751 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment MSC:

Physiological Integrity 8. A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to help determine whether the patient has had an AMI? a. Myoglobin b. Homocysteine c. C-reactive protein d. Cardiac-specific troponin

D Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI) and are highly specific indicators for MI. Myoglobin is released within 2 hours of MI, but it lacks specificity and its use is limited. The other laboratory data are useful in determining the patient's risk for developing coronary artery disease (CAD) but are not helpful in determining whether an acute MI is in progress. DIF: Cognitive Level: Understand (comprehension) REF: 749 TOP: Nursing Process: Assessment MSC:

. When administering IV nitroglycerin (Tridil) to a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication? A) a. Check blood pressure. B) b. Monitor apical pulse rate. C) c. Monitor for dysrhythmias. D) d. Ask about chest discomfort.

D Ask about chest discomfort.

A patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) is receiving heparin. What is the purpose of the heparin? A) a. Platelet aggregation is enhanced by IV heparin infusion. B) b. Heparin will dissolve the clot that is blocking blood flow to the heart. C) c. Coronary artery plaque size and adherence are decreased with heparin. D) d. Heparin will prevent the development of new clots in the coronary arteries.

D Heparin will prevent the development of new clots in the coronary arteries.

After noting a pulse deficit when assessing a patient who has just arrived in the emergency department, the nurse will anticipate that the patient may require A) a. a 2-D echocardiogram. B) b. a cardiac catheterization. C) c. hourly blood pressure (BP) checks. D) d. electrocardiographic (ECG) monitoring.

D electrocardiographic (ECG) monitoring.

Which action should the nurse take when preparing for cardioversion of a patient with supraventricular tachycardia who is alert and has a blood pressure of 110/66 mm Hg? A) a. Turn the synchronizer switch to the "off" position. B) b. Perform cardiopulmonary resuscitation (CPR) until the paddles are in correct position. C) c. Set the defibrillator/cardioverter energy to 300 joules. D) d. Administer a sedative before cardioversion is implemented.

D) d. Administer a sedative before cardioversion is implemented.

A patient's cardiac monitor shows sinus rhythm, rate 60 to 70. The P-R interval is 0.18 seconds at 1:00 AM, 0.20 seconds at 2:30 PM, and 0.23 seconds at 4:00 PM. Which action should the nurse take at this time? A) a. Prepare for possible temporary pacemaker insertion. B) b. Administer atropine sulfate 1 mg IV per agency protocol. C) c. Document the patient's rhythm and assess the patient's response to the rhythm. D) d. Call the health care provider before giving the prescribed metoprolol (Lopressor).

D) d. Call the health care provider before giving the prescribed metoprolol (Lopressor).

When analyzing the waveforms of a patient's electrocardiogram (ECG), the nurse will need to investigate further upon finding a A) a. T wave of 0.16 second. B) b. P-R interval of 0.18 second. C) c. Q-T interval of 0.34 second. D) d. QRS interval of 0.14 second.

D) d. QRS interval of 0.14 second.

Which laboratory result for a patient whose cardiac monitor shows multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider? A) a. Blood glucose 228 mg/dL B) b. Serum chloride 90 mEq/L C) c. Serum sodium 133 mEq/L D) d. Serum potassium 2.8 mEq/L

D) d. Serum potassium 2.8 mEq/L

Which information will the nurse include when teaching a patient who is scheduled to have a permanent pacemaker inserted for treatment of chronic atrial fibrillation with slow ventricular response? A) a. The pacemaker prevents or minimizes ventricular irritability. B) b. The pacemaker paces the atria at rates up to 500 impulses/minute. C) c. The pacemaker discharges if ventricular fibrillation and cardiac arrest occur. D) d. The pacemaker stimulates a heart beat if the patient's heart rate drops too low.

D) d. The pacemaker stimulates a heart beat if the patient's heart rate drops too low.

A patient has a normal cardiac rhythm and a heart rate of 72 beats/minute, except that the PR interval is 0.24 seconds. The appropriate intervention by the nurse is to A) a. notify the patient's health care provider immediately. B) b. administer atropine per agency bradycardia protocol. C) c. prepare the patient for temporary pacemaker insertion. D) d. document the finding and continue to monitor the patient.

D) d. document the finding and continue to monitor the patient.

The nurse obtains a monitor strip on a patient who has had a myocardial infarction and makes the following analysis: P wave not apparent, ventricular rate 162, R-R interval regular, P-R interval not measurable, and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as A) a. atrial fibrillation. B) b. sinus tachycardia. C) c. ventricular fibrillation. D) d. ventricular tachycardia.

D) d. ventricular tachycardia.

Which action should the nurse take when preparing for cardioversion of a patient with supraventricular tachycardia who is alert and has a blood pressure of 110/66 mm Hg? A. Turn the synchronizer switch to the "off" position. B. Perform cardiopulmonary resuscitation (CPR) until the paddles are in correct position. C. Set the defibrillator/cardioverter energy to 300 joules. D. Administer a sedative before cardioversion is implemented.

D. Administer a sedative before cardioversion is implemented. 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). CPR is not indicated for this patient.

A 50-year-old man who develops third-degree heart block reports feeling chest pressure and shortness of breath. Which instructions should the nurse provide to the patient before initiating emergency transcutaneous pacing? A. "The device will convert your heart rate and rhythm back to normal." B. "The device uses overdrive pacing to slow the heart to a normal rate." C. "The device is inserted through a large vein and threaded into your heart." D. "The device delivers a current through your skin that can be uncomfortable."

D. Before initiating transcutaneous pacing (TCP) therapy, it is important to tell the patient what to expect. The nurse should explain that the muscle contractions created by the pacemaker when the current passes through the chest wall are uncomfortable. Pacing for complete heart block will not convert the heart rhythm to normal. Overdrive pacing is used for very fast heart rates. Transcutaneous pacing is delivered through pacing pads adhered to the skin.

A patient's cardiac monitor shows sinus rhythm, rate 60 to 70. The P-R interval is 0.18 seconds at 1:00 AM, 0.20 seconds at 2:30 PM, and 0.23 seconds at 4:00 PM. Which action should the nurse take at this time? A. Prepare for possible temporary pacemaker insertion. B. Administer atropine sulfate 1 mg IV per agency protocol. C. Document the patient's rhythm and assess the patient's response to the rhythm. D. Call the health care provider before giving the prescribed metoprolol (Lopressor).

D. Call the health care provider before giving the prescribed metoprolol (Lopressor). The patient has progressive first-degree atrioventricular (AV) block, and the â-blocker should be held until discussing the medication with the health care provider. Documentation and assessment are appropriate but not fully adequate responses. The patient with first-degree AV block usually is asymptomatic, and a pacemaker is not indicated. Atropine is sometimes used for symptomatic bradycardia, but there is no indication that this patient is symptomatic.

When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having balloon angioplasty, the nurse obtains the following assessment data. Which data indicate the need for immediate intervention by the nurse? A. Pedal pulses 1+ B. Heart rate 100 beats/min C. Blood pressure 104/56 mm Hg D. Chest pain level 8 on a 10-point scale

D. Chest pain level 8 on a 10-point scale All others are normal

When monitoring a patient who is undergoing exercise (stress) testing on a treadmill, which assessment finding requires the most rapid action? A. Patient complaint of feeling tired. B. Pulse change from 80 to 96 beats/minute. C. BP increase from 134/68 to 150/80 mm Hg. D. Electrocardiographic (ECG) changes indicating coronary ischemia.

D. Electrocardiographic (ECG) changes indicating coronary ischemia. Everything else is considered ok

A 38-year-old teacher who reported dizziness and shortness of breath while supervising recess is admitted with a dysrhythmia. Which medication, if ordered, requires the nurse to carefully monitor the patient for asystole? A. Atropine sulfate B. Digoxin (Lanoxin) C. Metoprolol (Lopressor) D. Adenosine (Adenocard)

D. IV adenosine (Adenocard) is the first drug of choice to convert supraventricular tachycardia to a normal sinus rhythm. Adenosine is administered IV rapidly (over 1 or 2 seconds) followed by a rapid, normal saline flush. The nurse should monitor the patient's ECG continuously because a brief period of asystole after adenosine administration is common and expected. Atropine sulfate increases heart rate, whereas lanoxin and metoprolol slow the heart rate.

The nurse performs discharge teaching for a 74-year-old woman with an implantable cardioverter-defibrillator. Which statement by the patient indicates to the nurse that further teaching is needed? A. "The device may set off the metal detectors in an airport." B. "My family needs to keep up to date on how to perform CPR." C. "I should not stand next to antitheft devices at the exit of stores." D. "I can expect redness and swelling of the incision site for a few days."

D. Patients should be taught to report any signs of infection at incision site (e.g., redness, swelling, drainage) or fever to their primary care provider immediately. Teach the patient to inform airport security of presence of ICD because it may set off the metal detector. If hand-held screening wand is used, it should not be placed directly over the ICD. Teach the patient to avoid standing near antitheft devices in doorways of stores and public buildings, and to walk through them at a normal pace. Caregivers should learn cardiopulmonary resuscitation (CPR).

A 21-year-old student arrives at the student health center at the end of the quarter complaining that, "My heart is skipping beats." An electrocardiogram (ECG) shows occasional premature ventricular contractions (PVCs). What action should the nurse take first? A. Have the patient transported to the hospital emergency department (ED). B. Administer O2 at 2 to 3 L/min using nasal prongs. C. Ask the patient about any history of coronary artery disease. D. Question the patient about current stress level and coffee use.

D. Question the patient about current stress level and coffee use. In a patient with a normal heart, occasional PVCs are a benign finding. The timing of the PVCs suggests stress or caffeine as possible etiologic factors. It is unlikely that the patient has coronary artery disease, and this should not be the first question the nurse asks. The patient is hemodynamically stable, so there is no indication that the patient needs to be seen in the ED or that oxygen needs to be administered.

Which laboratory result for a patient whose cardiac monitor shows multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider? A. Blood glucose 228 mg/dL B. Serum chloride 90 mEq/L C. Serum sodium 133 mEq/L D. Serum potassium 2.8 mEq/L

D. Serum potassium 2.8 mEq/L Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation; the health care provider will need to prescribe a potassium infusion to correct this abnormality. Although the other laboratory values also are abnormal, they are not likely to be the etiology of the patient's PVCs and do not require immediate correction.

Which information will the nurse include when teaching a patient who is scheduled to have a permanent pacemaker inserted for treatment of chronic atrial fibrillation with slow ventricular response? A. The pacemaker prevents or minimizes ventricular irritability. B. The pacemaker paces the atria at rates up to 500 impulses/minute. C. The pacemaker discharges if ventricular fibrillation and cardiac arrest occur. D. The pacemaker stimulates a heart beat if the patient's heart rate drops too low.

D. The pacemaker stimulates a heart beat if the patient's heart rate drops too low. The permanent pacemaker will discharge when the ventricular rate drops below the set rate. The pacemaker will not decrease ventricular irritability or discharge if the patient develops ventricular fibrillation. Since the patient has a slow ventricular rate, overdrive pacing will not be used.

The nurse obtains a monitor strip on a patient who has had a myocardial infarction and makes the following analysis: P wave not apparent, ventricular rate 162, R-R interval regular, P-R interval not measurable, and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as A. atrial fibrillation. B. sinus tachycardia. C. ventricular fibrillation. D. ventricular tachycardia.

D. ventricular tachycardia. The absence of P waves, wide QRS, rate >150, and the regularity of the rhythm indicate ventricular tachycardia. Atrial fibrillation is grossly irregular, has a narrow QRS configuration, and has fibrillatory atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration.The absence of P waves, wide QRS, rate >150, and the regularity of the rhythm indicate ventricular tachycardia. Atrial fibrillation is grossly irregular, has a narrow QRS configuration, and has fibrillatory atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration.

After evaluating a client for hypertension, a physician orders atenolol (Tenormin), 50 mg P.O. daily. Which therapeutic effect should atenolol have?

Decreased cardiac output and decreased systolic and diastolic blood pressure

The nurse is assessing a patient with a probable diagnosis of first-degree AV block. He is aware that this dysrhythmia is evident on an ECG strip by which of the following?

Delayed conduction, producing a prolonged PR interval

The nurse is preparing a patient for upcoming electrophysiology (EP) studies and possible ablation for treatment of atrial tachycardia. Which of the following information should the nurse include?

During the procedure, the arrhythmia will be reproduced under controlled conditions.

18. The nurse notes premature ventricular contractions (PVCs) while suctioning a patient's endotracheal tube. Which action by the nurse is a priority? a. Decrease the suction pressure to 80 mm Hg. b. Document the dysrhythmia in the patient's chart. c. Stop and ventilate the patient with 100% oxygen. d. Give antidysrhythmic medications per protocol.

NS: C Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation. The nurse should stop suctioning and ventilate the patient with 100% oxygen. Lowering the suction pressure will decrease the effectiveness of suctioning without improving the hypoxemia. Because the PVCs occurred during suctioning, there is no need for antidysrhythmic medications (which may have adverse effects) unless they recur when the suctioning is stopped and patient is well oxygenated.

19. Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. The patient's oxygen saturation is 93%. b. The patient was last suctioned 6 hours ago. c. The patient's respiratory rate is 32 breaths/minute. d. The patient has occasional audible expiratory wheezes.

NS: C The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed, not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning the patient may induce bronchospasm and increase wheezing. An oxygen saturation of 93% is acceptable and does not suggest that immediate suctioning is needed.

10. When assisting with the placement of a pulmonary artery (PA) catheter, the nurse notes that the catheter is correctly placed when the monitor shows a a. typical PA pressure waveform. b. tracing of the systemic arterial pressure. c. tracing of the systemic vascular resistance. d. typical PA wedge pressure (PAWP) tracing.

NS: D The purpose of a PA line is to measure PAWP, so the catheter is floated through the pulmonary artery until the dilated balloon wedges in a distal branch of the pulmonary artery, and the PAWP readings are available. After insertion, the balloon is deflated and the PA waveform will be observed. Systemic arterial pressures are obtained using an arterial line and the systemic vascular resistance is a calculated value, not a waveform.

In analyzing a patient's electrocardiographic (ECG) rhythm strip, the nurse uses the knowledge that the time of the conduction of an impulse through the Purkinje fibers is represented by the __________________

PR interval.

Which of the following terms is used to describe a tachycardia characterized by abrupt onset, abrupt cessation, and a QRS of normal duration?

Paroxysmal atrial tachycardia

The nurse is analyzing the electrocardiogram (ECG) tracing of a client newly admitted to the cardiac step-down unit with a diagnosis of chest pain. Which of the following findings indicate the need for follow-up?

QT interval that is 0. 46 seconds long

A 21-year-old college student arrives at the student health center at the end of the quarter complaining, "My heart is skipping beats." The nurse obtains an ECG and notes the presence of occasional PVCs. What action should the nurse take first?

Question the patient about current stress level and coffee use.

The nurse is attempting to determine the ventricular rate and rhythm of a patient's telemetry strip. What should the nurse examine to determine this part of the analysis?

RR interval

A 66-year-old female client is having cardiac diagnostic tests to determine the cause of her symptoms. In her follow-up visit to the cardiologist, she is told that she has a dysrhythmia at a rate slower than 60 beats/minute. What type of dysrhythmia did the tests reveal?

Sinus bradycardia

A 26-year-old client is returning for diagnostic follow-up. Her Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minutes. What type of dysrhythmia would you expect the cardiologist to diagnose?

Sinus tachycardia

The licensed practical nurse is co-assigned with a registered nurse in the care of a client admitted to the cardiac unit with chest pain. The licensed practical nurse is assessing the accuracy of the cardiac monitor, which notes a heart rate of 34 beats/minute. The client appears anxious and states not feeling well. The licensed practical nurse confirms the monitor reading. When consulting with the registered nurse, which of the following is anticipated?

The registered nurse administering atropine sulfate intravenously

A nursing student is caring for one of the nurse's assigned cardiac clients. The student asks, "How can I tell the difference between ventricular tachycardia and ventricular fibrillation when I look at the EKG strip?" The best reply by the nurse is which of the following?

Ventricular fibrillation is irregular with undulating waves and no QRS complex. Ventricular tachycardia is usually regular and fast with wide QRS complexes.

A patient with supraventricular tachycardia (SVT) is hemodynamically stable and requires cardioversion. The nurse will plan to _______________

administer a sedative before the procedure is begun.

angiotensin-converting enzyme (ACE) inhibitors, such as captopril (Capoten).

A patient with dilated cardiomyopathy has an atrial fibrillation that has been unresponsive to drug therapy for several days. The nurse anticipates that further treatment of the patient will require ____________

anticoagulant therapy with warfarin (Coumadin).

During change-of-shift report, the nurse learns that a patient with a large myocardial infarction has been having frequent PVCs. When monitoring the patient for the effects of PVCs, the nurse will check the patient's _____________

apical radial heart rate.

A patient has a normal cardiac rhythm strip except that the PR interval is 0.34 seconds. The appropriate intervention by the nurse is to ________________

document the finding and continue to monitor the patient.

The nurse determines that a patient has ventricular bigeminy when the rhythm strip indicates that ________________

every other QRS complex is wide and starts prematurely.

A physician orders esmolol (Brevibloc) for a client with supraventricular tachycardia. During esmolol therapy, the nurse should monitor the client's:

heart rate and blood pressure.

A patient who has a history of sudden cardiac death has an ICD inserted. When performing discharge teaching with the patient, it is important for the nurse to instruct the patient and family that ______________

if the ICD fires and the patient loses consciousness, 911 should be called.

A patient with myocardial infarction develops symptomatic hypotension. The monitor shows a type 1, second-degree AV block with a heart rate of 30. The nurse administers IV atropine as prescribed. The nurse determines that the drug has been effective on finding a(n) _________________

increase in the patient's heart rate.

Premature ventricular contractions (PVCs) are considered precursors of ventricular tachycardia (VT) when they:

occur at a rate of more than six per minute

The nurse hears the cardiac monitor alarm and notes that the patient has a cardiac pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious with no pulse or respirations. After calling for assistance, the nurse should _______________

start basic cardiopulmonary resuscitation (CPR).

17. A patient has a permanent pacemaker inserted for treatment of chronic atrial fibrillation with slow ventricular response. The nurse teaches the patient that the pacemaker will ____________

stimulate a heart beat if the patient's own heart rate drops too low.

When needing to estimate the ventricular rate quickly for a patient with a regular heart rhythm using an ECG strip, the nurse will ______________

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

The nurse obtains a monitor strip on a patient admitted to the coronary care unit with a myocardial infarction and makes the following analysis: P wave not apparent; ventricular rate 162, R-R interval regular; PR interval not measurable; and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as _______________

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