Adult Theory III Exam 1

What dysrhythmia may develop in a client with frequent premature ventricular contractions? The nurse has administered adenosine (Adenocad), what is the expected therapeutic response? A client's ECG tracing shows a run of sustained ventricular tachycardia. What is the first action that the nurse will take?

-Ventricular tachycardia -A short period of asystole -Assess the client's airway, breathing, and level of consciousness.

A patient with a newly inserted pacemaker receives discharge instructions. Which patient statement indicates that further teaching is required? 1. "I should avoid using microwave ovens." 2. "I should avoid standing near antitheft devices." 3. "I should avoid direct blows to the pacemaker site." 4. "I should avoid close proximity to high-output electric generators."

ANS: 1 Microwaves do not interfere with a pacemaker's function and can be used safely. Electric signals from antitheft devices can affect pacemaker functioning. The patient should avoid direct blows to the pacemaker site to reduce pressure at the site. Electric signals from high-output electric generators can move the pacemaker from its position and affect its functioning.

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

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

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

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

A nurse is monitoring a patient on a wireless electrocardiogram (ECG) monitor. Which observation is a cause for concern? 1. Upright P wave 2. Flat ST segment 3. Prolonged QT interval 4. Upright T wave

ANS: 3 Prolonged QT interval is a cause for concern. QT disturbance may be caused by drugs, electrolyte imbalances, and changes in heart rate. Upright P wave, flat ST segment, and upright T wave are normal findings.

A pt w/ hypovolemic shock is receiving LR solution for fluid replacement therapy. During this therapy, which laboratory result is the most important for the nurse to monitor? a. serum pH b. serum sodium c. serum potassium d. Hgb and Hct

ANS: A

Which intervention may prevent GI bacterial and endotoxin translocation in a critically ill pt w/ SIRS? a. early enteral feedings b. surgical removal of necrotic tissue c. aggressive multiple antibiotic therapy d. strict aseptic technique in all procedures

ANS: A

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

ANS: 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.

Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine? a. The patient's central venous pressure is 3 mm Hg. b. The patient is in sinus tachycardia at 120 beats/min. c. The patient is receiving low dose dopamine (Intropin). d. The patient has had no urine output since being admitted.

ANS: A Adequate fluid administration is essential before administration of vasopressors to patients with hypovolemic shock. The patient's low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.

A patient is admitted to the hospital with a diagnosis of aortic valve stenosis. Which manifestation does the nurse expect when taking the health history? A. Angina B. Fatigue C. Orthopnea D. Weakness

ANS: A Angina is one of the classic triad of manifestations that occurs on exertion in aortic valve stenosis. Angina occurs when the myocardial oxygen demand of the hypertrophied left ventricle exceeds oxygen supply. Fatigue and orthopnea are associated with chronic aortic valve regurgitation. Weakness is not a clinical manifestation of aortic valve stenosis.

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

ANS: A Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well.

The nurse is caring for a 78-year-old patient with aortic stenosis. Which assessment data obtained by the nurse would be most important to report to the health care provider? a. The patient complains of chest pressure when ambulating. b. A loud systolic murmur is heard along the right sternal border. c. A thrill is palpated at the second intercostal space, right sternal border. d. The point of maximum impulse (PMI) is at the left midclavicular line.

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

The nurse reviews the medical record of a client with hemorrhagic shock, which contains the following information: Pulse 140 beats/min and thready, ABG respiratory acidosis, Blood pressure 60/40 mm Hg, Lactate level 7 mOsm/L, Respirations 40/min and shallow. All of these provider prescriptions are given for the client. Which does the nurse carry out first? A. Notify anesthesia for endotracheal intubation. B. Give Plasmanate 1 unit now. C. Give normal saline solution 250 mL/hr. D. Type and crossmatch for 4 units of packed red blood cells (PRBCs).

ANS: A Establishing an airway is the priority in all emergency situations. Although administering Plasmanate and normal saline, and typing and crossmatching for 4 units of PRBCs are important actions, airway always takes priority.

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

ANS: 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.

Which rhythm pattern finding is indicative of PVCs? a. A QRS complex ≥0.12 second followed by a P wave b. Continuous wide QRS complexes with a ventricular rate of 160 bpm c. P waves hidden in QRS complexes with a regular rhythm of 120 bpm d. Saw-toothed P waves with no measurable PR interval and an irregular rhythm

ANS: A PVC is an ectopic beat that causes a wide, distorted QRS complex ≥0.12 second because the impulse is not conducted normally through the ventricles. Because it is premature, it precedes the P wave and the P wave may be hidden in the QRS complex, or the ventricular impulse may be conducted retrograde and the P wave may be seen following the PVC but the rhythm is not regular. Continuous wide QRS complexes with a ventricular rate between 150 and 250 bpm are seen in ventricular tachycardia, whereas saw-toothed P waves are characteristic of atrial flutter

The nurse suspects cardiac tamponade in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, the nurse should a. note when Korotkoff sounds are auscultated during both inspiration and expiration. b. subtract the diastolic blood pressure (DBP) from the systolic blood pressure (SBP). c. check the electrocardiogram (ECG) for variations in rate during the respiratory cycle. d. listen for a pericardial friction rub that persists when the patient is instructed to stop breathing.

ANS: A Pulsus paradoxus exists when there is a gap of greater than 10 mm Hg between when Korotkoff sounds can be heard during only expiration and when they can be heard throughout the respiratory cycle. The other methods described would not be useful in determining the presence of pulsus paradoxus.

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

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

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.

ANS: 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.

A nurse is caring for a patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which collaborative intervention ordered by the health care provider should the nurse question? a. Infuse normal saline at 250 mL/hr. b. Keep head of bed elevated to 30 degrees. c. Hold nitroprusside (Nipride) if systolic BP <90 mm Hg. d. Titrate dobutamine (Dobutrex) to keep systolic BP >90 mm Hg

ANS: A The patient's elevated pulmonary artery wedge pressure indicates volume excess. A saline infusion at 250 mL/hr will exacerbate the volume excess. The other actions are appropriate for the patient.

Which type of valvular heart disease occurs almost exclusively in patients that abuse drugs intravenously? A. Tricuspid stenosis B. Pulmonic stenosis C. Aortic valve stenosis D. Mitral valve stenosis

ANS: A Tricuspid stenosis is the disease of the tricuspid valve that occurs in patients who abuse drugs intravenously or who have had rheumatic fever. Pulmonic stenosis is congenital. Aortic valve stenosis occurs due to rheumatic fever. Mitral valve stenosis occurs due to rheumatic heart disease.

A 20-year old patient has acute infective endocarditis. While obtaining a nursing history, the nurse should ask the patient about which of the following (select all that apply) a. renal dialysis b. IV drug abuse c. recent dental work d. cardiac catheterization e. recent urinary tract infection

ANS: A, B, C, D, E recent dental, urologic, surgical, or gynecologic procedures and history of IV drug abuse, heart disease, cardiac catheterization or surgery, renal dialysis, and infections all increase the risk of IE

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

ANS: A, B, C, E Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early ambulation should be included in the plan of care. Adequate nutrition is important in preventing SIRS. Enteral, rather than parenteral, nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine, thus decreasing infection risk. Antibiotics should be administered within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS.

What types of injuries cause a mechanical tissue trauma that can trigger SIRS (select all) a. burns b. fungi c. viruses d. crush injuries e. surgical procedures

ANS: A, D, E

A client is exhibiting signs and symptoms of early shock. What is important for the nurse to do to support the psychosocial integrity of the client? (Select all that apply.) A. Ask family members to stay with the client. B. Call the health care provider. C. Increase IV and oxygen rates. D. Remain with the client. E. Reassure the client that everything is being done for him or her.

ANS: A, D, E Having a familiar person nearby may provide comfort to the client. The nurse should remain with the client who is demonstrating physiologic deterioration. Offering genuine reassurance supports the client who is anxious. The health care provider should be notified, and increasing IV and oxygen rates may be needed, but these actions do not support the client's psychosocial integrity.

Which clients are at immediate risk for hypovolemic shock? (Select all that apply.) A. Unrestrained client in motor vehicle accident B. Construction worker C. Athlete D. Surgical intensive care client E. 85-year-old with gastrointestinal virus

ANS: A, D, E The client who is unrestrained in a motor vehicle accident is prone to multiple trauma and bleeding. Surgical clients are at high risk for hypovolemic shock owing to fluid loss and hemorrhage. Older adult clients are prone to shock; a gastrointestinal virus results in fluid losses. Unless injured or working in excessive heat, the construction worker and the athlete are not at risk for hypovolemic shock; they may be at risk for dehydration.

A patient w/ a gunshot wound to the abdomen is being treated for hypovolemic and septic shock. To monitor the pt for early organ damage associated w/ MODS, what is the most important for the nurse to assess? a. urine output b. breath sounds c. peripheral circulation d. central venous pressure

ANS: B

What abnormal finding should the nurse expect to find in early compensatory shock? a. metabolic acidosis b. increased serum sodium c. decreased BG d. increased serum potassum

ANS: B

Which finding is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been effective? a. Hemoglobin is within normal limits. b. Urine output is 60 mL over the last hour. c. Central venous pressure (CVP) is normal. d. Mean arterial pressure (MAP) is 72 mm Hg

ANS: B Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level, CVP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion.

The nurse is assessing clients at a community clinic. Which client does the nurse assess most carefully for atrial fibrillation? a. Middle-aged client who takes an aspirin daily b. Client who is dismissed after coronary artery bypass surgery c. Older adult client after a carotid endarterectomy d. Client with chronic obstructive pulmonary disease

ANS: B Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft (CABG) surgery. The other conditions do not place a client at higher risk for atrial fibrillation.

When caring for a critically ill patient who is being mechanically ventilated, the nurse will monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)? a. Increased serum albumin b. Decreased respiratory compliance c. Increased gastrointestinal (GI) motility d. Decreased blood urea nitrogen (BUN)/creatinine ratio

ANS: B Clinical manifestations of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decreased GI motility, acute neurologic changes, myocardial dysfunction, disseminated intravascular coagulation (DIC), and changes in glucose metabolism

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

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

A patient has ST segment changes that support an acute inferior wall myocardial infarction. Which lead would be best for monitoring the patient? a. I b. II c. V2 d. V6

ANS: B Leads II, III, and AVF reflect the inferior area of the heart and the ST segment changes. Lead II will best capture any electrocardiographic (ECG) changes that indicate further damage to the myocardium. The other leads do not reflect the inferior part of the myocardial wall and will not provide data about further ischemic changes in that area.

A postoperative client is admitted to the intensive care unit with hypovolemic shock. Which nursing action does the nurse delegate to an experienced nursing assistant? A. Obtain vital signs every 15 minutes. B. Measure hourly urine output. C. Check oxygen saturation. D. Assess level of alertness.

ANS: B Monitoring hourly urine output is included in nursing assistant education and does not require special clinical judgment; the nurse evaluates the results. Obtaining vital signs, monitoring oxygen saturation, and assessing mental status in critically ill clients requires the clinical judgment of the critical care nurse because immediate intervention may be needed.

The nurse is assessing a patient with myocarditis before administering the scheduled dose of digoxin (Lanoxin). Which finding is most important for the nurse to communicate to the health care provider? a. Leukocytosis b. Irregular pulse c. Generalized myalgia d. Complaint of fatigue

ANS: B Myocarditis predisposes the heart to digoxin-associated dysrhythmias and toxicity. The other findings are common symptoms of myocarditis and there is no urgent need to report these.

The patient with acute pericarditis is having a pericardiocentesis. Postoperatively what complication should the nurse monitor the patient for? a. Pneumonia b. Pneumothorax c. Myocardial infarction (MI) d. Cerebrovascular accident (CVA)

ANS: B Pneumothorax may occur as a needle is inserted into the pericardial space to remove fluid for analysis and relieve cardiac pressure with pericardiocentesis. Other complications could include dysrhythmias, further cardiac tamponade, myocardial laceration, and coronary artery laceration

The nurse is admitting a patient with possible rheumatic fever. Which question on the admission health history will be most pertinent to ask? a. "Do you use any illegal IV drugs?" b. "Have you had a recent sore throat?" c. "Have you injured your chest in the last few weeks?" d. "Do you have a family history of congenital heart disease?"

ANS: B Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal infection (strep throat). Although illicit IV drug use should be discussed with the patient before discharge, it is not a risk factor for rheumatic fever, and would not be as pertinent when admitting the patient. Family history is not a risk factor for rheumatic fever. Chest injury would cause musculoskeletal chest pain rather than rheumatic fever.

The patient had a history of rheumatic fever and has been diagnosed with mitral valve stenosis. The patient is planning to have a biologic valve replacement. What protective mechanisms should the nurse teach the patient about using after the valve replacement? A. Long-term anticoagulation therapy B. Antibiotic prophylaxis for dental care C. Exercise plan to increase cardiac tolerance D. Take β-adrenergic blockers to control palpitations.

ANS: B The patient will need to use antibiotic prophylaxis for dental care to prevent endocarditis. Long-term anticoagulation therapy is not used with biologic valve replacement unless the patient has atrial fibrillation. An exercise plan to increase cardiac tolerance is needed for a patient with heart failure. Taking β-adrenergic blockers to control palpitations is prescribed for mitral valve prolapse, not valve replacement.

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.

ANS: B The patient's clinical manifestations indicate pulseless electrical activity and the nurse should immediately start CPR. The other actions would not be of benefit to this patient.

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

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

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

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

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

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

What explains the measurement of pulsus paradoxus with cardiac tamponade (SATA)? a. A difference of less than 10 mm Hg occurs. b. A difference of greater than 10 mm Hg occurs. c. It is measured with an automatic sphygmomanometer. d. Rapidly inflate the cuff until you hear sounds throughout the respiratory cycle. e. Subtract the number when sounds are heard in the respiratory cycle from the number when the first Korotkoff sound during expiration is heard

ANS: B, E Pulsus paradoxus is measured with a manually operated sphygmomanometer. The cuff is deflated slowly until the first Korotkoff sound during expiration is heard and the number is noted. The slow deflation of the cuff is continued until sounds are heard throughout the respiratory cycle and that number is subtracted from the first number. When the difference is >10 mm Hg, cardiac tamponade may be present. The difference is normally <10 mm Hg

A pt in the progressive stage of shock has rapid, deep respirations. The nurse documents that the patient's hyperventilation is compensating for metabolic acidosis when the patient's ABG results include what? a. pH 7.42, PaO2 80 mm Hg b. pH 7.48, PaO2 69 mmHg c. pH 7.38, PaO2 30 mmHg d. pH 7.32, PaO2 48 mm Hg

ANS: C

A client with third-degree heart block is admitted to the telemetry unit. The nurse observes wide QRS complexes on the monitor with a heart rate of 35 beats/min. What priority assessment does the nurse perform? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability

ANS: C A heart rate of 40 beats/min or less, with widened QRS complexes, could have hemodynamic consequences, and the client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, lightheadedness, confusion, syncope, and seizure activity.

The emergency department (ED) nurse receives report that a patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 1 minute. In preparation for the patient's arrival, the nurse will obtain a. hypothermia blanket. b. lactated Ringer's solution. c. two 14-gauge IV catheters. d. dopamine (Intropin) infusion.

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

During discharge teaching with a 68-year-old patient who had a mitral valve replacement with a mechanical valve, the nurse instructs the patient on the a. use of daily aspirin for anticoagulation. b. correct method for taking the radial pulse. c. need for frequent laboratory blood testing. d. need to avoid any physical activity for 1 month.

ANS: C Anticoagulation with warfarin (Coumadin) is needed for a patient with mechanical valves to prevent clotting on the valve. This will require frequent international normalized ratio (INR) testing. Daily aspirin use will not be effective in reducing the risk for clots on the valve. Monitoring of the radial pulse is not necessary after valve replacement. Patients should resume activities of daily living as tolerated.

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.

ANS: 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.

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

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

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

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

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 bpm 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 bpm

ANS: 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

An older patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate doing next? a. Increase the rate for the dopamine (Intropin) infusion. b. Decrease the rate for the nitroglycerin (Tridil) infusion. c. Increase the rate for the sodium nitroprusside (Nipride) infusion. d. Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion.

ANS: C Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5/.9 NS and nitroglycerin infusions will not directly decrease SVR. Increasing the dopamine will tend to increase SVR.

A nurse ia caring for a client at risk for shock. Which of the following findings is the earliest indicator that this complication is developing? A. Hypotension B. Anuria C. Narrowing pulse pressure D. Decreased level of consciousness

ANS: C Pulse pressure is the difference between the systolic and diastolic blood pressures. In the initial stage of shock there is a slight increase in the diastolic blood pressure, which narrows the pulse pressure.

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

ANS: 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.

A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first? a. Insert two large-bore IV catheters. b. Initiate continuous electrocardiogram (ECG) monitoring. c. Provide oxygen at 100% per non-rebreather mask. d. Draw blood to type and crossmatch for transfusions.

ANS: C The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished but only after actions to maximize oxygen delivery have been implemented.

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.

ANS: C The patient has sinus tachycardia, which may have multiple etiologies such as pain, dehydration, anxiety, and myocardial ischemia. Further assessment is needed before determining the treatment. Vagal stimulation or -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.

The patient has an electrocardiographic (ECG) tracing that is 50 beats/minute, the rhythm is regular, and there is a P wave before every QRS complex. The QRS has a normal shape and duration, and the PR interval is normal. What is you response? A. Administer atropine by intravenous push (IVP). B. Administer epinephrine by IVP. C. Monitor the patient for syncope. D. Attach an external pacemaker.

ANS: C The rhythm described is sinus bradycardia. Treatment depends on the patient's response and whether adequate perfusion is occurring. If the patient tolerates the rhythm, no treatment is given

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.

ANS: 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.

What assessment findings does the nurse expect when caring for a patient with mitral valve stenosis? Select all that apply. A. Syncope B. Orthopnea C. Palpitations D. Atrial fibrillation E. Exertional dyspnea

ANS: C, D, E The overloaded left atrium places the patient at risk for atrial fibrillation. Dyspnea on exertion and palpitations may also occur. Orthopnea occurs with aortic valve regurgitation. Syncope occurs with mitral valve prolapse.

A pt in shock has a nursing diagnosis of fear r/t severity of condition and perceived threat of death as manifested by verbalization of anxiety about condition and fear of death. What is an appropriate nursing intervention for the pt? a. administer antianxeity agents b. allow caregivers to visit as much as possible c. call a member of the clergy to visit the pt d. inform the pt of the current plan of care and its rationale

ANS: D

During administration of IV norepinephrine (Levophed), what should the nurse assess the patient for? a. hypotension b. marked diuresis c. metabolic alkalosis d. decreased tissue perfusion

ANS: D

When assessing a patient in shock, the nurse recognizes that the hemodynamics of shock include A. a normal cardiac output in cardiogenic shock. B. an increase in central venous pressure in hypovolemic shock. C. an increase in systemic vascular resistance in all types of shock. D. variations in cardiac output and decreased systemic vascular resistance in septic shock.

ANS: D

The nurse is assisting in the care of several patients in the critical care unit. Which patient is most at risk for developing multiple organ dysfunction syndrome (MODS)? a. A 22-yr-old patient with systemic lupus erythematosus admitted with a pelvic fracture b. A 48-yr-old patient with lung cancer admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia c. A 65-yr-old patient with coronary artery disease, dyslipidemia, and primary hypertension admitted for unstable angina d. A 82-yr-old patient with type 2 diabetes mellitus and chronic kidney disease admitted for peritonitis related to a peritoneal dialysis catheter infection

ANS: D A patient with peritonitis is at high risk for developing sepsis. In addition, a patient with diabetes is at high risk for infections and impaired healing. Sepsis and septic shock are the most common causes of MODS. Individuals at greatest risk for developing MODS are older adults and persons with significant tissue injury or preexisting disease. MODS can be initiated by any severe injury or disease process that activates a massive systemic inflammatory response.

The ECG monitor of a patient in the cardiac care unit after an MI indicates ventricular bigeminy with a rate of 50 beats/min. The nurse would anticipate a. performing defibrillation b. treating with IV amiodarone c. inserting a temporary transvenous pacemaker d. assessing the patient's response to the dysrhythmia

ANS: D A premature ventricular contraction (PVC) is a contraction originating in an ectopic focus in the ventricles. When every other beat is a PVC, the rhythm is called ventricular bigeminy. PVCs are usually a benign finding in patients with a normal heart. In patients with heart disease, PVCs may reduce the cardiac output and precipitate angina and heart failure, depending on the frequency. Because PVCs in coronary artery disease (CAD) or acute myocardial infarction indicate ventricular irritability, the patient's physiologic response to PVCs must be monitored. Assessment of the patient's hemodynamic status is important for determining whether treatment with drug therapy is needed.

A patient with an acute MI has sinus tachycardia of 126 bpm. The nurse recognizes that if this dysrhythmia is not treated, the patient is likely to experience a. hypertension. b. escape rhythms. c. ventricular tachycardia. d. an increase in infarct size.

ANS: D Although many factors can cause a sinus tachycardia, in the patient who has had an acute MI, tachycardia increases myocardial oxygen need in a heart that already has impaired circulation and may lead to increasing angina and further ischemia and necrosis

What describes the SA node's ability to discharge an electrical impulse spontaneously? a. Excitability b. Contractility c. conductivity d. automaticity

ANS: D Automaticity describes the ability to discharge an electrical impulse spontaneously. Excitability is a property of myocardial tissue that enables it to depolarized by an impulse. Contractility is the ability of the chambers to respond mechanically to an impulse. Conductivity is the ability to transmit an impulse along a membrane.

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

ANS: D Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the oxygen saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.

A 55-year-old female patient develops acute pericarditis after a myocardial infarction. It is most important for the nurse to assess for which clinical manifestation of a possible complication? A. Presence of a pericardial friction rub B. Distant and muffled apical heart sounds C. Increased chest pain with deep breathing D. Decreased blood pressure with tachycardia

ANS: D Cardiac tamponade is a serious complication of acute pericarditis. Signs and symptoms indicating cardiac tamponade include narrowed pulse pressure, tachypnea, tachycardia, a decreased cardiac output, and decreased blood pressure. The other symptoms are consistent with acute pericarditis.

The nurse is caring for postoperative clients at risk for hypovolemic shock. Which condition represents an early symptom of shock? A. Hypotension B. Bradypnea C. Heart blocks D. Tachycardia

ANS: D Heart and respiratory rates increased from the client's baseline level or a slight increase in diastolic blood pressure may be the only objective manifestation of this early stage of shock. Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal. Early in shock, the client displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock; they are related to lack of oxygen to the heart.

The nurse is recovering a client after insertion of an implantable cardioverter-defibrillator (ICD). What complication must the nurse intervene for immediately? a. 2/4 bilateral peripheral edema b. Heart rate of 56 beats/min c. Temperature of 96° F (35.5° C) d. Muffled heart sounds

ANS: D In the postimplantation period, the nurse should be alert for complications of cardiac tamponade, bleeding, and dysrhythmias. Muffled heart sounds are a manifestation of cardiac tamponade. Edema and a lower temperature would not be indicative of a complication of this procedure. Bradycardia might need intervention, but this client's heart rate is not critically low.

The nurse is caring for a patient who received a mechanical aortic valve replacement two years ago. Current lab values include an international normalized ratio (INR) of 1.5, platelet count of 150,000/μL, and hemoglobin of 8.6g/dL. Which nursing action is most appropriate? a. Assess the vital signs. b. Start intravenous fluids. c. Monitor for signs of bleeding. d. Report laboratory values to the health care provider.

ANS: D Patients with mechanical valve replacement are placed on anticoagulants and should be in a therapeutic INR range of 2.5 to 3.5. Administration of Coumadin (Warfarin) prolongs clotting time and prevents clot formation on the valve. The low INR would require a call to the healthcare provider for an order increase the medication dose. Vital signs would be unchanged related to the low INR. Intravenous fluids are not indicated. The patient is at risk of forming clots, not bleeding

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

ANS: D Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments also will be done, but these will not help in determining the effectiveness of the pantoprazole administration.

After coronary artery bypass graft surgery a patient has postoperative bleeding that requires returning to surgery for repair. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient parameter is the most important for planning nursing care? a. Cardiac index (CI) of 5 L/min/m2 b. Central venous pressure of 8 mm Hg c. Mean arterial pressure (MAP) of 86 mm Hg d. Pulmonary artery pressure (PAP) of 28/14 mm Hg

ANS: D Pulmonary hypertension as indicated by an elevated PAP indicates impaired forward flow of blood because of left ventricular dysfunction or hypoxemia. Both can be a result of the MI. The CI, CVP, and MAP readings are normal

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.

ANS: 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

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

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

When performing discharge teaching for the patient following a mechanical valve replacement, the nurse determines that further instruction is needed when the patient says, a. I may begin an exercise program to gradually increase my cardiac tolerance b. I will always need to have my blood checked once a month for its clotting function c. I should wear a medic alert bracelet to identify my valve and anticoagulant therapy d. the biggest risk I have during invasive health procedures is bleeding because of my anticoagulants

ANS: D The greatest risk to a patient who has an artificial valve is the development of endocarditis with invasive medical or dental procedures; before any of these procedures, antibiotic prophylaxis is necessary to prevent infection. Health care providers must be informed of the presence of the valve and the anticoagulation therapy, but the most important factor is using antibiotic prophylaxis before invasive procedures

The patient's PR interval comprises six small boxes on the ECG graph. What does the nurse determine that this indicates? a. a normal finding b. a problem with ventricular depolarization c. a disturbance in the depolarization of the atria d. a problem, with conduction from the SA node to the ventricular cells

ANS: D The normal PR interval is 0.12 to 0.20 seconds and reflects the time taken for the impulse to spread through the atria, AV node and bundle of His, the bundle branches, and Purkinje fibers. A PR interval of six small boxes is 0.24 second and indicates that the conduction if the impulse from the atria tot he Purkinje fibers is delayed.

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."

ANS: 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.

Which problem places a person at highest risk for septic shock? A. Kidney failure B. Cirrhosis C. Lung cancer D. 40% burn injury

ANS: D The skin forms the first barrier to prevent entry of organisms into the body; this client is at very high risk for sepsis and death. Although the client with kidney failure has an increased risk for infection, his skin is intact, unlike the client with burn injury. Although the liver acts as a filter for pathogens, the client with cirrhosis has intact skin, unlike the burned client. The client with lung cancer may be at risk for increased secretions and infection, but risk is not as high as for a client with open skin

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

ANS: E, D, C, B, A The initial action for this hypotensive and hypoxemic patient should be to improve the O2 saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before giving antibiotics.

A Client with a stenotic mitral valve has presented to the clinic for further evaluation. Which intervention is the highest priority? A nurse has administered a drug that causes vasoconstriction. Which finding indicates an expected response? Which laboratory value is indicative of a myocardial infarction?

Assessment of blood pressure Increased diastolic BP Troponin T = 0.8 ng/mL (should be 0-0.4)

The use of catheter ablation therapy to "burn" areas of the cardiac conduction system is indicated for the treatment of a. sinus arrest. b. heart blocks. c. tachydysrhythmias. d. premature ventricular tachycardia.

C Catheter ablation therapy uses radiofrequency energy to ablate or "burn" accessory pathways or ectopic sites in the atria, AV node, or ventricles that cause tachydysrhythmias

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).

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

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

A nurse has administered corticosteroids to a patient with multiple organ dysfunction syndrome (MODS). In what order should the results of this medication occur in this situation. a. Renal excretion of potassium b. Increased intravascular volume c. Improved capillary permeability d. Enhanced renal artery perfusion

C, B, D, A Corticosteroids are administered to patients who have MODS to suppress the inflammatory response. If the patient responds positively to the corticosteroids, capillary permeability should improve, stopping leakage of intravascular fluid and helping restore intravascular blood volume. Improved intravascular volume should help improve the blood pressure, and if compensatory sympathetic discharge is halted, renal blood flow increases. Increased renal blood flow should increase the glomerular filtration rate and renal excretion of potassium.

The nurse performs discharge teaching for a patient with an implantable cardioverter-defibrillator (ICD). 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."

Patients should be taught to report any signs of infection at incision site (e.g., redness, swelling, drainage) or fever to their primary care providers immediately. Teach patients to inform TSA airport security of presence of ICD because it may set off metal detectors. If a handheld screening wand is used, it should not be placed directly over the ICD. Teach patients 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.