NUR 334 EXAM 2: random questions

Post ♡ Cath: points to consider

- bedrest for 6-8 hours with leg where insertion was performed EXTREMELY STRAIGHT!! (may need knee mobilizer) - if back hurts: roll onto left side - wait for gag reflex to return to feed

small box on EKG

0.04 secs

Large box on EKG

0.20 secs

BLS steps

1. Establish Unresponsiveness (No breathing or pulse within 10 seconds) 2. Call Code/Activate EMS Get AED/defibrillator 3. Palpable pulse within 10 seconds? If YES: Maintain Patient Airway Administer 1 breath every 5-6 sec Reassess for pulse every 2 min If NO Immediately begin CPR 4. CPR compression rate: 100-120 BPM adults 2"-2.5" depth (with complete recoil) switch compressors q 2 minutes compression to breath: 30:2 5. Defibrillate 6. Continue CPR after shock until victim responds 7. RECOVERY POSITION = SIDE LYING

INR normal range

2-3 (standard warfarin therapy)

what is an intervention you want to carry out when giving anti arrhythmic medications?

6 minute walk test

how many seconds is an EKG

6 secs

Paddle Placement for Defibrillation

8 cm away from pacemaker make sure good skin contact use conductive gel (or appropriate pads) make sure nobody is touching beds - say "CLEAR" and make visual check record joules delivered

The nurse is caring for a client who has just been diagnosed with sinus bradycardia. The client asks the nurse to explain what sinus bradycardia is. What would be the nurses best explanation? A: in many clients a HR slower than 60 BPM is considered too slow to maintain adequate CO B: This means your heart is not beating fast enough to keep you alive C: It is nothing to worry about D: In many clients, a HR slower than 70 BPM is considered too slow to maintain adequate CO

A Rationale: A heart rate < 60 beats per minute is pathologic in clients with heart disorders, increased intracranial pressure, hypothyroidism, or digitalis toxicity. Danger o/ sinus bradycardia is that the slow rate may be insufficient to maintain cardiac output. Option B is incorrect as it is an incomplete answer to the client's question. Option C minimizes the client's concern so it is incorrect. Option D is incorrect as it gives the client incorrect information

A patient is admitted with shock after a traumatic injury. You expect that his afterload will be: A.Low B.High C.Normal

A. Low

The nurse cares for a patient with a dysrhythmias and understands that the P wave on the ECG represents which phase of the cardiac cycle? a: atrial depolarization b: early ventricular repolarization c: ventricular depolarization d: ventricular depolarization

A: atrial depolarization

A nurse is caring for a client who is experiencing sinus bradycardia w a HR of 40 BPM, BP 80/50 mm Hg, and dizziness. Which medication does the nurse anticipate on administering to treat bradycardia? A: atropine B: dobutamine C: amiodarone D: lidocaine

A: atropine I.V. push atropine is used to treat symptomatic bradycardia. Dobutamine is used to treat heart failure and low cardiac output. Amiodarone is used to treat ventricular fibrillation and unstable ventricular tachycardia. Lidocaine is used to treat ventricular ectopy, ventricular tachycardia, and ventricular fibrillation.

The nurse witnesses a client experiencing ventricular fibrillation. What is the nurse's priority action? A: defibrillation B: cardioversion C: IV bolus of atropine D: IV bolus of dobutamine

A: defibrillation Advanced cardiac life support recommends early defibrillation for witnessed ventricular fibrillation. A cardioversion is used with a client who has a pulse. Atropine is used for bradycardia Dobutamine is an inotropic medication used to increased cardiac output.

Cath ______ therapy is the treatment that destroys specific cells that are the cause or central conduction route of a tachyarrhythmia that did not respond to medications and is not suitable for antitachycardia pacing

Ablation

A pt has been diagnosed with Afib. What class of medications are expected? A. anticholinergic B. anticoagulants C. PPIs D. Histamine blockers

B

What is your immediate response after you assess your patient and he is unresponsive? A. Call the doctor B. Start CPR C. Defibrillate D. Call rapid response and give atropine 1 mg IVP

B

what is the best way to treat sinus tachycardia? A. administer beta blockers B. encourage deep breathing exercises C. treat the underlying cause D. cardiovert

C. treat the underlying cause

Chronic causes of respiratory failure

COPD

the nurse is caring for a pt with pericarditis. Which of the following findings should the nurse expect? A. Petechiae B. Murmur C. Rash D. Friction Rub

D R: A friction rub can be heard during auscultation of a client who has pericarditis A. Petechiae are an expected finding in a client who has endocarditis. B. A murmur is an expected finding in a client who has myocarditis and endocarditis. C. Rash is an expected finding in a client who has rheumatic endocarditis.

A nurse is admitting a client who had suspected rheumatic endocarditis. The nurse should expect a prescription for which of the following lab tests to assist in confirmation of this diagnosis? A. ABG B. Serum albumin C. Liver enzymes D. Throat culture

D R: A throat culture can reveal the presence of streptococcus, which is the leading cause of rheumatic endocarditis A. Arterial blood gases are used to monitor the respiratory status of a client who has suspected rheumatic endocarditis, but they do not confirm the diagnosis. B. Blood albumin monitors the nutrition status of a client who has a suspected inflammatory disorder, but it does not confirm the diagnosis. C. Liver enzymes monitor a client's response to antibiotic therapy, which is used to treat rheumatic endocarditis, but they do not confirm the diagnosis.

The nurse expects that a client with mitral stenosis would demonstrate symptoms associated with congestion in the: A.Right atrium B.Superior vena cava C.Aorta D.Pulmonary circulation

D R: hydrostatic pressure builds backward into the pulmonary veins causing pulmonary edema

The nurse is caring for a pt who is displaying third-degree AV block on the EKG monitor. What is the priority nursing intervention for the client A. assessing BP and HR frequently B. identifying a code level status C. maintaining IVF D. alerting the HCP of the third degree heart block

D Rationale: The client may experience low cardiac output with third-degree AV block. The healthcare provider needs to intervene to preserve the client's cardiac output. Monitoring the blood pressure and heart rate are important, but not a priority. The identification of a code status during a heart block is not appropriate. IV fluids are not helpful if the heart is not perfusing.

what is the drug of choice for SVT? A. Atenolol B. Amiodipine C. Atropine D. Adenosine

D. Adenosine

endocardium

inner lining of the heart

ToF: you should check for a pulse after you defibrillate a patient

False

ToF: The primary goal in treating cardiogenic shock is to limit further myocardial damage

False R: The primary goal in treating cardiogenic shock is to treat the oxygenation needs of the heart muscle (and the tissues of the body)

cardiac arrest

sudden, unexpected stoppage of heart action, often leading to sudden cardiac death - asystole - PEA - Vfib - progressive bradycardia no pulse, no BP, loss of consciousness

Pericardium

Membrane surrounding the heart

Patients with AFIB are at an increased risk of HF, _____, ischemia, and embolic events

Myocardial

Respiratory failure ranges: PaO2, PaCO2, pH

PaO2: < 60 mm Hg PaCO2: > 50 mm Hg pH: < 7.35

T o F: anticoagulants need to be given 48 hours prior to cardio version if scheduled

True

ToF: AFIB is the most common sustained arrhythmia

True

cardiac temponade (result of a pericardial effusion)

a medical emergency that takes place when abnormal amounts of fluid accumulate in the pericardial sac compressing the heart and leading to a decrease in cardiac output and shock

relative refractory period

a stronger than usual stimulus is necessary to initiate an action potential

what is ablation and what is it used for?

ablation uses heat or cold energy to create tiny scars in the heart to block the faulty electrical signals and restore a typical heart beat used for AFIB

what is atropine and what is it used for?

atropine is a synthetic muscarinic antagonist. used to treat sinus bradycardia and works on the SA/AV node not effective in second-degree AV type II or third degree AV block

what is epinephrine and what is it used for

epinephrine is an agonist that binds with alpha adrenergic / beta adrenergic receptors used to stimulate the SNS

NUR considerations: valve replacement

focus on hemodynamic stability and recovery from anesthesia frequent assessment w attention to neuro, respiratory, and cardiovascular systems maintain INR for warfarin therapy - 2.0 - 3.5 for mitral valve replacement - 1.8 - 2.2 for aortic valve replacement educate its about infective endocarditis - abs before oral procedures

Myocardium

muscular, middle layer of the heart

When are pacemakers used?

symptomatic bradycardia symptomatic 2nd degree AV block: type I EXTREME CASES!!!! symptomatic 2nd degree AV block: type 2 Third degree AV block

The electrical simulator of the cardiac muscle cell is called depolarization, the mechanical contraction is called _______

systole

SIRS criteria

tachycardia: >90 BPM tachypnea: >20 BPM hyperthermia >101 or hypothermia <96.8 leukocytosis (>12,000), leukopenia (<4,000), or >10% immature cells

A nurse is caring for a client who experienced defibrillation. Which of the following should be included in the documentation of this procedure? SATA A. Follow-up ECG B. Energy settings used C. IV fluid intake D. UO E. Skin condition under electrodes

A, B, E R: the client's ECG rhythm is documented following the procedure. Energy settings used during the procedure are documented. the condition of the client's skin where electrodes were placed is documented. C. Iv fluid intake is not documented during defibrillation. D. Urinary output is not documented during defibrillation.

A client has an irregular heart rate of around 100 beats/minute and a significant pulse deficit. What component of the client's history would produce such symptoms? A. atrial fibrillation B. atrial flutter C. heart block D. bundle branch block

A In atrial fibrillation, several areas in the right atrium initiate impulses resulting in disorganized, rapid activity. The atria quiver rather than contract, producing a pulse deficit due to irregular impulse conduction to the AV node. The ventricles respond to the atrial stimulus randomly, causing an irregular ventricular heart rate, which may be too infrequent to maintain adequate cardiac output. Atrial flutter, heart block, and bundle branch block would not produce these symptoms.

A nurse is competing discharge teaching with a client who has a permanent pacemaker. Which of the following statements by the client indicates understanding of the teaching? A. "I will notify airport screeners about my pacemaker" B. "I will expect to have occasional hiccups" C. " I will have to disconnect my garage door opener" D. "I will take my pulse every 2-3 days

A R: the client should notify airport screening personnel about a pacemaker. B. the client should report hiccups to the provider because they can indicate improper lead placement. C. the use of household appliances, such as microwaves and garage door openers, does not affect pacemaker function. D. the client should check their pulse at the same time every day to ensure the pacemaker is maintaining the prescribed heart rate.

The nursing student asks the instructor why a loss of the "atrial kick" causes a decrease in CO, bc the ventricles are still contracting. What is the nursing instructors best response? A: The atrial contraction fills the ventricles and accounts for 1/3 of the volume ejected during ventricular contraction B: Loss of this does not affect the CO; CO remains the same with or without it C: This is only helpful if the ventricles are failing D: the atrial kick is never lost; there is always some ki

A Rationale: The atria contract slightly before the ventricles, giving the atria time to contract and fill the ventricles with blood. This part of atrial contraction is often referred to as the "atrial kick" and accounts for nearly one-third of the blood volume ejected during ventricular contraction. The "atrial kick" is lost with an atrial fibrillation rhythm and disturbed ventricular filling.

The nurse is caring for a client following the insertion of a temporary venous pacemaker via the femoral artery that is set as a VVI pacemaker rate of 70 BPM. Which of the following findings should the nurse report to the provider?? A. Cool and clammy foot with cap refill of 5 seconds B. Observed pacing spike followed by a QRS C. Persistant hiccups D. HR 84 BPM E. BP 104/62

A, C R: A cool, clammy foot can be an indication of a femoral hematoma secondary to insertion of the lead wires and should be reported. Persistent hiccups can indicate lead wire perforation and stimulation of the diaphragm and should be reported. B. A pacing spike followed by a QRS complex is an expected finding. D. A heart rate of 84/min is an expected finding.E. A blood pressure of 104/62 mm hg is an expected finding.

A nurse is completing discharge teaching with a client following the placement of the ICD. Which of the following info should the nurse include? (SATA) A. Avoid large magnetic fields B. caution family members that they can receive harmful unexpected shocks from the ICD C. Take body temperature at the same time each day D. Wear tight clothing to hold device in place E. Perform arm stretching exercises to strengthen muscled surrounding the ICD

A, C R: Large magnetic fields can deactivate the device, causing it to be ineffective for dysrhythmias. The client should take their temperature at the same time each day and report any increase to the provider. this is done to monitor for infection. B. Family members can feel the shock of an ICD if in contact with the client, but the shock is not harmful. D. the client should avoid wearing tight clothing, as this can cause friction over the insertion site. E. the client should restrict arm movement until healing of the incision occurs. the client should not raise arms above the head for 2 weeks.

A nurse on the cardiac unit is caring for a group of clients. The nurse should recognize which of the following clients as being at risk for the development of a dysrhythmia? SATA A. A client with metabolic acidosis B. A client w a blood potassium level of 4.3 C. A client who has a SpO2 of 96% D. A client who has COPD E. A client who underwent stent placement in a coronary artery

A, D, E R: A client who has an acid‐base imbalance such as metabolic alkalosis is at risk for a dysrhythmia. A client who has lung disease, such as COPD, is at risk for a dysrhythmia. A client who has cardiac disease and underwent a stent placement is at risk for a dysrhythmia. B. A blood potassium of 4.3 mEq/L is within the expected reference range and does not increase the risk of a dysrhythmia. C. O2 of 96% is within the expected reference range and does not increase the risk of a dysrhythmia.

A nurse is assessing a client who has splinter hemorrhages of the nail beds and reports a fever. The nurse should identify these findings as manifestations of which of the following disorder? A. Infective endocarditis B. Pericarditis C. Myocarditis D> Rheumatic endocarditis

A. R: splinter hemorrhages in nail beds and a report of fever are findings associated with infective endocarditis. B. A client who has pericarditis would report chest pain C. A client who has myocarditis would report a rapid heart rate. D. A client who has rheumatic endocarditis would report joint pain

A cardiac nurse educator is reviewing the use of the fixed rate mode pacemaker with a group of newly hired nurses. Which of the following statements by a newly hired nurse indicated understanding of the review? A. "This means the pacemaker fires at a asynchronous rate" B: "This means the pacemaker fires only when the HR is below a certain rate" C. "The pacemaker can automatically adjust to the clients increased activity level" D. "The pacemaker activity is triggered by heart muscle activity"

A. R: Fixed rate mode is asynchronous, meaning the pacemaker fires without regard for electrical activity in the heart. B. Demand mode detects an electrical impulse, and the pacemaker will then fire only if this impulse remains below a certain level. C. Fixed rate pacemaker mode means the rate does not change in relation to activity level. D. Fixed rate mode means the pacemaker fires without regard for electrical activity in the heart.

NUR considerations to note for pacemakers

obtained signed consent done shave, rub, or apply alcohol to skin prep skin (clean w soap and water, trim excess hair) PACEMAKER MONITORING IS THE NURSES RESPONSIBILITY!

A nurse is caring for 4 clients. Which of the following clients should the nurse identify as being at risk for developing rheumatic endocarditis? A. older adult with COPD B. child with streptococcal pharyngitis C. Middle aged adult with SLE D. Young adult who recently got a body tattoo

B R: A child who has streptococcal pharyngitis is at risk for developing rheumatic fever, whichcould result in rheumatic endocarditis. A. An older adult who has chronic obstructive pulmonary disease is not at risk for rheumatic endocarditisunless they develop rheumatic fever. C. A middle‐age adult who has lupus erythematosus is not at risk for rheumatic endocarditis unless they develop rheumatic fever. D. A young adult who receives a body tattoo is at increased risk for infective endocarditis but is not at risk for rheumatic endocarditis unless they develop rheumatic fever.

A nurse on a cardiac unit is caring for a client who is on telemetry. The nurse recognizes the client's HR is 46 BPM and notifies the provider. Which of the following prescriptions may be appropriate for this pt? A. Defibrillation B. Pacemaker C. Synchronized cardioversion D. Administration of IV lidocaine

B. R: A client who has bradycardia is a candidate for a pacemaker to increase his heart rate A. Defibrillation is used when a client has ventricular fibrillation or pulseless ventricular tachycardia. C. synchronized cardioversion is used when a client has a dysrhythmia such as atrial fibrillation, supraventricular tachycardia (svt), or ventricular tachycardia with pulse D. the administration of Iv lidocaine is used in clients who have a pulseless ventricular dysrhythmiato stimulate cardiac electrical function.

Which of the following are always ECG characteristics of first-degree AV Block? (Select all that apply) A.Atrial rate of 120/bpm B. QRS follows the p wave C.P-R interval above .20 seconds D.Irregular R-R interval E.No T wave F.No discernible p waves G. Irregular pulse

B. QRS follows the p wave C.P-R interval above .20 seconds

Your 87-year-old patient is admitted in the emergency department from home with severe dehydration. What is your highest priority? A.Obtaining a BP and treating B.Assessing pulses C.Making sure his airway is patent and he is breathing D.Contacting the family

C

A nurse is admitting a client who has a complete heart block as demonstrated by ECG. The client's HR is 34 BPM and BP is 83/48 mm Hg. The client is lethargic and unable to compete a sentence. Which of the following action should the nurse perform first? A. Transport the client to the Cardiovascular lab B. Prepare the client for insertion of permanent pacemaker C. Obtain a signed informed consent form for a pacemaker D. Apply transcutaneous pacemaker pads

D R: The greatest risk to this client is injury or death from inadequate tissue perfusion; therefore, the first action the nurse should take is to apply transcutaneous pacemaker pads and begin external pacing of the heart until a permanent pacemaker can be placed. A. Plan to transport the client to the cardiovascular laboratory for placement of a permanent pacemaker to control the client's heart; however, there is another action the nurse should take first. B. Plan to prepare the client for insertion of a permanent pacemaker by cleansing the skin and clipping excess hair; however, there is another action the nurse should take first. C. Obtain informed consent for placement of a permanent pacemaker if an individual with authority to make decisions for the client is present; however, there is another action the nurse should take first. Emergency procedures can be performed without consent if the client is not coherent.

Acute causes of respiratory failure

Drug / ETOH OD HF PE

Septecemia

bacteria and their toxins enter the blood and produce a reaction; "blood poisoning" GOAL = STOP SYSTEMIC RESPONSE!!!

If the tachycardia is persistent and causing hemodynamic instability, synchronized _____ is the tx of choice

cardioversion

respiratory failure: intermediate sx

confusion lethargy tachycardia tachypnea diaphoresis accessory muscle use

electrical signal (stimulus) of pacemaker travels....

from the pacemaker: through the leads: to the wall of the myocardium (myocardium is "captured" and stimulated to contract)

NUR Considerations: balloon angioplasty

monitor for heart failure and emboli assess heart sounds q 4 hrs same care as after cardiac Cath

Systemic Inflammatory Response Syndrome (SIRS)

overwhelming inflammatory response to an insult (injury) to the body: NOT able to contain inflammatory reaction **insult may be: trauma, infection, hemorrhage, pancreatitis **immunological and cytokine (pro-inflammatory), clotting cascade, massive endocrine and SNS response - stress response (glucocorticoid released, increased catecholamines) bringing increased HR, BP, blood glucose - RAAS system activation

effective refractory period

phase in which cells are incapable of depolarizing

Repolarization

potassium goes into cell sodium exits cell

Respiratory failure: early sx

restlessness anxiety fatigue increased BP

respiratory failure: late

severe cyanosis coma

Sinus ___________ occurs when the SA node creates an impulse at a rate less than 60 beats per minute in an adult.

sinus bradycardia

Depolarization

sodium goes into cell potassium exits cell

which are causes of bradycardia?? SATA - fever - sleeping - infection - vagal nerve stimulation - spinal cord injury

vagal nerve stim sleep spinal cord injury