Nursing Interventions
A nurse is caring for a patient who has just undergone cardioversion. The nurse should immediately do which of the following?
A. Monitor for return of normal sinus rhythm
B. Administer IV heparin
C. Begin chest compressions
D. Assess for possible shock site burns
Answer: A. Monitor for return of normal sinus rhythm
Which of the following medications should be administered to a patient with symptomatic bradycardia?
A. Amiodarone
B. Atropine
C. Lidocaine
D. Adenosine
Answer: B
A patient has a heart rate greater than 100 beats per minute. The nurse explains that tachycardia can decrease perfusion by:
A. Decreasing the preload and reducing cardiac output
B. Increasing the diastolic time and improving cardiac output
C. Increasing heart rate while decreasing myocardial oxygen demand
D. Reducing the workload of the heart
Answer: A
Tachycardia, with a heart rate above 100 beats per minute, can negatively affect perfusion because it decreases diastolic time, which reduces ventricular filling time and ultimately cardiac output. Additionally, the heart is working harder at a faster rate, increasing its workload and oxygen demand.
Who would be a candidate for an implantable defibrillator?
A. Patient with a third-degree heart block
B. Patient with a history of Vfib
C. Patient admitted to the ER with SVT
D. Patient with a history of symptomatic bradycardia
Answer: B. Patient with a history of Vfib
Rationale:
An implantable cardioverter defibrillator (ICD) is typically recommended for patients with a history of life-threatening arrhythmias such as ventricular fibrillation (Vfib) or ventricular tachycardia. The ICD helps to prevent sudden cardiac death by detecting and treating these rhythms with electrical shocks.
What does the T wave represent?
A. Atrial depolarization
B. Ventricular depolarization
C. Atrial Repolarization
D. Ventricular Repolarization
D. Ventricular Repolarization
A nurse is caring for a patient who has a pacemaker. Which of the following is most important for the nurse to monitor in the immediate post-op period?
A. Oxygen saturation levels
B. Blood pressure and heart rate
C. Respiratory rate
D. Urine output
Answer: B. Blood pressure and heart rate
A nurse is providing care for a patient with symptomatic bradycardia. The nurse is planning to administer atropine. The nurse should know that atropine has which of the following actions?
A. Decreases the heart rate by blocking vagal tone
B. Increases the heart rate by blocking vagal tone
C. Slows conduction through the AV node
D. Increases cardiac output by improving contractility
Answer: B. Increases the heart rate by blocking vagal tone
What is the intervention for a patient in asystole?
A. Continue to monitor
B. Begin placing quick combo pads and prepare for defibrillation
C. CPR and epinephrine 1 mg
D. Emergency cardioversion
A patient who recently had a transvenous pacemaker inserted asks the nurse where the pacemaker is located in the heart. How should the nurse explain the location of the pacemaker?
A. Left ventricle
B. Right ventricle
C. Left atrium
D. Right atrium
B. Right ventricle
The nurse is determining whether the client's rhythm strip demonstrates proper firing of the sinoatrial (SA) node. Which waveform indicates proper function of the SA node?
a. The QRS complex is present.
b. The PR interval is 0.24 second.
c. A P wave precedes every QRS complex.
d. The ST segment is elevated.
C
A P wave is generated by the SA node and represents atrial depolarization.
Nurse Kinsey is looking after Mr. Harris, a 59-year-old patient who has recently had a myocardial infarction (MI). She observes eight premature ventricular contractions (PVCs) in one minute on the cardiac monitor. Mr. Harris is currently receiving D5W intravenously and is on 2 L/minute of oxygen. What should be Nurse Kinsey's immediate course of action?
A. Provide a prescribed pain reliever.
B. Promptly alert the physician.
C. Boost the concentration of administered oxygen.
D. Elevate the rate of the IV infusion.
Answer: B
Promptly alert the physician. In the context of a recent myocardial infarction (MI), the observation of eight premature ventricular contractions (PVCs) in one minute is concerning and indicates potential instability in the patient's cardiac condition. PVCs can be a sign of irritability in the ventricles and can lead to more serious arrhythmias, especially in the context of an MI. The immediate action should be to promptly alert the physician, as this situation may require a reassessment of the patient's condition, modification of treatment, or further diagnostic testing.
A nurse is caring for a patient who has been prescribed amiodarone for the treatment of a ventricular arrhythmia. Which of the following actions best describes how amiodarone works to manage arrhythmias?
A. It increases the automaticity of the SA node.
B. It blocks sodium channels, shortening the refractory period.
C. It slows conduction and prolongs repolarization and the refractory period of the AV node.
D. It slows conduction through the AV node and interrupts reentry pathways.
Answer: C.
Rationale: Amiodarone works by slowing conduction and prolonging repolarization and the refractory period of the AV node, which helps to manage arrhythmias and stabilize the heart rhythm.
A nurse is caring for a patient with atrial fibrillation (A-fib). Which of the following is a major complication associated with A-fib?
A. Increased heart rate and cardiac output
B. Reduced risk of stroke due to increased atrial contraction
C. Blood pooling in the atria leading to clot formation
D. Improved ventricular filling time
Answer: C
A nurse is providing education to a patient receiving an implantable cardioverter-defibrillator (ICD). Which statement by the patient indicates understanding of the device?
Answer: A.
During the QRS complex on an EKG, which of the following is occurring?
A. The signal is traveling through the atria, leading to atrial depolarization and contraction.
B. The signal is traveling through the Purkinje fibers and up through the ventricles while depolarizing and contracting the ventricles.
C. The ventricles are repolarizing, preparing for the next contraction.
D. The signal is passing through the AV node and entering the atria to initiate a new cycle
Answer: B. The signal is traveling through the Purkinje fibers and up through the ventricles while depolarizing and contracting the ventricles.
A patient presents to the emergency department with a cardiac monitor displaying atrial fibrillation (A-fib). Their blood pressure is 80/54 mmHg, and their skin is cold and clammy to the touch. The patient reports experiencing syncopal episodes over the past three days. They have a history of A-fib and indicate non-adherence to daily medications. What should the nurse prioritize FIRST in the management of this patient?
A. Emergency cardioversion
B. Obtain an EKG on the patient
C. Anticipate initiating IV heparin
D. Place the patient on NPO status
Answer: C. Anticipate initiating IV heparin
Rationale: When a patient has been in atrial fibrillation for more than 48 hours, there is a risk of clot formation in the atria. Emergency cardioversion could dislodge a clot and lead to serious complications, such as a stroke. Therefore, it is essential to start anticoagulation (e.g., IV heparin) first to reduce the risk of thromboembolic events before performing cardioversion. Once the patient is properly anticoagulated, cardioversion can then be considered.
Nurse Chelsea is in Mrs. Lavender's room, a 56-year-old patient with cardiac concerns. She notices on the cardiac monitor that Mrs. Lavender has suddenly entered into ventricular tachycardia. Surprisingly, Mrs. Lavender remains awake and alert with good skin color. What should Nurse Chelsea prepare to do?
A. Get ready for the insertion of a pacemaker.
B. Prepare to administer epinephrine (Adrenaline) intravenously.
C. Prepare to immediately defibrillate the patient.
D. Prepare to administer amiodarone (Cordarone) intravenously.
Answer: D
Prepare to administer amiodarone (Cordarone) intravenously. In the case of a patient with ventricular tachycardia (VT) who is hemodynamically stable (meaning they have adequate blood pressure and are conscious and alert, as indicated by good skin color and alertness), the immediate goal is to convert the heart back to a normal rhythm using antiarrhythmic drugs. Amiodarone is a common choice for this situation due to its effectiveness in treating and preventing a wide range of arrhythmias, including VT. It works by slowing the electrical conduction and prolonging the refractory period of heart tissue, which can help to restore a normal heart rhythm.
8. Nurse Sarah is monitoring the cardiac status of Mr. Adams, a 47-year-old patient. She wants to determine if he is exhibiting a normal sinus rhythm on the cardiac monitor. Which criteria should Nurse Sarah use to confirm a normal sinus rhythm?
A. The duration of the QRS complex is between 0.12 to 0.20 second.
B. The ST segment is elevated compared to the PR interval.
C. Four to eight complexes are present on a 6-second ECG strip.
D. The intervals between R waves (RR intervals) are relatively consistent.
answer: D
The intervals between R waves (RR intervals) are relatively consistent. In a normal sinus rhythm, the heart's sinus node, which is the natural pacemaker, sends out a regular, consistent electrical impulse. This causes the heart to contract at a regular and consistent rate. The RR interval, which is the time between two consecutive R waves (representing one cardiac cycle), should be relatively consistent in a normal sinus rhythm. Variability in the RR interval indicates irregularities in heart rhythm, which can be indicative of various cardiac conditions. Therefore, Nurse Sarah should look for consistent RR intervals to confirm a normal sinus rhythm.
A patient is post-operative from a pacemaker placement and is experiencing persistent hiccups. What does this symptom indicate?
A. The patient has a pneumothorax.
B. The pacemaker leads stimulate the diaphragm.
C. The patient hase a myocardial perforation.
D. The pacemaker is malfunctioning
Answer: B
Persistent hiccups after pacemaker placement are often indicative that the pacemaker leads are stimulating the diaphragm. This occurs when the leads are placed in a position close to the diaphragm, causing involuntary contractions.
A nurse is assessing a patient for symptoms of dysrhythmias. Which of the following symptoms are commonly associated with dysrhythmias? (Select all that apply.)
A. Chest pain
B. Weak/thready pulse
C. Hypotension
D. Increased urinary output
E. Vomiting
F. Edema
Correct Answers:
A. Chest pain
B. Weak/thready pulse
C. Hypotension
Rationale: Symptoms like chest pain, a weak/thready pulse, and hypotension are commonly observed with dysrhythmias due to decreased cardiac output or impaired perfusion. Increased urinary output, vomiting, and edema are not typically linked with dysrhythmias but may be seen in other conditions.
Which of the following are true when administering Adenosine? Select all that apply.
A. Adenosine should be administered on a peripheral IV site.
B. The patient must be on a cardiac monitor.
C. Filter tubing must always be used when administering Adenosine.
D. The patient should raise their arm following the push.
E. Adenosine will be implemented as an IV drip.
F. Flush with 20 ml NSS following administration immediately.
Correct Answers:
B. The patient must be on a cardiac monitor.
D. The patient should raise their arm following the push.
F. Flush with 20 ml NSS following administration immediately.
Beta blockers work by blocking beta 1 receptors in the heart, which result in which three actions? (Select all that apply.)
A. Decrease the absolute refractory period
B. Increase automaticity
C. Decrease heart rate
D. Decrease impulse of the SA node and transmission through the AV node
E. Decrease contractility
F. Increase the impulse of the SA node and transmission through the AV node
Correct Answers:
C. Decrease heart rate
D. Decrease impulse of the SA node and transmission through the AV node
E. Decrease contractility
What would be the patient's s/s if you looked at the monitor and saw Vfib, Select all that apply!
A. Tachycardic
B. Seizing
C. No perfusion
D. Jaundice
E. No pulse
F. Bradycardic
Answer: C and E
A nurse is preparing to administer defibrillation to a patient in ventricular fibrillation. Which of the following actions should the nurse take? (Select all that apply.)
A. Administer amiodarone
B. Perform CPR immediately after the shock
C. Press charge
D. Perform CPR while setting up the defibrillation machine
E. Clear the patient twice
F. Press sync
Answer:
B. Perform CPR immediately after the shock
C. Press charge
D. Perform CPR while setting up the defibrillation machine
E. Clear the patient twice
A nurse is reviewing the characteristics of different dysrhythmias. Which of the following are true regarding the characteristics of common dysrhythmias? Select all that apply.
A. Atrial fibrillation (A-fib) is characterized by an irregularly irregular rhythm with no identifiable P waves.
B. In sinus tachycardia, the heart rate exceeds 100 bpm, and the rhythm is regular with P waves before each QRS complex.
C. Atrial flutter shows no identifiable P waves, and the conduction ratio is typically 1:1, 2:1, or 3:1.
D. In ventricular fibrillation (V-fib), the heart rhythm is totally irregular, with no identifiable QRS complexes or P waves.
E. A patient with second-degree heart block Type 2 (Mobitz) experiences progressively lengthening PR intervals until a QRS complex is dropped.
F. In normal sinus rhythm, the heart rate is between 60-100 bpm, and the rhythm is regular with P waves preceding each QRS complex.
Correct Answers:
A. Atrial fibrillation (A-fib) is characterized by an irregularly irregular rhythm with no identifiable P waves.
B. In sinus tachycardia, the heart rate exceeds 100 bpm, and the rhythm is regular with P waves before each QRS complex.
D. In ventricular fibrillation (V-fib), the heart rhythm is totally irregular, with no identifiable QRS complexes or P waves.
F. In normal sinus rhythm, the heart rate is between 60-100 bpm, and the rhythm is regular with P waves preceding each QRS complex.