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A patient with AFib suddenly becomes dizzy and hypotensive. What is the nurse’s first assessment?
Check blood pressure
This cardiac biomarker rises with myocardial injury and is a key lab test for diagnosing an MI.
Troponin
What is Virchow’s Triad?
This "triad" of risk factors for Pulmonary Embolism includes venous stasis, vessel wall injury, and hypercoagulability.
To ensure accurate readings, the transducer must be leveled at the Phlebostatic Axis, located here.
4th intercostal space, mid-axillary line
normal time duration for a PR interval
0.12–0.20 seconds
The nurse is managing a patient with a chest tube. Upon assessment, the nurse notes continuous bubbling in the water seal chamber. How should the nurse interpret this finding?
A. This is a normal finding indicating drainage.
B. The suction pressure is set too high.
C. There is an air leak in the system.
D. The patient's lung has fully re-expanded.
Correct Answer: C
Rationale: The notes explicitly state that bubbling in the air leak (water seal) chamber = problem (specifically an air leak), whereas "tidaling" is normal
This rapid IV push medication is used to treat symptomatic Supraventricular Tachycardia (SVT) and may cause brief asystole.
Adenosine
A patient with a tension pneumothorax will likely display tracheal deviation toward this side.
What is the unaffected side?
This hemodynamic value reflects the patient's fluid volume status or "filling pressure" of the ventricle
preload
this medication is the first-line treatment for symptomatic Sinus Bradycardia
Atropine (0.5 mg IV Push)
A nurse observes a rhythm on the cardiac monitor characterized by a rate of 170 bpm, a narrow QRS complex, and P waves that are "smushed" or buried. The patient complains of palpitations and dizziness. Which intervention should the nurse anticipate?
A. Administering Atropine 0.5 mg IV push
B. Defibrillation at 200 Joules
C. Administering Adenosine rapid IV push
D. Inserting a temporary pacemaker
Correct Answer: C
Rationale: The rhythm described is Supraventricular Tachycardia (SVT) (Rate 150-250, narrow QRS, P waves buried). The treatment for symptomatic SVT is Adenosine (rapid IV push). Atropine is for bradycardia; defibrillation is for pulseless VT/VF.
A patient is admitted with a diagnosis of Pulmonary Embolism (PE). Which of the following are recognized risk factors? (Select All That Apply)
A. History of Deep Vein Thrombosis (DVT)
B. Recent hip or knee replacement surgery
C. Chronic ambulation (daily walking)
D. Oral contraceptive use
E. Obesity
A, B, D, E Rationale: The notes list risk factors (Virchow's Triad) including venous stasis (immobility), vessel wall injury (surgery/trauma), and hypercoagulability (OCPs). Specific factors listed include DVT, major surgery (hip/knee), and obesity. Walking (ambulation) prevents stasis and is not a risk factor
What is the Water Seal (or Air Leak) Chamber?
In a chest tube drainage system, bubbling in this chamber indicates an air leak.
Before inserting a radial arterial line, this test must be performed to confirm sufficient collateral blood supply.
allen test
This dysrhythmia is characterized by a "sawtooth" pattern between QRS complexes and no true P waves
Atrial Flutter
A patient in cardiogenic shock is being treated with an Intra-Aortic Balloon Pump (IABP). The family asks the nurse how this device helps the patient's heart. Which explanation by the nurse is accurate based on the device's mechanics?
A. "It inflates during the heart's contraction to push blood into the body."
B. "It inflates during the heart's resting phase (diastole) to increase blood flow to the heart muscle."
C. "It constantly keeps the aorta open to reduce blood pressure."
D. "It takes over the electrical pacing of the heart completely.
B Rationale: Chapter 32 states that the IABP "Inflates during diastole → Increases coronary perfusion" and "Deflates during systole → Decreases SVR (afterload)." It does not inflate during contraction (systole).
Arterial Blood Gas (ABG) Interpretation A patient's ABG results are: pH 7.23, PaCO2 58 mmHg, and HCO3 24 mEq/L. How should the nurse interpret these findings?
A. Respiratory Alkalosis
B. Metabolic Acidosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Answer: C Rationale: Based on Chapter 27 normal ranges:
pH 7.23 is low (< 7.35), indicating Acidosis.
PaCO2 58 is high (> 45), indicating a Respiratory cause (High CO2 = Acid).
HCO3 24 is normal (22–26), indicating no metabolic compensation yet. Therefore, it is Respiratory Acidosis
A nurse is caring for a patient in the ICU who has an arterial line in the right radial artery. Which assessment finding requires immediate intervention?
A. The blood pressure waveform is clearly visible on the monitor.
B. The patient’s hands are cool and pale with a capillary refill > 3 seconds.
C. The transducer is leveled at the 4th intercostal space, mid-axillary line.
D. The low-pressure alarm sounds briefly when the patient moves their arm.
Correct Answer: B
Rationale: The notes state that assessment of an arterial line includes checking for bleeding, perfusion, and reliability. Cool, pale hands with delayed capillary refill indicate poor perfusion, suggesting the radial artery may be occluded, which is a complication described where the provider might need to choose a different site if flow is insufficient.
this value represents the force (resistance) the left ventricle must overcome to eject blood into the body.
afterload
This lethal rhythm involves chaotic ventricular impulses with no organized contraction and requires immediate CPR and defibrillation
Ventricular Fibrillation (V-Fib)
A nurse is analyzing a cardiac rhythm strip and notes that the P waves march out regularly and the QRS complexes march out regularly, but there is no relationship between the atria and ventricles (AV dissociation). What is the priority treatment for this rhythm?
A. Administration of Adenosine
B. Defibrillation
C. Transcutaneous Pacing
D. Amiodarone infusion
Answer: C Rationale: Chapter 29 identifies this rhythm as a 3rd Degree (Complete) AV Block, characterized by complete AV dissociation. The treatment listed is "Immediate: Transcutaneous pacing (if symptomatic)" and "Long-Term: Permanent pacemaker."
Chest Trauma A patient arrives at the ED following a motor vehicle collision. Assessment reveals distended neck veins (JVD), muffled heart sounds, and hypotension. The nurse recognizes these as signs of which life-threatening condition?
A. Tension Pneumothorax
B. Cardiac Tamponade
C. Pulmonary Embolism
D. Flail Chest
B Rationale: The Pulmonary Embolism / Chest Trauma notes identify this cluster of symptoms (Hypotension, JVD, Muffled heart sounds) as Beck’s Triad, which indicates Cardiac Tamponade. (Note: Tension Pneumothorax presents with tracheal deviation, not necessarily muffled heart sounds).
What is a V/Q Mismatch?
This term describes the condition where air reaches the alveoli but blood does not (high ventilation, low perfusion), often caused by a PE.
To prevent pulmonary artery occlusion or hemorrhage, the PA catheter balloon should be inflated for no more than this amount of time.
10 sec
In this type of heart block, there is complete AV dissociation where the atria and ventricles beat independently of each other.
3rd Degree (Complete) AV Block