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Chapter 31

Terms in this set (12)

A nurse assesses a client's electrocardiograph tracing and observes that not all QRS
complexes are preceded by a P wave. How would the nurse interpret this observation?
a.
The client has hyperkalemia causing irregular QRS complexes.
b.
Ventricular tachycardia is overriding the normal atrial rhythm.
c.
The client's chest leads are not making sufficient contact with the skin.
d.
Ventricular and atrial depolarizations are initiated from different sites
d.
Ventricular and atrial depolarizations are initiated from different sites

Normal rhythm shows one P wave preceding each QRS complex, indicating that all
depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a
different source of initiation of depolarization. This finding on an electrocardiograph tracing is
not an indication of hyperkalemia, ventricular tachycardia, or disconnection of lea
A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse
symptoms. Which activity modification would the nurse suggest to avoid further slowing of
the heart rate?
a.
"Make certain that your bath water is warm."
b.
"Avoid straining while having a bowel movement."
c.
"Limit your intake of caffeinated drinks to one a day."
d.
"Avoid strenuous exercise such as running.
b.
"Avoid straining while having a bowel movement.

Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which
stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not
desirable in a person who has bradycardia. The other instructions are not appropriate for this
condition.
A nurse is assessing clients on a medical-surgical unit. Which client would the nurse identify
as being at greatest risk for atrial fibrillation?
a.
A 45-year-old who takes an aspirin daily.
b.
A 50-year-old who is post coronary artery bypass graft surgery.
c.
A 78-year-old who had a carotid endarterectomy.
d.
An 80-year-old with chronic obstructive pulmonary disease.
b.
A 50-year-old who is post coronary artery bypass graft surgery.

Atrial fibrillation occurs commonly in clients with cardiac disease. Other risk factors include
hypertension (HTN), previous ischemic stroke, transient ischemic attack (TIA) or other
thromboembolic event, diabetes mellitus, heart failure, obesity, hyperthyroidism, chronic
kidney disease, excessive alcohol use, and mitral valve disease. The other conditions do not
place these clients at higher risk for atrial fibrillation.
A nurse assesses a client with atrial fibrillation. Which manifestation would alert the nurse to
the possibility of a serious complication from this condition?
a.
Sinus tachycardia
b.
Speech alterations
c.
Fatigue
d.
Dyspnea with active
b.
Speech alterations

Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events
includes changes in mentation, speech, sensory function, and motor function. Clients with
atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific
complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased
cardiac output caused by the rhythm disturbance.
A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication
would the nurse expect to find on this client's medication administration record to prevent a
common complication of this condition?
a.
Sotalol
b.
Warfarin
c.
Atropine
d.Lidocaine
b.
Warfarin

Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are
treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and
lidocaine are not appropriate for preventing this complication.
A nurse administers prescribed adenosine to a client. Which response would the nurse assess
for as the expected therapeutic response?
a.
Decreased intraocular pressure
b.
Increased heart rate
c.
Short period of asystole
d.
Hypertensive crisis
c.
Short period of asystole

Clients usually respond to adenosine with a short period of asystole, bradycardia with long
pauses, nausea, or vomiting. Adenosine has no impact on intraocular pressure nor does it
cause increased heart rate or hypertensive crisi
A telemetry nurse assesses a client who has a heart rate of 35 beats/min on the cardiac
monitor. Which assessment would the nurse complete next?
a.
Pulmonary auscultation
b.
Pulse strength and amplitude
c.
Level of consciousness
d.
Mobility and gait stability
c.
Level of consciousness

A heart rate of 40 beats/min or less could have hemodynamic consequences. The client is at
risk for inadequate cerebral perfusion. The nurse would assess for level of consciousness,
dizziness, confusion, syncope, chest pain, shortness of breath. Although the other assessments
would be completed, the nurse would assess the client's neurologic status ne
A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The
nurse observes the presence of a pacing spike but no QRS complex on the client's
electrocardiogram. What action would the nurse take next?
a.
Administer intravenous diltiazem.
b.
Assess vital signs and level of consciousness.
c.
Administer sublingual nitroglycerin.
d.
Assess capillary refill and temperature.
b.
Assess vital signs and level of consciousness.


In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit
through the chest wall. The pacemaker spike would be followed immediately by a QRS
complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If
there is no capture, then there is no ventricular depolarization and contraction. The nurse
would assess for cardiac output via vital signs and level of consciousness. The other
interventions would not determine if the client is tolerating the loss of capture.
A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which intervention is
appropriate for the nurse to perform prior to defibrillating this client?
a.
Make sure that the defibrillator is set to the synchronous mode.
b.
Administer 1 mg of intravenous epinephrine.
c.
Test the equipment by delivering a smaller shock at 100
M
d.
Ensure that everyone is clear of contact with the client and the bed
d.
Ensure that everyone is clear of contact with the client and the bed

o avoid injury, the rescuer commands that all personnel clear contact with the client or the
bed and ensures their compliance before delivery of the shock. Defibrillation is done in
asynchronous mode. Equipment would not be tested before a client is defibrillated because
this is an emergency procedure; equipment would be checked on a routine basis.
Defibrillation takes priority over any medication
After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse
assesses the client's understanding. Which statement by the client indicates correct
understanding of the teaching?
a.
"I would wear a snug-fitting shirt over the ICD."
b.
"I will avoid sources of strong electromagnetic fields."
c.
"I would participate in a strenuous exercise program."
d.
"Now I can discontinue my antidysrhythmic medication."
b.
"I will avoid sources of strong electromagnetic fields."

The client being discharged with an ICD is instructed to avoid strong sources of
electromagnetic fields, such as devices emitting microwaves (not microwave ovens);
transformers; radio, television, and radar transmitters; large electrical generators; metal
detectors, including handheld security devices at airports; antitheft devices; arc welding
equipment; and sources of 60-cycle (Hz) interference. Also avoid leaning directly over the
alternator of a running motor of a car or boat. Clients would avoid tight clothing, which could
cause irritation over the ICD generator. The client would be encouraged to exercise but would
not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff
point because the ICD can discharge inappropriately. The client would continue all prescribed medications
A nurse cares for a client with atrial fibrillation who reports fatigue when completing
activities of daily living. What intervention would the nurse implement to address this client's
concerns?
a.
Administer oxygen therapy at 2 L per nasal cannula.
b.
Provide the client with a sleeping pill to stimulate rest.
c.
Schedule periods of exercise and rest during the day.
d.
Ask assistive personnel (AP) to help bathe the client.
c.
Schedule periods of exercise and rest during the day

lients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when
completing activities of daily living. The nurse would schedule periods of exercise and rest
during the day to decrease fatigue. The other interventions will not assist the client with
performing self-care activities and there is no indication for oxygen
A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. What
action would the nurse take prior to the cardioversion?
a.
Administer intravenous adenosine.
b.
Turn off oxygen therapy.
c.
Ensure that a tongue blade is available.
d.
Position the client on the left side.
b.
Turn off oxygen therapy.

For safety during cardioversion, the nurse would turn off any oxygen therapy to prevent fire.
The other interventions are not appropriate for a cardioversion. The client would be placed in
a supine position.
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