The telemetry nurse is unable to read the telemetry monitor at the nurse’s station. Which intervention should the telemetry nurse implement first? a. go to the client’s room to check the client c. contact the client on the client call system The client shows ventricular fibrillation on the telemetry at the nurse’s station. Which action should the telemetry nurse implement first? a. administer epinephrine IVP c. call
a STAT code The client is experiencing multifocal premature ventricular contractions. Which antidysrhythmic medication would the nurse expect the health-care provider to order for this client? a.
lidocaine a. lidocaine suppresses ventricular ectopy and is the drug of choice for ventricular dysrhythmias
b. instruct the primary nurse to assess the client
c. contact the client on the client call
system
d. request the nursing assistant to take the crash cart to the client’s room
if the client answers the call light and is not experiencing chest pain, then there is probably a monitor artifact, which is not a life-threatening emergency. after talking with the client, send a nurse to the room to check the monitor
b. prepare to defibrillate the client
c. call a STAT code
d. start cardiopulmonary resuscitation
the nurse must call a code that activates the crash cart being brought to the room and a team of health-care providers that will care for the client according to an established protocol.
b. atropine
c. digoxin
d. adenosine
The client is exhibiting sinus bradycardia, is complaining of syncope and weakness, and has a BP of 98/60. Which collaborative treatment should the nurse anticipate being implemented?
a. administer a thrombolytic medication
b. assess the client’s cardiovascular status
c. prepare for insertion of a pacemaker
d. obtain a permit for synchronized cardioversion
c. prepare for insertion of a pacemaker
the client is symptomatic and will require a pacemaker
Which intervention should the nurse implement when defibrillating a client who is in ventricular fibrillation?
a. defibrillate the client at 50, 100, 200 joules
b. do not remove the oxygen source during defibrillation
c. place petroleum jelly on the defibrillator pads
d. shout “all clear” prior to defibrillating the client
d. shout “all clear” prior to defibrillating the client
if any member of the health-care team is touching the client or the bed during defibrillation, that person could possibly be shocked. therefore, the nurse should shout “all clear”
The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client?
a. instruct the client to use a soft-bristle toothbrush
b. discuss the importance of getting a monthly partial thromboplastin time (PTT).
c. teach the client about signs of pacemaker malfunction
d. explain to the client the procedure for synchronized cardioversion
a. instruct the client to use a soft-bristle toothbrush
a client with chronic atrial
fibrillation will be taking an anticoagulant to help prevent clot formation. Therefore, the client is at risk for bleeding and should be instructed to use a soft-bristle toothbrush
The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first?
a. administer lidocaine, an antidysrhytmic, IVP
b. prepare to defibrillate the client
c. assess the
client’s apical pulse and blood pressure
d. start basic cardiopulmonary resuscitation
c. assess the client’s apical pulse and blood pressure
The nurse must assess apical pulse and blood pressure to determine if the client is in cardiac arrest and then treat as ventricular fibrillation. if the client’s heart is beating, the nurse would then administer lidocaine
The client is in complete heart block. Which interventions should the nurse implement first?
a. prepare to insert a pacemaker
b. administer atropine, an antidysrhythmic
c. obtain a STAT electrocardiogram (ECG)
d. Notify the health-care provider
b. administer atropine, an antidysrhythmic
atropine will decrease vagal stimulation and increase the heart rate. Therefore, it is the first intervention
The client is in ventricular fibrillation. Which interventions should the nurse implement?
a. start cardiopulmonary resuscitation
b. prepare to administer the antidysrhythmic adenosine IVP
c. Prepare to defibrillate the client
d. bring the crash
cart to the bedside
e. prepare to administer the antidysrhythmic amiodarone IVP
a. start cardiopulmonary resuscitation
- ventricular fibrillation indicates the client does not have a heartbeat. Therefore, CPR should be instituted
c. prepare to defibrillate the client
- defibrillation is the treatment of choice for ventricular fibrillation
d. bring the crash cart to
the bedside
- the crash cart has the defibrillator and is used when performing advanced cardiopulmonary resuscitation
e. prepare to administer the antidysrhythmic amiodarone IVP
- amiodarone is an antidysrhytmic that is used in ventricular dysrhythmias
The client who is one day postoperative coronary artery bypass surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement?
a. assess the apical heart rate for on full minute
b. notify the client’s cardiac surgeon
c. prepare the client for synchronized cardioversion
d. determine if the client is having pain
d. determine if the client is having pain
- Sinus tachycardia means the sinoatrial node is the pacemaker, but the rate is greater than 100 because of pain, anxiety,
or fever. The nurse must determine the cause and treat appropriately. There is no specific medication for sinus tachycardia
The client’s telemetry reading shows a P wave before each QRS complex and the rate is 78. Which action should the nurse implement?
a. document this as normal sinus rhythm
b. request a 12-lead electrocardiogram
c. prepare to administer the cardiotonic digoxin
PO
d. assess the client’s cardiac enzymes
a. document this as normal sinus rhythm
- the P wave represents atrial contraction and the QRS complex represents ventricular contraction— a normal telemetry reading. A rate between 60 and 100 indicates normal sinus rhythm. Therefore, the nurse should document this as normal sinus rhythm and not take any action.
Which client problem has priority for the client with a cardiac dysrhythmia?
a. alteration in comfort
b. decreased cardiac output
c. impaired gas exchange
d. activity intolerance
B. decreased cardiac output
-any abnormal electrical activity of the heart causes decreased cardiac output