The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats/minute. Which would be a correct interpretation based on these characteristics? 1. Sinus bra...
1. A client admitted to the hospital with chest pain and a history of type 2
diabetes mellitus is scheduled for cardiac catheterization. Which medication
would need to be withheld for 24 hours before the procedure and for 48
hours after the procedure?
Metformin needs to be withheld 24 hours before and for 48 hours after cardiac
catheterization because of the injection of contrast medium during the procedure.
If the contrast medium affects kidney function, with metformin in the system the
client would be at increased risk for lactic acidosis. The medications in the
remaining options do not need to be withheld 24 hours before and 48 hours after
cardiac catheterization.
2. A client who had cardiac surgery 24 hours ago has had a urine output
averaging 20 mL/hour for 2 hours. The client received a single bolus of 500
mL of intravenous fluid. Urine output for the subsequent hour was 25 mL.
Daily laboratory results indicate that the blood urea nitrogen level is 45
mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194
mcmol/L). On the basis of these findings, the nurse would anticipate that the
client is at risk for which problem?
The client who undergoes cardiac surgery is at risk for renal injury from poor
perfusion, hemolysis, low cardiac output, or vasopressor medication therapy.
Renal injury is signaled by decreased urine output and increased blood urea
nitrogen (BUN) and creatinine levels. Normal reference levels are BUN, 10-20
mg/dL (3.6-7.1 mmol/L), and creatinine, male, 0.6-1.2 mg/dL (53-106 mcmol/L)
and female 0.5-1.1 mg/dL (44-97 mcmol/L). The client may need medications to
increase renal perfusion and possibly could need peritoneal dialysis or
hemodialysis. No data in the question indicate the presence of hypovolemia,
glomerulonephritis, or urinary tract infection. 3. The nurse is reviewing an
electrocardiogram rhythm strip. The P waves and QRS complexes are
regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06
seconds. The overall heart rate is 64 beats/minute. Which action should the
nurse take?
1.
Check vital signs.
2.
Check laboratory test results.
3.
Notify the health care provider.
4.
Continue to monitor for any rhythm change.: Continue to monitor for any
rhythm change.
Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to
100 beats/minute. The PR and QRS measurements are normal, measuring
between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There
are no irregularities in this rhythm currently, so there is no immediate need to
check vital signs or laboratory results, or to notify the health care provider.
Therefore, the nurse would continue to monitor the client for any rhythm change.
4. A client is wearing a continuous cardiac monitor, which begins to sound
its alarm. The nurse sees no electrocardiographic complexes on the screen.
Which is the priority nursing action?
, Saunders NCLEX Cardiovascular
1.
Call a code.
2.
Call the health care provider.
3.
Check the client's status and lead placement.
4.
Press the recorder button on the electrocardiogram console.: Check the
client's status and lead placement.
Sudden loss of electrocardiographic complexes indicates ventricular asystole or
possibly electrode displacement. Accurate assessment of the client and
equipment is necessary to determine the cause and identify the appropriate
intervention. The remaining options are secondary to client assessment.
5. The nurse is evaluating a client's response to cardioversion. Which
assessment would be the priority?
1.
Blood pressure
2.
Status of airway
3.
Oxygen flow rate
4.
Level of consciousness: Status of airway
Nursing responsibilities after cardioversion include maintenance first of a patent
airway, and then oxygen administration, assessment of vital signs and level of
consciousness, and dysrhythmia detection.
6. The nurse is caring for a client who has just had implantation of an
automatic internal cardioverter-defibrillator. The nurse should assess which
item based on priority?
1.
, Saunders NCLEX Cardiovascular
Anxiety level of the client and family
2.
Presence of a MedicAlert card for the client to carry
3.
Knowledge of restrictions on postdischarge physical activity
4.
Activation status of the device, heart rate cutoff, and number of shocks it
is programmed to deliver: Activation status of the device, heart rate cutoff, and
number of shocks it is programmed to deliver
The nurse who is caring for the client after insertion of an automatic internal
cardioverter-defibrillator needs to assess device settings, similar to after insertion
of a permanent pacemaker. Specifically, the nurse needs to know whether the
device is activated, the heart rate cutoff above which it will fire, and the number of
shocks it is programmed to deliver. The remaining options are also nursing
interventions but are not the priority.
7. A client's electrocardiogram strip shows atrial and ventricular rates of 110
beats/minute. The PR interval is 0.14 seconds, the QRS complex measures
0.08 seconds, and the PP and RR intervals are regular. How should the
nurse correctly interpret this rhythm?
Sinus tachycardia has the characteristics of normal sinus rhythm, including a
regular PP interval and normal-width PR and QRS intervals; however, the rate is
the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are
greater than 100 beats/minute.
8. The nurse is assessing the neurovascular status of a client who returned
to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass
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