Rasmussen Final MDC3
What does A Fib ECG look like? - ANS-impulse rate of 350-600 times per minute
-no P waves
-no atrial contractions
-loss of atrial kick
-irregular ventricular response
How often do you assess vital signs on a patient with a dysrhythmia
(gray box) - ANSat least every 4 hours
Nursing Safety Priority for Sinus tachycardia what to assess
(gray box) - ANS-fatigue, weakness, SOB, orthopnea, decreased O2, increased HR,
decreased BP, angina, palpitations
-ECG: T wave inversion or ST elevation/depression
-decreased cerebral perfusion may occur. Symptoms: restlessness and anxiety
-impaired renal function may occur symptoms: decreased urine output.
The nurse is assessing the client's cardiac rhythm and notes the following: HR 64, regular
rhythm, PR interval 0.20; QRS 0.10. How will the nurse document this rhythm interpretation
in the electronic health record?
A. Sinus tachycardia
B. Sinus bradycardia
C. Normal sinus rhythm
D. Sinus arrhythmia - ANSC
NURSING SAFETY PRIORITY
patient education with permanent pacemakers include - ANS-Avoid strong electromagnetic
fields (magnets and telecommunication transmitters)
-carry pacemaker identification card
-medical alert bracelet
A fib may lead to - ANS-DVT or PE due to blood pooling
-HF
A fib signs and symptoms - ANS-symptoms depend on ventricular rate*
-some patients are asymptomatic*
irregular pulse, poor perfusion, fatigue, weakness, SOB, dizziness, anxiety, syncope,
palpitations, chest pain/discomfort, and hypotension
Nursing intervention for a PE - ANS-stay with patient
-monitor for SOB, chest pain, and hypotension
-initiate a rapid
-notify the provider
,T/F patients on anticoagulation should report bleeding gums to their provider immediately -
ANST
NURSING SAFETY PRIORITY
before a cardioversion what needs to be turned off and removed from patient - ANSOxygen
what does the nurse assess for in a patient with a dysrthymia? - ANSAngina, hypotension,
HF, decreased cerebral profusion, and decreased renal profusion.
How to decrease/prevent dysthymias - ANS-avoid vagus nerve stimulation
-take medications
-stop smoking
-avoid caffeine
-alcohol in moderation
-manage stress
The nurse is caring for client who is experiencing occasional premature ventricular
contractions. What assessment data are most concerning to the nurse?
A. Potassium 4.8 mEq/L
B. Magnesium 2 mEq/L
C. Heart rate 90
D. History of smoking - ANSD
Nursing Safety Priority
1. V tach stable nursing intervention:
2. V tach unstable nursing intervention: - ANS1. administer O2 and confirm with 12 lead
ECG (possible amiodarone/lidocaine administration)
2. may case cardiac arrest, assess ABCs, LOC, and O2
T/F ventricular asystole is shockable rythm. - ANSFALSE
no electrical impulses are present to disrupt
T/F
V tach and V fib are shockable rhythms. - ANSTrue
disrupt chaotic rhythm allowing SA node signals to restart
Upon entering a client's room, the nurse finds the client unresponsive. In what order will the
nurse provide care?
A. Begin chest compressions
B. Check carotid pulse
C. Notify the Rapid Response Team
D. Get the crash cart/AED
E. Provide rescue breaths - ANSC,D,B,A,E
2. A client in the telemetry unit is on a cardiac monitor. The monitor technician alerts the
nurse that there are no ECG complexes, and the alarm is sounding. What is the first action
by the nurse?
A. Suspend the alarm.
, B. Call the emergency response team.
C. Press the record button to get an ECG strip.
D. Assess the client and check lead placement. - ANSD
3. The primary health care provider prescribes warfarin for a client with atrial fibrillation.
Which client statement indicates that additional education is needed?
A. "I need to go to the clinic once a week to have my blood level checked."
B. "If my stools turn black, I will be sure to call my primary health care provider."
C. "I'm glad I don't need to change my diet. Salads are my favorite food."
D. "I need to stop taking my herbal supplement." - ANSC
Female CAD symptoms - ANSfatigue, malaise, anxiety, SOB
Veterans experience a higher number of CVD, mental illness, and substance use disorders
compared to nonvets. - ANS.
NURSING SAFETY PRIORITY
Angina - ANSThoroughly evaluate the nature and characteristics of the chest pain . Because
pain resulting from myocardial ischemia is life threatening and can lead to serious
complications, its cause should be considered ischemic (reduced or obstructed blood flow to
the myocardium) until proven otherwise. When assessing for symptoms, ask the patient if he
or she has "discomfort," "heaviness," "pressure," and/or "indigestion." It is important to note
that chest pain can occur in any setting. Proper assessment of the pain can decrease the
potential for serious complications.
Physiological Integrity
The nurse is assessing a client with heart failure. Which assessment data are the best
indicator of fluid balance?
A. Blood pressure 144/79 mm Hg
B. Urine output 200 mL in the last 4 hours
C. Weight increase of 9 lb in the past week
D. Generalized edema in the lower extremities - ANSC
NURSING PRIORITY - ANSIf the patient experiences symptoms of cardiac ischemia such
as chest pain , dysrhythmias, bleeding, hematoma formation, or a dramatic change in
peripheral pulses in the affected extremity, contact the Rapid Response Team or provider
immediately to provide prompt intervention! Remain with the patient and obtain a 12-lead
ECG for patients experiencing chest pain or dysrhythmias. For bleeding or hematoma
formation, hold steady, firm pressure to the access site until the Rapid Response Team
arrives. Neurologic changes indicating a possible stroke, such as visual disturbances,
slurred speech, swallowing difficulties, and extremity weakness, should also be reported
immediately.
The nurse is caring for a client immediately following a cardiac catheterization. Which
assessment data require immediate nursing intervention?
A. Blood pressure 146/70 mm Hg
B. Hematoma developing at insertion site
C. Client reports headache pain
What does A Fib ECG look like? - ANS-impulse rate of 350-600 times per minute
-no P waves
-no atrial contractions
-loss of atrial kick
-irregular ventricular response
How often do you assess vital signs on a patient with a dysrhythmia
(gray box) - ANSat least every 4 hours
Nursing Safety Priority for Sinus tachycardia what to assess
(gray box) - ANS-fatigue, weakness, SOB, orthopnea, decreased O2, increased HR,
decreased BP, angina, palpitations
-ECG: T wave inversion or ST elevation/depression
-decreased cerebral perfusion may occur. Symptoms: restlessness and anxiety
-impaired renal function may occur symptoms: decreased urine output.
The nurse is assessing the client's cardiac rhythm and notes the following: HR 64, regular
rhythm, PR interval 0.20; QRS 0.10. How will the nurse document this rhythm interpretation
in the electronic health record?
A. Sinus tachycardia
B. Sinus bradycardia
C. Normal sinus rhythm
D. Sinus arrhythmia - ANSC
NURSING SAFETY PRIORITY
patient education with permanent pacemakers include - ANS-Avoid strong electromagnetic
fields (magnets and telecommunication transmitters)
-carry pacemaker identification card
-medical alert bracelet
A fib may lead to - ANS-DVT or PE due to blood pooling
-HF
A fib signs and symptoms - ANS-symptoms depend on ventricular rate*
-some patients are asymptomatic*
irregular pulse, poor perfusion, fatigue, weakness, SOB, dizziness, anxiety, syncope,
palpitations, chest pain/discomfort, and hypotension
Nursing intervention for a PE - ANS-stay with patient
-monitor for SOB, chest pain, and hypotension
-initiate a rapid
-notify the provider
,T/F patients on anticoagulation should report bleeding gums to their provider immediately -
ANST
NURSING SAFETY PRIORITY
before a cardioversion what needs to be turned off and removed from patient - ANSOxygen
what does the nurse assess for in a patient with a dysrthymia? - ANSAngina, hypotension,
HF, decreased cerebral profusion, and decreased renal profusion.
How to decrease/prevent dysthymias - ANS-avoid vagus nerve stimulation
-take medications
-stop smoking
-avoid caffeine
-alcohol in moderation
-manage stress
The nurse is caring for client who is experiencing occasional premature ventricular
contractions. What assessment data are most concerning to the nurse?
A. Potassium 4.8 mEq/L
B. Magnesium 2 mEq/L
C. Heart rate 90
D. History of smoking - ANSD
Nursing Safety Priority
1. V tach stable nursing intervention:
2. V tach unstable nursing intervention: - ANS1. administer O2 and confirm with 12 lead
ECG (possible amiodarone/lidocaine administration)
2. may case cardiac arrest, assess ABCs, LOC, and O2
T/F ventricular asystole is shockable rythm. - ANSFALSE
no electrical impulses are present to disrupt
T/F
V tach and V fib are shockable rhythms. - ANSTrue
disrupt chaotic rhythm allowing SA node signals to restart
Upon entering a client's room, the nurse finds the client unresponsive. In what order will the
nurse provide care?
A. Begin chest compressions
B. Check carotid pulse
C. Notify the Rapid Response Team
D. Get the crash cart/AED
E. Provide rescue breaths - ANSC,D,B,A,E
2. A client in the telemetry unit is on a cardiac monitor. The monitor technician alerts the
nurse that there are no ECG complexes, and the alarm is sounding. What is the first action
by the nurse?
A. Suspend the alarm.
, B. Call the emergency response team.
C. Press the record button to get an ECG strip.
D. Assess the client and check lead placement. - ANSD
3. The primary health care provider prescribes warfarin for a client with atrial fibrillation.
Which client statement indicates that additional education is needed?
A. "I need to go to the clinic once a week to have my blood level checked."
B. "If my stools turn black, I will be sure to call my primary health care provider."
C. "I'm glad I don't need to change my diet. Salads are my favorite food."
D. "I need to stop taking my herbal supplement." - ANSC
Female CAD symptoms - ANSfatigue, malaise, anxiety, SOB
Veterans experience a higher number of CVD, mental illness, and substance use disorders
compared to nonvets. - ANS.
NURSING SAFETY PRIORITY
Angina - ANSThoroughly evaluate the nature and characteristics of the chest pain . Because
pain resulting from myocardial ischemia is life threatening and can lead to serious
complications, its cause should be considered ischemic (reduced or obstructed blood flow to
the myocardium) until proven otherwise. When assessing for symptoms, ask the patient if he
or she has "discomfort," "heaviness," "pressure," and/or "indigestion." It is important to note
that chest pain can occur in any setting. Proper assessment of the pain can decrease the
potential for serious complications.
Physiological Integrity
The nurse is assessing a client with heart failure. Which assessment data are the best
indicator of fluid balance?
A. Blood pressure 144/79 mm Hg
B. Urine output 200 mL in the last 4 hours
C. Weight increase of 9 lb in the past week
D. Generalized edema in the lower extremities - ANSC
NURSING PRIORITY - ANSIf the patient experiences symptoms of cardiac ischemia such
as chest pain , dysrhythmias, bleeding, hematoma formation, or a dramatic change in
peripheral pulses in the affected extremity, contact the Rapid Response Team or provider
immediately to provide prompt intervention! Remain with the patient and obtain a 12-lead
ECG for patients experiencing chest pain or dysrhythmias. For bleeding or hematoma
formation, hold steady, firm pressure to the access site until the Rapid Response Team
arrives. Neurologic changes indicating a possible stroke, such as visual disturbances,
slurred speech, swallowing difficulties, and extremity weakness, should also be reported
immediately.
The nurse is caring for a client immediately following a cardiac catheterization. Which
assessment data require immediate nursing intervention?
A. Blood pressure 146/70 mm Hg
B. Hematoma developing at insertion site
C. Client reports headache pain
