Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias
1. After reviewing an electrocardiogram, the nurse identifies that an electrical impulse originated in the
patient's sinoatrial (SA) node. What did the nurse observe on this tracing?
- A positive P wave before a QRS complex
Feedback:
- This observation indicates that the electrical impulse originated in the SA node, as the SA node is
responsible for initiating the atrial depolarization, which is represented by the P wave preceding the QRS
complex.
2. The nurse is reinforcing teaching for a patient with a pacemaker. Which measure should the nurse
include when explaining how the pulse should be monitored?
- Take radial pulse for 1 minute
Feedback:
- Monitoring the radial pulse for 1 minute is the appropriate method for assessing heart rate in patients
with a pacemaker. This allows for accurate detection of any abnormalities or changes in heart rate,
which is crucial for monitoring pacemaker function and overall cardiac health.
,Feedback
1 Patients are taught to take a radial pulse, as it is easier to learn than an apical pulse, for 1 minute and
to report if it is five beats over or under the set pacemaker rate
2 It is difficult for a patient to learn how to take his or her own apical pulse.
3 This pulse point is difficult for the patient to learn.
4 This pulse point is difficult for the patient to learn.
The nurse is sitting at the desk watching the telemetry monitors and notes a patient's rhythm suddenly
shows asystole. Which action should the nurse take first?
1. Start cardiopulmonary resuscitation (CPR).
2. Document the rhythm as normal.
3. Prepare to administer adenosine (Adenocard).
4. Prepare the patient for cardioversion.
Page: 450 ✔️ANS: 1
Feedback
1 When the rhythm reads asystole, CPR is started immediately.
2 When the rhythm reads asystole, CPR is started immediately.
, 3 When the rhythm reads asystole, CPR is started immediately.
4 When the rhythm reads asystole, CPR is started immediately.
The nurse is caring for a patient receiving warfarin (Coumadin). Which finding would be of most concern
to the nurse?
1. The patient reports blood in the urine.
2. The patient reports nausea.
3. The patient's apical heart rate is 72 beats/min.
4. The patient has a dry cough.
Page: 447 ✔️ANS: 1
Feedback
1 Hematuria indicates the patient may be receiving too much Coumadin.
2 Nausea is not a priority.
3 The heart rate is normal.
4 Dry cough is not the most concerning effect.
1. After reviewing an electrocardiogram, the nurse identifies that an electrical impulse originated in the
patient's sinoatrial (SA) node. What did the nurse observe on this tracing?
- A positive P wave before a QRS complex
Feedback:
- This observation indicates that the electrical impulse originated in the SA node, as the SA node is
responsible for initiating the atrial depolarization, which is represented by the P wave preceding the QRS
complex.
2. The nurse is reinforcing teaching for a patient with a pacemaker. Which measure should the nurse
include when explaining how the pulse should be monitored?
- Take radial pulse for 1 minute
Feedback:
- Monitoring the radial pulse for 1 minute is the appropriate method for assessing heart rate in patients
with a pacemaker. This allows for accurate detection of any abnormalities or changes in heart rate,
which is crucial for monitoring pacemaker function and overall cardiac health.
,Feedback
1 Patients are taught to take a radial pulse, as it is easier to learn than an apical pulse, for 1 minute and
to report if it is five beats over or under the set pacemaker rate
2 It is difficult for a patient to learn how to take his or her own apical pulse.
3 This pulse point is difficult for the patient to learn.
4 This pulse point is difficult for the patient to learn.
The nurse is sitting at the desk watching the telemetry monitors and notes a patient's rhythm suddenly
shows asystole. Which action should the nurse take first?
1. Start cardiopulmonary resuscitation (CPR).
2. Document the rhythm as normal.
3. Prepare to administer adenosine (Adenocard).
4. Prepare the patient for cardioversion.
Page: 450 ✔️ANS: 1
Feedback
1 When the rhythm reads asystole, CPR is started immediately.
2 When the rhythm reads asystole, CPR is started immediately.
, 3 When the rhythm reads asystole, CPR is started immediately.
4 When the rhythm reads asystole, CPR is started immediately.
The nurse is caring for a patient receiving warfarin (Coumadin). Which finding would be of most concern
to the nurse?
1. The patient reports blood in the urine.
2. The patient reports nausea.
3. The patient's apical heart rate is 72 beats/min.
4. The patient has a dry cough.
Page: 447 ✔️ANS: 1
Feedback
1 Hematuria indicates the patient may be receiving too much Coumadin.
2 Nausea is not a priority.
3 The heart rate is normal.
4 Dry cough is not the most concerning effect.
