You are the nurse working on the telemetry unit and you have finally
gotten to sit down to work on some charting. Suddenly the heart
monitors at the station start beeping. Patient in room 18 is showing this
rhythm on the monitor. The medical team advances together into the
room and finds them unconscious. What is priority action by the nurse?
A) Prepare to administer adenosine to the patient
B) Begin chest compressions
C) Prepare for defibrillation
D) Check for a pulse
Answer: D. A pulse would be assessed for first. Then the patient will be
defibrillized and chest compressions will begin immediately.
,The nurse sees the following rhythm on the monitor. Which of the
following lab values does the nurse identify as being most likely to have
caused this dysrhythmia?
a) K 3.0
b) Ca 10.5
c) Hgb 9
d) Magnesium 2.1
Answer: C. Anemia can contribute to sinus tachycardia.
The patient who has recently been experiencing runs of ventricular
tachycardia suddenly loses consciousness. The patient is defibrillated,
and the rate returns as the following. What should the nurse do first?
A) Begin compressions
B) Shock the client again immediately
C) Prepare for intubation
D) Administer adenosine
Answer: A. Following defibrillation, CPR is immediately initiated if a
perfusable rhythm is not initiated. The client may need to be shocked
again, but chest compressions must begin first.
,A patient with cardiomyopathy has been given an ICD. Which of the
following medications would the nurse expect to see in the MAR for
this patient?
A) Warfarin
B) Cardizem
C) Nitroglycerin
D) Digoxin
Answer: B. Antiarrhythmic medications are prescribed with the use of
an ICD in order to prevent the tachycardic (or other deadly arrhythmia)
from occurring in the first place. This makes sure that the ICD is used
only when absolutely necessary.
, The patient with a history of hypertension and diabetes has the
following rhythm strip. The patient's vitals are as follows: BP 145/89, HR
90, SpO2 95%, RR 19. Which of the following does the nurse expect to
do at this time?
a) Prepare the client for cardioversion STAT
b) Begin administering anticoagulants
c) Grab the crash cart for administration of adenosine
d) Teach the client about possibility of pacemaker installation
Answer: B. Atrial flutter places the client at high risk for development of
clot formation in the atria. Because the client is stable at this time,
cardioversion or adenosine would not be performed at this time.
Before cardioversion can occur in a patient, anticoagulant therapy
should be begun at least 48 hours beforehand if possible.
gotten to sit down to work on some charting. Suddenly the heart
monitors at the station start beeping. Patient in room 18 is showing this
rhythm on the monitor. The medical team advances together into the
room and finds them unconscious. What is priority action by the nurse?
A) Prepare to administer adenosine to the patient
B) Begin chest compressions
C) Prepare for defibrillation
D) Check for a pulse
Answer: D. A pulse would be assessed for first. Then the patient will be
defibrillized and chest compressions will begin immediately.
,The nurse sees the following rhythm on the monitor. Which of the
following lab values does the nurse identify as being most likely to have
caused this dysrhythmia?
a) K 3.0
b) Ca 10.5
c) Hgb 9
d) Magnesium 2.1
Answer: C. Anemia can contribute to sinus tachycardia.
The patient who has recently been experiencing runs of ventricular
tachycardia suddenly loses consciousness. The patient is defibrillated,
and the rate returns as the following. What should the nurse do first?
A) Begin compressions
B) Shock the client again immediately
C) Prepare for intubation
D) Administer adenosine
Answer: A. Following defibrillation, CPR is immediately initiated if a
perfusable rhythm is not initiated. The client may need to be shocked
again, but chest compressions must begin first.
,A patient with cardiomyopathy has been given an ICD. Which of the
following medications would the nurse expect to see in the MAR for
this patient?
A) Warfarin
B) Cardizem
C) Nitroglycerin
D) Digoxin
Answer: B. Antiarrhythmic medications are prescribed with the use of
an ICD in order to prevent the tachycardic (or other deadly arrhythmia)
from occurring in the first place. This makes sure that the ICD is used
only when absolutely necessary.
, The patient with a history of hypertension and diabetes has the
following rhythm strip. The patient's vitals are as follows: BP 145/89, HR
90, SpO2 95%, RR 19. Which of the following does the nurse expect to
do at this time?
a) Prepare the client for cardioversion STAT
b) Begin administering anticoagulants
c) Grab the crash cart for administration of adenosine
d) Teach the client about possibility of pacemaker installation
Answer: B. Atrial flutter places the client at high risk for development of
clot formation in the atria. Because the client is stable at this time,
cardioversion or adenosine would not be performed at this time.
Before cardioversion can occur in a patient, anticoagulant therapy
should be begun at least 48 hours beforehand if possible.
