AND ANSWERS GRADE A+ GUARANTEED
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 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.
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.
The nurse is preparing to administer adenosine to the patient with
the following rhythm which is symptomatic. What should the nurse plan
on having in the patient room? Select All That Apply:
a) Physician
b) Crash cart
c) IV pump
d) EKG monitor
e) Lidocaine
Answer: A, B, and D
Adenosine is administered as a very quick IV push. The physician must
be present in the room and the crash cart must be on hand. An ekg
monitor should be in the room to monitor the effectiveness of the
medication.
The nurse has just administered adenosine via IV push and sees the
following rhythm on the monitor. What is the nurse's priority
intervention?
a) Apply conductive gel and defibrillate the patient
b) Document the findings and continue to monitor
c) Administer another mg of the medication
d) Begin chest compressions
Answer: B
This finding would be expected upon administration of adenosine. The
rhythm should then begin again in some other rhythm, hopefully normal
sinus rhythm. It would be important to document the exact time of
this change and continue to monitor the change back to NSR. If this
change does not occur, or if another rhythm is produced, appropriate
action would then be taken based on the result.
A group of nursing students are discussing atrial flutter. These
students recognize that which of the following are seen with atrial
flutter? Select all that apply:
1) Ventricular rate of 220-300 bpm.
2) Regular rhythm
3) Saw-tooth pattern
, 4) Measurable PR interval
5) Long QRS interval
Answer(s): 2, 3
The ATRIAL rate is 250-400 bpm. Ventricular is about 75-150. The
rhythm is regular, with the P wave appearing as little flutter or a
"saw tooth pattern". The PR interval is not measurable r/t this saw-
tooth P wave. The QRS is normal.
A nursing student is aware that which of the following is the
treatment for unstable atrial flutter?
1) Adenosine (Adenocard) 6 mg rapid IVP.
2) Cardioversion with adjacent Heparin therapy
3) Defibrillation STAT followed by CPR.
4) Altemose 3 mg IVP over 1-2 seconds.
Answer: 2
Cardioversion is used if the patient is unstable. Anticoagulants are
used if the arrhythmia has stuck around for 48 hr +. Adenosine may be
used with a narrow QRS and regular RR interval
A nurse working on a CVT unit receives report from day shift. After
receiving report, which patient should the nurse see first?
1) A 23-year-old professional tennis player with a HR of 47 bpm.
2) A 69-year-old male with atrial fibrillation who has new onset
confusion.
3) A 72-year-old female with atrial flutter who reports feeling
unusually tired today and yesterday.
4) A 33-year-old female with sinus tachycardia who is asking for her
at-home Metoprolol.
Answer: 2
Patients with a-fib are at risk for pulmonary and systemic emboli,
and new onset of confusion may indicate a stroke in this patient.
Patients with atrial flutter may feel more tired some days than
others.
A nurse on a CVT unit views the monitor and sees the patient in room
452 has just begun having occasional PVCs. Which action should the
nurse take first?
1) Check on the patient
2) Check last magnesium and potassium levels
3) Document the occurrence and watch for further PVCs
4) Contact the physician
Answer: 1
Although electrolytes are likely the culprit, the nurse first needs