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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?
Sinus bradycardia
Sick sinus syndrome
Normal sinus rhythm
First-degree heart block - ✔✔ 3 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 0.12 to 0.20 second and 0.04 to 0.10 second, respectively.
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiographic complexes on the screen. Which is the priority action of the nurse?
Call a code.
Call the health care provider.
Check the client's status and lead placement.
Press the recorder button on the electrocardiogram console. - ✔✔ 3 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. A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item?
Sensation of palpitations
Oxygen flow rate
Level of consciousness - ✔✔ 2 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. A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 second, the QRS complex measures 0.08 second, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm?
Sinus dysrhythmia
Sinus tachycardia
Sinus bradycardia
Normal sinus rhythm - ✔✔ 2 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. The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status?
The neurovascular status is normal because of increased blood flow through the leg.
The neurovascular status is moderately impaired, and the surgeon should be called.
The neurovascular status is slightly deteriorating and should be monitored for another hour.
The neurovascular status is adequate from an arterial approach, but venous complications are arising. - ✔✔ 1
Stable angina
Variant angina
Unstable angina
Nonanginal pain - ✔✔ 2 Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often at rest. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction. The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication?
Flat neck veins
A pulse rate of 60 beats/min
Muffled or distant heart sounds
Wheezing on auscultation of the lungs - ✔✔ 3 Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention with clear lung sounds, and a falling blood pressure accompanied by pulsus paradoxus (a drop in inspiratory blood pressure greater than 10 mm Hg). Bradycardia is not a sign of cardiac tamponade. The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction?
"I need to be sure not to go barefoot around the house."
"If I cut my toenails, I need to be sure that I cut them straight across."
Ventricular tachycardia - ✔✔ 3 Cardiac troponin T or cardiac troponin I has been found to be a protein marker in the detection of myocardial infarction, and assay for this protein is used in some institutions to aid in the diagnosis of a myocardial infarction. The test is not used to diagnose heart failure, ventricular tachycardia, or atrial fibrillation. The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a ventricular rate of 150 beats/min. The nurse should next assess the client for which finding?
Hypotension
Flat neck veins
Complaints of nausea
Complaints of headache - ✔✔ 1
The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/min is at risk for low cardiac output owing to loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. The nurse is reviewing the electrocardiogram (ECG) rhythm strip obtained on a client with a diagnosis of myocardial infarction. The nurse notes that the PR interval is 0.20 second. The nurse should make which interpretation about this finding?
A normal finding
Indicative of atrial flutter
Indicative of atrial fibrillation
Indicative of impending reinfarction - ✔✔ 1 The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The normal range for the PR interval is 0.12 to 0.20 second. Options 2, 3, and 4 are incorrect.
"I'll need to become a strict vegetarian."
"I should use polyunsaturated oils in my diet."
"I need to substitute eggs and whole milk for meat."
"I should eliminate all cholesterol and fat from my diet." - ✔✔ 2 The client with coronary artery disease should avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is recommended to control hypercholesterolemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian. A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places highest priority on telling the client to report which sensation during the procedure?
Chest pain
Urge to cough
Warm, flushed feeling
Pressure at the insertion site - ✔✔ 1 The client is taught to report chest pain or any unusual sensations immediately. The client also is told that he or she may be asked to cough or breathe deeply from time to time during the procedure. The client is informed that a warm, flushed feeling may accompany dye injection and is normal. Because a local anesthetic is used, the client is expected to feel pressure at the insertion site. A client with a first-degree heart block has an electrocardiogram (ECG) taken during an episode of chest pain. The nurse knows that which ECG finding would be an indication of first-degree heart block?
Presence of Q waves
Tall, peaked T waves
Prolonged PR interval
Thrombolytic agents are used to dissolve existing thrombi, and the nurse should monitor the client for obvious or occult signs of bleeding. This includes assessment for obvious bleeding within the gastrointestinal (GI) tract, urinary system, and skin. It also includes Hematest testing of secretions for occult blood. The correct option is the only one that indicates the presence of blood. A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily responsible for the symptoms?
Left atrium
Right atrium
Left ventricle
Right ventricle - ✔✔ 3 Hypertension increases the workload of the left ventricle because the ventricle has to pump the stroke volume against increased resistance (afterload) in the major blood vessels. Over time this causes the left ventricle to fail, leading to signs and symptoms of heart failure. Options 1, 2, and 4 are not the chambers that are primarily responsible for this disease process although these chambers may become affected as the disease becomes more
A client has experienced a myocardial infarction. The nurse plans care for the client, knowing that the person's chest pain is caused by tissue hypoxia in which layer of the heart?
Myocardium
Endocardium
Parietal pericardium
Visceral pericardium - ✔✔ 1 The myocardial layer of the heart is damaged when a client experiences a myocardial infarction. This is the middle layer that contains the striated muscle fibers responsible for the contractile force of the heart. The endocardium is the thin inner layer of cardiac tissue. The parietal pericardium and visceral pericardium are outer layers that protect the heart from injury and infection. A client is admitted to the hospital with a diagnosis of mitral stenosis. The narrowing of this valve will impede circulation of blood through which structures?
Right ventricle to right atrium
Pulmonary artery to right ventricle - ✔✔ 1 The aortic valve separates the aorta from the left ventricle. Options 2, 3, and 4 describe the mitral, tricuspid, and pulmonic valves, respectively. A hospitalized client is experiencing a decrease in blood pressure. The nurse plans care for the client, knowing that this change will have which primary effect on his or her heart?
Decreased heart rate
Increased contractility
Decreased myocardial blood flow
Increased resistance to electrical stimulation - ✔✔ 3 The primary effect of a decrease in blood pressure is reduced blood flow to the myocardium. This in turn decreases oxygenation of the cardiac tissue. Cardiac tissue is likely to become more excitable or irritable in the presence of hypoxia. Correspondingly, the heart rate is likely to increase, not decrease, in response to this change. The effects of tissue ischemia lead to decreased contractility over time. A hospitalized client's serum calcium level is 7.9 mg/dL. The nurse is immediately concerned and takes action, knowing that this level could ultimately lead to which complication?
Stroke
Cardiac arrest
High blood pressure
Urinary stone formation - ✔✔ 2 The normal calcium level is 8.6 to 10 mg/dL. A low calcium level could lead to severe ventricular dysrhythmias, prolonged QT interval, and ultimately cardiac arrest. Calcium is needed by the heart for contraction. Calcium ions move across cell membranes into cardiac cells during depolarization and move
