ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 26 : Caring for Clients With Cardiac Arrhythmias Questions
Question 1 of 5
The nurse enters the client's room and finds the client pulseless and unresponsive. What would be the treatment of choice for this client?
Correct Answer: C
Rationale: Defibrillation is used during pulseless ventricular tachycardia and ventricular fibrillation.
Question 2 of 5
The client has returned to the floor with a transthoracic pacemaker ready to be connected. The nurse knows that a transthoracic pacemaker is a temporary pacemaker used in what situation?
Correct Answer: A
Rationale: The leads of a transthoracic pacemaker are inserted during open heart surgery. They extend from the chest incision. If the client requires cardiac pacing during postoperative recovery, the leads are connected to a temporary pacing unit.
Question 3 of 5
The nurse is caring for clients on a telemetry unit. Which nursing consideration best represents concerns of altered rhythmic patterns of the heart?
Correct Answer: D
Rationale: The best representation of a nursing concern related to a cardiac arrhythmia is the inability of the heart to fill the chambers and eject blood flow efficiently. Lack of an efficient method to circulate blood and bodily fluids produces a variety of complications such as tissue ischemia, pulmonary edema, hypotension, decreased urine output, and impaired level of consciousness. The other options can occur with arrhythmias, but the cause stemming from the altered pattern is the best answer.
Question 4 of 5
The nurse is caring for a client with an arrhythmia. While assessing the data in the history of the chart, the nurse anticipates the cause of the arrhythmia to be which of the following?
Correct Answer: B
Rationale: The nurse realizes that the most common cause of arrhythmias is ischemic heart disease. When the heart does not obtain sufficient blood to meet demands, the heart works harder to circulate body fluids and becomes inefficient in the process. Problems with the peripheral vessels, narrowing of the aorta and plaque build-up in the vessels may be a component of the disease process but not the best answer.
Question 5 of 5
The nurse is caring for a client on the cardiac unit. The licensed practical nurse on the previous shift reported the following vital signs/assessment information: temperature, 100.6?°F; pulse, 56 beats/minute; respirations 24 breaths/minute; blood pressure, 116/60 mm Hg; pulse oximetry reading, 92%; and with 2+ edema noted in the lower extremities. Prior to 9 AM antiarrhythmic medication administration, which of the following will the nurse reassess?
Correct Answer: B
Rationale: Of the vital signs noted, the pulse rate is found to be abnormal, below 60 beats/minute. Before administering an antiarrhythmic medication, which often slows the heart rate further, the pulse rate would be reassessed, and a rate of 60 beats/minute would need to be obtained.