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 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.
Question 2 of 5
The licensed practical nurse is co-assigned with a registered nurse in the care of a client admitted to the cardiac unit with chest pain. The licensed practical nurse is assessing the accuracy of the cardiac monitor, which notes a heart rate of 34 beats/minute. The client appears anxious and states not feeling well. The licensed practical nurse confirms the monitor reading. When consulting with the registered nurse, which of the following is anticipated?
Correct Answer: B
Rationale: The licensed practical nurse and registered nurse both identify that client's bradycardia. Atropine sulfate, a cholinergic blocking agent, is given intravenously (IV) to increase a dangerously slow heart rate. Lanoxin is not administered when the pulse rate falls under 60 beats/minute. It is dangerous to wait until the pulse rate increases without nursing intervention or administering additional medications until the imminent concern is addressed.
Question 3 of 5
A client presents to the emergency department via ambulance with a heart rate of 210 beats/minute and a sawtooth waveform pattern per cardiac monitor. The nurse is most correct to alert the medical team of the presence of a client with which disorder?
Correct Answer: C
Rationale: Atrial flutter is a disorder in which a single atrial impulse outside the SA node causes the atria to contract at an exceedingly rapid rate. The atrioventricular (AV) node conducts only some impulses to the ventricle, resulting in a ventricular rate slower than the atrial rate, thus forming a sawtooth pattern on the heart monitor. Asystole is the absence of cardiac function and can indicate death. Premature ventricular contraction indicates an early electric impulse and does not necessarily produce an exceedingly rapid heart rate. Ventricular fibrillation is the inefficient quivering of the ventricles and indicative of a dying heart.
Question 4 of 5
Which of the following medication classifications is more likely to be expected when the nurse is caring for a client with atrial fibrillation?
Correct Answer: B
Rationale: Clients with persistent atrial fibrillation are prescribed anticoagulation therapy to reduce the risk of emboli formation associated with ineffective circulation. The other options may be prescribed but not expected in most situations.
Question 5 of 5
The licensed practical nurse is monitoring the waveform pattern on the cardiac monitor of the client admitted following a myocardial infarction. The nurse notes that every other beat includes a premature ventricular contraction (PVC). The nurse notes which of the following in the permanent record?
Correct Answer: A
Rationale: The nurse is correct to note bigeminy on the permanent record when every other beat is a PVC. Couplets are two PVCs in a row. Multifocal PVCs originate from more than one location. R-on-T phenomenon occurs when the R wave falls on the T wave.