Question 1

The nurse is providing care to a client who has signs of pacemaker failure.Which will the nurse document for pacemaker failure? Select all that apply.

Accepted Answer

Pacemaker failure can lead to inadequate heart rate control, resulting in bradycardia (A), as the heart may not be stimulated sufficiently to maintain an appropriate rate. Decreased urine output (C) can occur due to reduced cardiac output associated with pacemaker failure, leading to decreased perfusion of the kidneys.

Question 2

The RN is precepting a new graduate RN who is preparing to transfuse blood.For which action by the new graduate nurse will the nurse intervene immediately?

Accepted Answer

Starting a blood transfusion immediately upon return to the unit without verifying the correct blood product and patient identity, among other safety checks, can lead to serious transfusion errors. It is essential to follow proper protocols to ensure patient safety.

Question 3

How should the nurse calculate the heart rate from a rhythm strip?

Accepted Answer

The correct method to calculate the heart rate from a rhythm strip is to count the number of R waves (QRS complexes) in 30 large blocks (6 seconds on a standard ECG where each large block represents 0.20 seconds) and then multiply by 10 to estimate the heart rate per minute. This method provides a quick and easy estimation of heart rate.

Question 4

How will the nurse know that the electrodes have been placed properly?

Accepted Answer

Running an ECG strip to check the signal of transmission ensures that the electrodes are placed correctly and are functioning properly.

Question 5

A nurse is providing care to a client with a temporary pacemaker.The nurse observes a spike on the ECG.What should the nurse do first?

Accepted Answer

The observation of a spike on the ECG in a client with a temporary pacemaker indicates that the pacemaker is delivering an electrical impulse. This is an expected finding, not an arrhythmia or an indication of pain. The first action the nurse should take is to document the client's rhythm, pacing spikes, and post a strip in the client's chart. This documentation is crucial for ongoing assessment and management of the client's condition. Notifying the healthcare provider, assessing for pain, or delegating care to an unlicensed assistive personnel (UAP) are not appropriate first steps in response to this expected finding.

Question 6

The nurse is providing care to a client with an arrhythmia.For which arrhythmia will the nurse administer prescribed digoxin?

Accepted Answer

Digoxin is commonly used to treat atrial fibrillation as it helps to control the heart rate by increasing vagal tone and decreasing conduction through the AV node.

Question 7

The nurse observes an irregular chaotic rhythm.Which arrhythmia should the nurse document?

Accepted Answer

Ventricular fibrillation is characterized by an irregular, chaotic rhythm with no discernible P waves, QRS complexes, or T waves, leading to ineffective heart contractions.

Question 8

The nurse is reading a 12-lead recording.Which lead will the nurse review as the best for monitoring atrial functioning?

Accepted Answer

Lead II is considered the best for monitoring atrial functioning because it provides a clear view of the P waves, which represent atrial depolarization. This lead's orientation is most aligned with the electrical activity of the atria, making it ideal for observing atrial rhythms.

Question 9

A new nurse asks the RN why blood needs to be hung within 30 minutes after leaving the blood bank.Which is the most appropriate answer by the nurse?

Accepted Answer

The primary concern with delaying the administration of blood after it has left the controlled environment of the blood bank is the risk of bacterial growth as the blood warms up. Blood products are stored at specific temperatures to minimize this risk, and once they are out of this environment, the risk increases the longer the blood is kept at room temperature.

Question 10

A client receiving a blood transfusion begins to have difficulty breathing and complains of itchiness.What action should the nurse instruct a new graduate RN to take first?

Accepted Answer

Stopping the infusion is the first action to take when a client shows signs of a transfusion reaction, such as difficulty breathing and itchiness, to prevent further exposure to the potentially harmful blood product.

Question 11

A nurse is providing care to a client on complete bed rest.Which is the best explanation by the nurse as to the function of sequential compression devices?

Accepted Answer

Sequential compression devices (SCDs) work by inflating compartments in a graduated sequential fashion to promote venous return and prevent blood clots in the legs.

Question 12

The nurse receives a prescription to administer blood stat to a client receiving total parenteral nutrition (TPN).Which is the first action the nurse should implement?

Accepted Answer

Before administering blood, especially to a client receiving total parenteral nutrition (TPN), it's crucial to start a new IV line. This is because TPN requires a dedicated line due to its high glucose content and osmolarity, which can lead to complications if mixed with other infusions. Blood administration requires its own line to prevent interactions and ensure accurate monitoring and infusion rates.

Question 13

The nurse is providing care to a client with a history of a diagnosis of heart disease who has been placed on a telemetry monitor.The nurse observes an irregular rhythm on the monitor.Which is the first action the nurse should implement?

Accepted Answer

The first action the nurse should take upon observing an irregular rhythm on a telemetry monitor is to complete a cardiac assessment. This allows the nurse to gather more information about the client's condition before deciding on further interventions. Immediate interventions like cardioversion or administering medications may not be appropriate without a thorough assessment.

Question 14

The nurse is administering a blood transfusion to a client.Which should the nurse implement first when a client is complaining of chills and back pain within the first 15 minutes of this transfusion?

Accepted Answer

Stopping the infusion is the first and most critical step when a client exhibits signs of a transfusion reaction, such as chills and back pain, to prevent further exposure to the potentially harmful blood product.

Question 15

A client asked the nurse "Why do I need to have this transcutaneous pacemaker?" Which is the most appropriate response by the nurse?

Accepted Answer

Transcutaneous pacing is used as a temporary measure for symptomatic bradycardia that does not respond to atropine, providing electrical stimulation to maintain adequate heart rate and perfusion.

Question 16

Which dysrhythmia is considered life threatening?

Accepted Answer

Ventricular tachycardia (choice D) is considered life-threatening because it can lead to ventricular fibrillation, which is a cause of sudden cardiac arrest.

Question 17

Before removing a unit of blood from the blood bank,what should the nurse ask first?

Accepted Answer

The answer of Before removing a unit of blood from...

Question 18

The nurse is placing electrodes on a client.Which is the correct placement of a 3-lead telemetry?

Accepted Answer

The correct placement for a 3-lead telemetry involves positioning the RA (white) electrode below the right clavicle, the LA (black) electrode below the left clavicle, and the LL (red) electrode in the left lowest rib cage area. This configuration allows for accurate monitoring of the heart's electrical activity from different angles.

Question 19

The client diagnosed with anemia has the following lab results: hemoglobin 7.8 g/dL,platelets 150,000,white blood cells 4.7,and hematocrit 23.4%.Which lab result indicates the transfusion worked after receiving 2 units of packed red blood cells?

Accepted Answer

The increase in hemoglobin from 7.8 g/dL to 11 g/dL indicates the transfusion of packed red blood cells was effective, as it directly increases the hemoglobin level, which is a primary indicator of anemia treatment success.

Question 20

The nurse is providing care to a client with a history of a diagnosis of organic heart disease.The nurse received a phone call from the telemetry base station and reported a reading of ventricular rate <40 beats/min from the Purkinje fibers.After the nurse checks the client,what should the nurse do next?

Accepted Answer

The client has a dangerously low heart rate, indicating a need for a pacemaker to regulate the heart rhythm.

Quiz 12: Perfusion