he 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? 1. Sinus brad...
1. A client is admitted to the emergency department with chest pain that is
consistent with myocardial infarction based on elevated troponin levels.
Heart sounds are normal and vital signs are noted on the client's chart. The
nurse should alert the health care provider because these changes are most
consistent with which complication?
Time: 11:00 a.m. 11:15 a.m. 11:30 a.m. 11:45 a.m
Pulse: 92 beats/min 96 beats/ min 104 beats/ min 118 beats/ min
Respiratory rate: 24 breaths/min 26 breaths/ min 28 breaths/ min 32
breaths/min
Blood pressure: 140/88 mm Hg 128/82 mm Hg 104/ 68 mm Hg 88/58 mm Hg
Rationale: Cardiogenic shock occurs with severe damage (more than 40%) to the
left ventricle. Classic signs include hypotension; a rapid pulse that becomes
weaker; decreased urine output; and cool, clammy skin. Respiratory rate
increases as the body develops metabolic acidosis from shock. Cardiac
tamponade is accompanied by distant, muffled heart sounds and prominent neck
vessels. Pulmonary embolism presents suddenly with severe dyspnea
accompanying the chest pain. Dissecting aortic aneurysms usually are
accompanied by back pain.
2. A client admitted to the hospital with chest pain and a history of type 2
diabetes mellitus is scheduled for cardiac catheterization. Which medication
would need to be withheld for 24 hours before the procedure and for 48
hours after the procedure?
1. Glipizide
2. Metformin
1/6
, Saunders NCLEX questions: Cardiovascular
3. Repaglinide
4. Regular insulin: 2
Rationale: Metformin needs to be withheld 24 hours before and for 48 hours after
cardiac catheterization because of the injection of contrast medium during the
procedure. If the contrast medium affects kidney function, with metformin in the
system the client would be at increased risk for lactic acidosis. The medications in
the remaining options do not need to be withheld 24 hours before and 48 hours
after cardiac catheterization.
3. A client in sinus bradycardia, with a heart rate of 45 beats/minute,
complains of dizziness and has a blood pressure of 82/60 mm Hg. Which
prescription should the nurse anticipate will be prescribed?
1. Administer digoxin.
2. Defibrillate the client.
3. Continue to monitor the client.
4. Prepare for transcutaneous pacing: 4
Rationale: Sinus bradycardia is noted with a heart rate less than 60 beats per
minute. This rhythm becomes a concern when the client becomes symptomatic.
Hypotension and dizziness are signs of decreased cardiac output.
Transcutaneous pacing provides a temporary measure to increase the heart rate
and thus perfusion in the symptomatic client. Defibrillation is used for treatment of
pulseless ventricular tachycardia and ventricular fibrillation. Digoxin will further
decrease the client's heart rate. Continuing to monitor the client delays necessary
intervention.
4. The nurse in a medical unit is caring for a client with heart failure. The
client suddenly develops extreme dyspnea, tachycardia, and lung crackles
and the nurse suspects pulmonary edema. The nurse immediately asks
another nurse to contact the health care provider and prepares to implement
which priority interventions?
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