1. The life partner of a patient diagnosed with atrial fibrillation (AF) demonstrates a need for instruction when asking the nurse, "Can you tell me why
... [Show More] this is a prob- lem?" What is the nurse's best response? 2. The medical record states that the pa- tient's pulse is "small and weak." Which characteristic will the nurse expect to de- tect when performing a cardiovascular as- sessment on this patient? (Select all that apply.) 3. Preparing for an electrocardiogram (ECG) is a priority nursing intervention for which patient? (Select all that apply.) The abnormal heartbeat re- sults in poor blood flow to the heart. Rationale:The result of the ir- regular, rapid heartbeats is im- paired blood flow that can re- sult in a stroke, thromboem- bolism, and heart failure. Phys- ical findings include hypoten- sion, and laboratory findings can reveal hyperthyroidism. AF is most common in patients older than 60 but affects only approximately 5% of this age group. -Diminished pulse pressure -A prolonged systolic peak -Slow upstroke Rationale:Pulse characteristics of a small, weak pulse would include slow upstroke, dimin- ished pulse pressure, and a prolonged systolic peak. Bounding on palpation and a rapid rise and fall of the systolic peak are associated with large, bounding pulses. A patient newly diagnosed with mild hypokalemia, A patient who just had a pacemaker placed, A patient reporting, "I feel like my heart is skipping beats", A patient experiencing diaphoresis and arm pain 4. The nurse is providing care for a patient whose partner says, "We're told that he occasionally has an irregular heartbeat. Is that bad?" Which response should the nurse make to best address the partner's concern? 5. A nurse is discussing the evaluation of Rationale: The ECG is used to iden- tify conduction abnormalities, cardiac arrhythmias (associat- ed with hypokalemia), and my- ocardial infarctions. It is also used to document pacemaker performance. It is reasonable to expect that the patient recov- ering from the MI will be pre- scribed an ECG to monitor on- going status of heart conduc- tion, but this does not take pri- ority over identifying the acute presence of cardiac dysfunc- tion presented by the correct options. It's normal to experience occa- sional premature beats. Rationale: Occasional premature beats are normal. Frequent episodes of irregular cardiac rhythm may be a result of a potassium im- balance or hypoxia or triggered by digoxin toxicity. -Heart rate is between 60 and an electrocardiograph recently performed 100 beats/min (bpm) on a patient with a nursing student. Which data will the nurse identify for the student as being within normal limits? (Select all that apply.) -The T wave is rounded and smooth -A P wave is visible be- fore each QRS complex Rationale: Normal results for an ECG in- clude a heart rate between 60 and 100 beats/min, normal si- 6. The nurse is preparing a patient for a car- diovascular assessment. When providing the patient with information concerning the examination, which physical positions will the nurse indicate will be used during the examination? (Select all that apply.) 7. When preparing a patient for an electro- cardiograph (ECG) the nurse will include which instructional information? (Select all that apply.) nus rhythm, a P wave that pre- cedes each QRS complex, a PR interval that lasts 0.12 to 0.20 seconds, a QRS complex that lasts 0.12 seconds, an ST segment less than or equal to 0.1 mV, a T wave that is round- ed, smooth, and is positive in leads I, II, V3, V4, V5, and V6. Finally, the QT interval duration varies but usually lasts 0.36 to 0.44 seconds. -Sitting upright while leaning forward Supine -Left lateral Rationale: The positions commonly used to facilitate this assessment in- clude supine, left lateral, and sitting upright while leaning for- ward. Neither the right lateral nor prone position is useful. -It is important that the patient remain as still and relaxed as possible during the test -The test is painless -The patient will be asked to lie on his or her back for the length of the test, which is 5-10 min- utes, -Sticky-backed electrodes will be attached directly to the skin on the patient's arms, legs, and chest Rationale: Instructional infor- mation regarding an ECG 8. The nurse and a nursing student are re- viewing the electrocardiograph (ECG) of a patient diagnosed with atrial fibrillation (AF). Which characteristics noted will the nurse identify as being associated with this cardiac condition? (Select all that apply.) 9. A patient is diagnosed with atrial fibrilla- tion (AF) based on an electrocardiogram (ECG). Which of the following nursing as- sessment findings could also be demon- strated by a patient experiencing AF? (Se- lect all that apply.) should include the use of sticky electrodes being attached to the skin on the arms, legs, and chest. The importance of re- maining physically still and re- laxed while lying on the back for approximately 5-10 minutes should also be discussed. It is important that the patient be re- assured that the test is pain- less. The patient is not required to answer questions during the test, and talking is discouraged. -Irregular QRS complexes -Absent P waves -Low-amplitude fibrillation waves Rationale: The ECG associated with atri- al fibrillation is characterized by irregular QRS complexes with low-amplitude fibrillation waves without a P wave. Neither of the other options is associated with AF. -History of chest pain -Jugular vein distension -Tachycardia -An irregular pulse Rationale: Irregular pulse, tachycardia, el- evated jugular venous pressure (leading to jugular vein disten- sion), and a history of chest pain are assessment findings 10. The nurse is gathering subjective data during a cardiovascular assessment from a patient's spouse. Which question is par- ticularly appropriate for a patient who has reported that, "My heart seems to skip beats"? 11. Which action taken during a cardiovascu- lar assessment will best assist the nurse in determining the hemodynamics of the right side of a patient's heart? that support a diagnosis of AF. An audible carotid bruit is not associated with AF. "Have you seen periods when your spouse seems to experi- ence uncommon fatigue?" Rationale: Episodes of fatigue are a symp- tom associated with compro- mised cardiac output. Irregular cardiac rhythm (skipped beats) can be a factor associated with impaired cardiac output. Ede- ma and an urgent need to uri- nate at night (nocturia) are as- sociated with congested heart failure (CHF). Tobacco use is a risk factor for heart disease. Inspection of the jugular ve- nous pulse level Rationale: The level of the jugular ve- nous pressure reflects right atrial (central venous) pres- sure and, usually, right ventric- ular diastolic ï¬lling pressure. Right-sided heart failure rais- es pressure and volume, thus raising jugular venous pres- sure. Auscultation of the carotid artery is associated with the detection of a bruit, indicative of some degree of occlusion. Palpation of the carotid artery is done to detect a loss of elastic- 12. Which assessment findings suggest an arterial vascular system abnormality? (Se- lect all that apply.) 13. Of the medications Mr. Griffin has been prescribed, which one will the nurse dis- cuss with the surgeon regarding its possi- ity that is associated with arte- riosclerosis. Inspection for api- cal impulse is done to deter- mine the presence of an en- larged ventricle. Thin, shiny skin over calves, Absence of hair over the lower legs Rationale: Cold, pale, clammy skin on the extremities and thin, shiny skin with loss of hair, espe- cially over the lower legs, are associated with arterial insuffi- ciency. Warm skin and brown pigmentation around the an- kles are associated with ve- nous insufficiency. Intermittent claudication is characterized by weakness, cramping, aching, fatigue, or frank pain located in the calves, thighs, or but- tocks—but rarely in the feet with activity. These symptoms are quickly relieved by rest. Ul- cers associated with arterial disease are usually painful and are often located on the toes, foot, or lateral ankle. Venous ul- cers are usually painless and occur on the lower leg or medial ankle. Oxycodone/acetaminophen Rationale: A cardiovascular adverse re- ble association with the patient's irregular heartbeat? 14. What is the nurse's response when Mr. Griffin asks, "What is the biggest worry about having atrial fibrillation?" 15. To assess a patient's heart during a phys- ical assessment, which actions will the nurse perform? (Select all that apply.) action associated with oxy- codone/acetaminophen is ar- rhythmia. None of the remain- ing options has this known risk The blood tends to pool in your heart's upper chamber, in- creasing the risk of developing a clot. Rationale:I n atrial fibrillation, or A-Fib, the signals to the upper part of the heart are very fast and not regular. Instead of beating as usual, the atria just quiver. The blood does not empty fully from the upper chambers. It can just pool in the atria. Clots may form, which puts the patient at risk for a stroke. Atrial fibrillation is not responsible for causing dysfunctional valves, triggering an MI, or weakening the car- diac muscle itself. Assess heart rate and rhythm using the diaphragm of the stethoscope, Ask the patient to lie on the left side to as- sess sounds from the apex of the heart, Assess the apex, left sternal border, and base of the heart for abnormal pulsations, Auscultate over the aortic, pul- monic, tricuspid, and mitral ar- eas, as well as Erb's point Rationale: Effective technique for the as- 16. Which point on the heart will the nurse use to auscultate an apical pulse? 17. When reviewing Mr. Griffin's medical record, the nurse recognizes what infor- mation as being a risk factor for atrial fib- rillation? (Select all that apply.) sessment of the heart would in- clude assessing the apex, left sternal border, and base of the heart for abnormal pulsations; auscultating over the aortic, pulmonic, tricuspid, and mitral areas, as well Erb's point; as- sessing sounds from the apex of the heart while the pa- tient is positioned on the left side; and using the diaphragm of the stethoscope to assess the heart's rate and rhythm. Assessing S1 and S2 heart sounds is done using the di- aphragm of the stethoscope, not the bell. Apex Rationale: An apical pulse is best heard at the apex of the heart. The remaining options are locations used to auscultate the sounds related to the heart's valves. History of hypertension, Male over the age of 60 Rationale: Mr. Griffin's medical record confirms risk factors including a history of hypertension and being a male over the age of 60. Neither being black nor being a methicillin-resistant Staphylo- coccus aureus (MRSA) carrier is considered a risk factor for 18. Which patient is expected to have the low- est resting pulse rate (RPR)? 19. Which example of nursing documentation best indicates that the patient has periph- eral perfusion that reflects adequate car- diac output? 20. A patient has been recently diagnosed with atrial fibrillation. Which expected out- come will the nurse include in the care plan to address the resulting anxiety? atrial fibrillation, nor is taking enoxaparin. A non-Hispanic Black male Rationale: Non-Hispanic Black males have a lower mean RPR than those of non-Hispanic White males or Mexican American males, whereas non-Hispan- ic Black females and Mexican American females have lower mean RPRs than non-Hispan- ic White females. Adult females generally have RPRs that are a few beats faster than adult males. Capillary refill noted in less than 2 seconds Rationale: A capillary refill time of 2 sec- onds or less is indication of car- diac output that supports pe- ripheral perfusion. The remain- ing options are examples of abnormal findings associated with insufficient peripheral per- fusion. Patient will learn and demon- strate effective coping behav- iors Rationale:Effective coping will assist the patient in effectively managing the resulting anxiety. Increased energy is associat- ed with the presence of activi- ty intolerance. Mental status is associated with cardiac output, whereas an understanding of treatment regimen is directed toward correcting a knowledge deficiency. [Show Less]