Answers
You are the nurse working on the telemetry unit and you Answer: D
have finally gotten to sit down to work on some charting.
Suddenly the heart monitors at the station start beeping. A pulse would be assessed for first. Then the patient will be defibrillized and chest
Patient in room 18 is showing this rhythm on the monitor. compressions will begin immediately.
The medical team advances together into the room and
finds them unconscious. What is priority action by the
nurse?
A) Prepare to administer adenosine to the patient
B) Begin chest compressions
C) Prepare for defibrillation
D) Check for a pulse
The patient who has recently been experiencing runs of Answer: A
ventricular tachycardia suddenly loses consciousness.
The patient is defibrillated, and the rate returns as the Following defibrillation, CPR is immediately initiated if a perfusable rhythm is not
following. What should the nurse do first? initiated. The client may need to be shocked again, but chest compressions must
A) Begin compressions begin first.
B) Shock the client again immediately
C) Prepare for intubation
D) Administer adenosine
, The patient with a history of hypertension and diabetes Answer: B
has the following rhythm strip. The patient's vitals are as
follows: BP 145/89, HR 90, SpO2 95%, RR 19. Which of the Atrial flutter places the client at high risk for development of clot formation in the
following does the nurse expect to do at this time? atria. Because the client is stable at this time, cardioversion or adenosine would
a) Prepare the client for cardioversion STAT not be performed at this time. Before cardioversion can occur in a patient,
b) Begin administering anticoagulants anticoagulant therapy should be begun at least 48 hours beforehand if possible.
c) Grab the crash cart for administration of adenosine
d) Teach the client about possibility of pacemaker
installation
The nurse is preparing to administer adenosine to the Answer: A, B, and D
patient with the following rhythm which is symptomatic.
What should the nurse plan on having in the patient Adenosine is administered as a very quick IV push. The physician must be present
room? Select All That Apply: in the room and the crash cart must be on hand. An ekg monitor should be in the
a) Physician room to monitor the effectiveness of the medication.
b) Crash cart
c) IV pump
d) EKG monitor
e) Lidocaine
The nurse has just administered adenosine via IV push Answer: B
and sees the following rhythm on the monitor. What is the
nurse's priority intervention? This finding would be expected upon administration of adenosine. The rhythm
a) Apply conductive gel and defibrillate the patient should then begin again in some other rhythm, hopefully normal sinus rhythm. It
b) Document the findings and continue to monitor would be important to document the exact time of this change and continue to
c) Administer another mg of the medication monitor the change back to NSR. If this change does not occur, or if another
d) Begin chest compressions rhythm is produced, appropriate action would then be taken based on the result.
A group of nursing students are discussing atrial flutter. Answer(s): 2, 3
These students recognize that which of the following are
seen with atrial flutter? Select all that apply: The ATRIAL rate is 250-400 bpm. Ventricular is about 75-150. The rhythm is regular,
1) Ventricular rate of 220-300 bpm. with the P wave appearing as little flutter or a "saw tooth pattern". The PR interval
2) Regular rhythm is not measurable r/t this saw-tooth P wave. The QRS is normal.
3) Saw-tooth pattern
4) Measurable PR interval
5) Long QRS interval
A nursing student is aware that which of the following is Answer: 2
the treatment for unstable atrial flutter?
1) Adenosine (Adenocard) 6 mg rapid IVP. Cardioversion is used if the patient is unstable. Anticoagulants are used if the
2) Cardioversion with adjacent Heparin therapy arrhythmia has stuck around for 48 hr +. Adenosine may be used with a narrow
3) Defibrillation STAT followed by CPR. QRS and regular RR interval
4) Altemose 3 mg IVP over 1-2 seconds.