Critical Care Exam 1
Which of the following nursing diagnoses would be appropriate for a client with heart failure?
Select all that apply.
A
Ineffective tissue perfusion related to decreased peripheral blood flow secondary to
decreased cardiac output.
B
Activity intolerance related to increased cardiac output.
C
Decreased cardiac output related to structural and functional changes.
D
Impaired gas exchange related to decreased sympathetic nervous system activity. - correct
answer-A, D
HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart
muscle becomes weak and does not adequately pump the blood out of the chambers. As a
result, blood pools in the left ventricle and backs up into the left atrium, and eventually into
the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction
thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and
ineffective tissue perfusion because of the decrease in blood flow to the other organs and
tissues of the body. Typically, these clients have an ejection fraction of less than 50% and
poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in cardiac
output. Gas exchange is impaired. However, the decrease in cardiac output triggers
compensatory mechanisms, such as an increase in sympathetic nervous system activity.
When interpreting an ECG, the nurse would keep in mind which of the following about the P
wave? Select all that apply.
A
Reflects electrical impulse beginning at the SA node
B
Indicated electrical impulse beginning at the AV node
C
Reflects atrial muscle depolarization
D
Identifies ventricular muscle depolarization
E
Has duration of normally 0.11 seconds or less - correct answer-A,C,E
In a client who has had an ECG, the P wave represents the activation of the electrical
impulse in the SA node, which is then transmitted to the AV node. In addition, the P wave
represents atrial muscle depolarization, not ventricular depolarization. The normal duration
of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height.
A 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 notifies the registered nurse and expects which interventions
to be prescribed? Select all that apply.
,A
Administering oxygen
B
Inserting a Foley catheter
C
Administering furosemide (Lasix)
D
Administering morphine sulfate intravenously
E
Transporting the client to the coronary care unit
F
Placing the client in a low Fowler's side-lying position - correct answer-A,B,C,D
Pulmonary edema is a life-threatening event that can result from severe heart failure. In
pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in
the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is
placed in a high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting
diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to accurately measure
output. Intravenously administered morphine sulfate reduces venous return (preload),
decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary
care unit is not a priority intervention. In fact, this may not be necessary at all if the client's
response to treatment is successful
The nurse is preparing a client for cardiac catheterization. Which nursing interventions are
necessary in preparing the client for this procedure. Select all that apply:
A
Verify consent has been signed.
B
Explain procedure to client.
C
Provide clear liquid, no caffeine diet.
D
Evaluate peripheral pulses.
E
Obtain a 12 lead ECG
F
Obtain history of shellfish allergy. - correct answer-A,B,E,F
In cardiac catheterization contrast dye is injected into the coronary artery and provides info
on patency. Informed consent must be signed prior to any invasive procedure. The physician
is responsible for explaining the procedure, the nurse can reinforce. Patient would be NPO
6-18 hours prior. An ECG would be done, but measures electrical not blood flow. Peripheral
pulses is important afterwards. Shellfish is an indicator of an allergy to the medium injected.
The nurse is assessing the rhythm strip of a patient for pacemaker malfunctions. What will
the nurse assess when analyzing this patient's rhythm strip?
Select all that apply.
1. Failure to pace
2. Failure to capture
3. Failure to sense
, 4. Oversensing
5. Failure to discharge - correct answer-Correct Answer: 1,2,3,4
Rationale 1: Failure to pace occurs when the pacemaker fails to deliver an electrical stimulus
(fire) when it should have fired. This can be seen on the ECG as an absence of pacer spikes
when the patient's heart rate is less than the demand pacer rate is set, indicating that the
pacemaker did not fire.
Rationale 2: Failure to capture occurs when the pacemaker fires, but the chamber that is
being paced (atria or ventricles, or both) does not depolarize. This is seen on the ECG strip
as a pacer spike that is not followed by a P wave or QRS complex.
Rationale 3: Failure to sense occurs when the pacer fails to recognize, or sense, the heart's
natural electrical activity. This is seen on the ECG as pacer spikes that occur too closely
behind the patient's QRS complex.
Rationale 4: Oversensing occurs when the pacer senses extraneous electrical stimuli, or
artifact, for actual atrial or ventricular depolarization and therefore fails to fire. This is seen on
the ECG as pacemaker spikes that are at a slower rate than the pacemaker's preset rate or
no paced beats, even though the patient's heart rate is slower than the pacer's preset rate.
Rationale 5: A pacemaker does not discharge.
The nurse is reviewing the list of a patient's prescribed scheduled and prn medications.
Which of them will affect cardiac contractility?
Select all that apply.
1. Digoxin
2. Dopamine
3. Epinephrine
4. Morphine
5. Atropine - correct answer-Correct Answer: 1,2,3
Rationale 1: Digoxin enhances the contractility of the heart.
Rationale 2: Dopamine enhances the contractility of the heart.
Rationale 3: Epinephrine enhances the contractility of the heart.
Rationale 4: Morphine does not enhance the contractility of the heart.
Rationale 5: Atropine is an anticholinergic drug that blocks the cholinergic and
parasympathetic stimulation of the heart.
What action is appropriate for the nurse to implement when monitoring the ECG of a patient
with a transvenous ventricular demand pacemaker? The ECG strip shows QRS complexes
without pacer spikes.
1. Plan for immediate removal of pacer lead wires.
2. Continue to observe the patient and the ECG rhythm.
3. Call the health care provider and explain that capture has been lost.
4. Call a code for ventricular fibrillation. - correct answer-Correct Answer: 2
Rationale 1: "Transvenous" means that the battery is external and the lead wires are passed
through the vein into the heart muscle. There is no need to remove or displace the lead
wires because it only comes on when the patient's heart rate drops below the programmed
set point. "On demand" means it only comes on sometimes.
Rationale 2: The demand pacemaker only fires when the patient's heart rate drops below the
preset rate. The patient's own rhythm will continue to dominate if it stays above a
predetermined rate. The patient's QRS complexes will not have a spike. QRS complexes
that have a spike indicate that QRS complex is pacemaker generated, not an intrinsic beat.
Which of the following nursing diagnoses would be appropriate for a client with heart failure?
Select all that apply.
A
Ineffective tissue perfusion related to decreased peripheral blood flow secondary to
decreased cardiac output.
B
Activity intolerance related to increased cardiac output.
C
Decreased cardiac output related to structural and functional changes.
D
Impaired gas exchange related to decreased sympathetic nervous system activity. - correct
answer-A, D
HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart
muscle becomes weak and does not adequately pump the blood out of the chambers. As a
result, blood pools in the left ventricle and backs up into the left atrium, and eventually into
the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction
thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and
ineffective tissue perfusion because of the decrease in blood flow to the other organs and
tissues of the body. Typically, these clients have an ejection fraction of less than 50% and
poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in cardiac
output. Gas exchange is impaired. However, the decrease in cardiac output triggers
compensatory mechanisms, such as an increase in sympathetic nervous system activity.
When interpreting an ECG, the nurse would keep in mind which of the following about the P
wave? Select all that apply.
A
Reflects electrical impulse beginning at the SA node
B
Indicated electrical impulse beginning at the AV node
C
Reflects atrial muscle depolarization
D
Identifies ventricular muscle depolarization
E
Has duration of normally 0.11 seconds or less - correct answer-A,C,E
In a client who has had an ECG, the P wave represents the activation of the electrical
impulse in the SA node, which is then transmitted to the AV node. In addition, the P wave
represents atrial muscle depolarization, not ventricular depolarization. The normal duration
of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height.
A 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 notifies the registered nurse and expects which interventions
to be prescribed? Select all that apply.
,A
Administering oxygen
B
Inserting a Foley catheter
C
Administering furosemide (Lasix)
D
Administering morphine sulfate intravenously
E
Transporting the client to the coronary care unit
F
Placing the client in a low Fowler's side-lying position - correct answer-A,B,C,D
Pulmonary edema is a life-threatening event that can result from severe heart failure. In
pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in
the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is
placed in a high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting
diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to accurately measure
output. Intravenously administered morphine sulfate reduces venous return (preload),
decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary
care unit is not a priority intervention. In fact, this may not be necessary at all if the client's
response to treatment is successful
The nurse is preparing a client for cardiac catheterization. Which nursing interventions are
necessary in preparing the client for this procedure. Select all that apply:
A
Verify consent has been signed.
B
Explain procedure to client.
C
Provide clear liquid, no caffeine diet.
D
Evaluate peripheral pulses.
E
Obtain a 12 lead ECG
F
Obtain history of shellfish allergy. - correct answer-A,B,E,F
In cardiac catheterization contrast dye is injected into the coronary artery and provides info
on patency. Informed consent must be signed prior to any invasive procedure. The physician
is responsible for explaining the procedure, the nurse can reinforce. Patient would be NPO
6-18 hours prior. An ECG would be done, but measures electrical not blood flow. Peripheral
pulses is important afterwards. Shellfish is an indicator of an allergy to the medium injected.
The nurse is assessing the rhythm strip of a patient for pacemaker malfunctions. What will
the nurse assess when analyzing this patient's rhythm strip?
Select all that apply.
1. Failure to pace
2. Failure to capture
3. Failure to sense
, 4. Oversensing
5. Failure to discharge - correct answer-Correct Answer: 1,2,3,4
Rationale 1: Failure to pace occurs when the pacemaker fails to deliver an electrical stimulus
(fire) when it should have fired. This can be seen on the ECG as an absence of pacer spikes
when the patient's heart rate is less than the demand pacer rate is set, indicating that the
pacemaker did not fire.
Rationale 2: Failure to capture occurs when the pacemaker fires, but the chamber that is
being paced (atria or ventricles, or both) does not depolarize. This is seen on the ECG strip
as a pacer spike that is not followed by a P wave or QRS complex.
Rationale 3: Failure to sense occurs when the pacer fails to recognize, or sense, the heart's
natural electrical activity. This is seen on the ECG as pacer spikes that occur too closely
behind the patient's QRS complex.
Rationale 4: Oversensing occurs when the pacer senses extraneous electrical stimuli, or
artifact, for actual atrial or ventricular depolarization and therefore fails to fire. This is seen on
the ECG as pacemaker spikes that are at a slower rate than the pacemaker's preset rate or
no paced beats, even though the patient's heart rate is slower than the pacer's preset rate.
Rationale 5: A pacemaker does not discharge.
The nurse is reviewing the list of a patient's prescribed scheduled and prn medications.
Which of them will affect cardiac contractility?
Select all that apply.
1. Digoxin
2. Dopamine
3. Epinephrine
4. Morphine
5. Atropine - correct answer-Correct Answer: 1,2,3
Rationale 1: Digoxin enhances the contractility of the heart.
Rationale 2: Dopamine enhances the contractility of the heart.
Rationale 3: Epinephrine enhances the contractility of the heart.
Rationale 4: Morphine does not enhance the contractility of the heart.
Rationale 5: Atropine is an anticholinergic drug that blocks the cholinergic and
parasympathetic stimulation of the heart.
What action is appropriate for the nurse to implement when monitoring the ECG of a patient
with a transvenous ventricular demand pacemaker? The ECG strip shows QRS complexes
without pacer spikes.
1. Plan for immediate removal of pacer lead wires.
2. Continue to observe the patient and the ECG rhythm.
3. Call the health care provider and explain that capture has been lost.
4. Call a code for ventricular fibrillation. - correct answer-Correct Answer: 2
Rationale 1: "Transvenous" means that the battery is external and the lead wires are passed
through the vein into the heart muscle. There is no need to remove or displace the lead
wires because it only comes on when the patient's heart rate drops below the programmed
set point. "On demand" means it only comes on sometimes.
Rationale 2: The demand pacemaker only fires when the patient's heart rate drops below the
preset rate. The patient's own rhythm will continue to dominate if it stays above a
predetermined rate. The patient's QRS complexes will not have a spike. QRS complexes
that have a spike indicate that QRS complex is pacemaker generated, not an intrinsic beat.
