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Nursing Cardiac
Lesson 3
| Question | Answer |
|---|---|
| List the electrical impulse for the conduction cycle in the heart, beginning with the natural pacemaker. | sinoatrial (SA) node (natural pacemaker) → internodal pathway → atrioventricular (AV) node → bundle of His → right and left bundle branches→ Purkinje fibers. |
| Match the numeric value the nurse would document for each pulse description. | Normal pulse, able to palpate with normal pressure- 2+ Bounding pulse, may be able to see pulsation- 3+ Weak and thready, difficult to palpate- 1+ Absent pulse- 0 |
| Which factors would the nurse consider when the patient’s pulse rate is decreased? | Age & Hypothyroidism |
| At which site would the nurse assess the patient’s apical pulse? | Left fifth and sixth intercostal space |
| Which actions would the nurse take for a patient who develops tachycardia with dizziness and lightheadedness from hypovolemia? | Offer noncaffeinated beverages, Administer fluid replacement., Monitor potassium and calcium levels. |
| Which action would the nurse take after obtaining a patient’s regular radial pulse rate of 45 in 30 seconds? | Document the appropriate heart rate. The nurse would document the appropriate heart rate (45 × 2 = 90) because the patient's pulse is regular. |
| Which factors would the nurse consider for an elevated heart rate in a 78-year-old patient who had surgery 1 day prior and currently has a temperature of 102°F (38.9°C) and the nurse is having a difficult time obtaining a blood pressure? | A drop in blood pressure. pain, and fever. |
| Match the pulse site to when each site is assessed by the nurse. | To check pulse during cardiopulmonary resuscitation (CPR) or cardiac arrest- Carotid To measure blood pressure- Brachial To determine discrepancies with radial pulse- Apical To assess circulation to the foot- Dorsalis pedis |
| Which action would the nurse take to obtain a patient’s apical pulse? | Count “lub-dub” as one beat. |
| Which patient pulse rates would the nurse report as unexpected (abnormal)? | 52 for an older adult, 110 for a 15-year-old, 180 for a 1-year-old |
| Which short-term outcome would the nurse develop for a patient experiencing a decreased heart rate? | Patient will exhibit pulse rate within expected range after 12 hours of beginning prescribed interventions. |
| Which pulse site would the nurse check when an infant appears lifeless? | Brachial- The brachial pulse in the arm is the best choice as it is easily accessible on an infant. |
| In which patient instances would the nurse use a Doppler unit to assess pulse? | 62-year-old patient with obstructed blood vessels in the feet, 26-year-old patient with poor circulation in the lower extremities, 56-year-old morbidly obese patient with hardening of the arteries |
| Which actions would the nurse take when the nurse finds the following pulse rates on the flow sheet: 86, 94, 100, 105, 110? | Reassess cardiac system, Perform a head-to-toe assessment, Review medications, Notify the health care provider, Review electrolyte levels. |
| What heart rate would the nurse record for a patient’s heart rate of 46 beats in 30 seconds? beats/min | 92 |
| Which information would the nurse share about a Holter monitor with a patient who is suffering from arrhythmias and has fainting spells? | This test utilizes a portable device attached to the chest by electrodes. |
| Which conditions would prompt the nurse to consider a hypothesis of Bradycardia? | Hypothermia, Beta blocker administration, Increased intracranial pressure |
| Which cues would the nurse assess for in an adult patient with bradycardia? | Sluggish, Lethargic, Confused |
| Which finding would the nurse observe in an adult patient with Bradycardia who is improving? | Reflexes increase. |
| Which actions would the nurse take for a patient who has Impaired Cardiac Function caused by overhydration and edema? | Elevate legs when at rest, Check peripheral pulses, Balance periods of rest and exercise. |
Created by:
Jason Clark