Question

When assisting with defibrillating an adult client who has gone into ventricular fibrillation, what must the nurse do?

Answer 1

Correct Answers:

Maintain firm contact between paddles and client skin

Rationale :

💎 Firm paddle contact is essential to ensure effective delivery of electrical energy from the defibrillator to the myocardium, reducing resistance (impedance) and increasing the likelihood of successful defibrillation.

💎 Adequate pressure—about 25 pounds (11 kg) with handheld paddles—helps the current pass through the chest wall effectively and prevents arcing of electricity.

💎 Conductive gel or pads should be used to further lower skin impedance, but water should never be used as it can cause burns and ineffective conduction.

💎 For ventricular fibrillation, the defibrillator should be set to defibrillation (unsynchronized) mode, not sync mode, since immediate shock is required.

💎 Safety checks, including calling “all clear” and ensuring no one is in contact with the client or bed, must be done before delivering the shock, but continuous firm contact ensures optimal shock effectiveness.

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Answer 2

Correct Answers:

Control ventricular heart rate

Rationale :

💎 In atrial fibrillation with rapid ventricular response (RVR), the primary risk is decreased cardiac output due to inadequate ventricular filling time.

💎 Initial management focuses on slowing the ventricular rate to allow better diastolic filling and improve perfusion.

💎 Diltiazem is a calcium channel blocker that slows AV node conduction, effectively controlling the ventricular rate.

💎 Once the rate is controlled, anticoagulation (heparin) is important to prevent thromboembolic events, but it is secondary in this acute moment.

💎 Rapid heart rates increase myocardial oxygen demand, so controlling the rate reduces ischemic risk.

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Answer 3

Correct Answers:

An aspirin a day can help prevent some of the blockages that can cause chest pain or heart attacks

Rationale :

💎 Aspirin acts as an antiplatelet agent, reducing platelet aggregation and thrombus formation in coronary arteries.

💎 This helps prevent acute coronary syndromes (MI, unstable angina) by keeping vessels patent.

💎 The benefit is preventive, not for pain relief, which is why it is taken daily even without symptoms.

💎 Regular low-dose aspirin therapy is a standard recommendation for many patients with coronary artery disease.

💎 Preventing blockages reduces the risk of future cardiac events and improves long-term outcomes.

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Answer 4

Correct Answers:

Systole

Rationale :

💎 Systole is the phase of the cardiac cycle when the ventricles contract, ejecting blood into the systemic and pulmonary circulation.

💎 It follows ventricular depolarization (QRS complex) and ends with closure of the semilunar valves.

💎 During systole, ventricular volume decreases as blood is pushed into the aorta and pulmonary artery.

💎 The efficiency of systole is measured by ejection fraction, but systole itself refers to the contraction phase.

💎 Proper systolic function is crucial for maintaining adequate cardiac output.

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Answer 5

Correct Answers:

Risk for falls related to orthostatic hypotension

Rationale :

💎 The significant drop in blood pressure from lying to standing (≥20 mm Hg systolic and/or ≥10 mm Hg diastolic) indicates orthostatic hypotension.

💎 Orthostatic hypotension increases risk for dizziness, syncope, and falls, especially in older adults.

💎 This condition can be due to autonomic dysfunction, dehydration, or medication side effects.

💎 Nursing care focuses on fall prevention strategies, slow position changes, and monitoring vital signs.

💎 Identifying this as a risk allows interventions to prevent injury.

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Answer 6

Correct Answers:

Atrial Fibrillation

Rationale :

💎 Atrial fibrillation is identified by the absence of P waves and the presence of fibrillatory waves before QRS complexes.

💎 The ventricular rhythm is usually irregularly irregular, with variable R-R intervals.

💎 AF disrupts atrial contraction, increasing the risk for thrombus formation.

💎 Causes include heart disease, electrolyte imbalances, and hyperthyroidism.

💎 Treatment focuses on rate control, rhythm control, and anticoagulation.

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Answer 7

Correct Answers:

Throbbing headache and dizziness

Rationale :

💎 Nitroglycerin is a potent vasodilator that can cause headaches due to cerebral vessel dilation.

💎 It can also cause dizziness and hypotension from systemic vasodilation.

💎 These are common and often dose-related effects; clients should be advised to sit or lie down after taking nitroglycerin.

💎 Other effects include flushing and reflex tachycardia.

💎 Education should focus on managing side effects while continuing therapy as prescribed.

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Answer 8

Correct Answers:

Ensure no one is touching the client at the time shock is delivered

Rationale :

💎 Safety is critical during defibrillation to prevent electrical injury to healthcare providers.

💎 Before delivering the shock, the nurse must loudly call “Clear!” and visually confirm no one is in contact with the client or bed.

💎 This step ensures the electrical current passes only through the intended path—the patient’s heart.

💎 External defibrillation is the definitive treatment for VF and pulseless VT.

💎 Correct pad placement and conduction medium are also essential, but safety clearance is priority at shock delivery.

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Answer 9

Correct Answers:

Antiplatelet action

Rationale :

🔹 Mechanism: Aspirin irreversibly inhibits cyclooxygenase-1 in platelets, reducing thromboxane A₂ production.

🔹 Effect: This prevents platelet aggregation, lowering the risk of thrombus formation.

🔹 MI benefit: Limits clot propagation in coronary arteries during acute myocardial infarction.

🔹 Onset: Antiplatelet effect occurs within minutes of administration, crucial in emergent care.

🔹 Guideline role: Standard in ACS management unless contraindicated.

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Answer 10

Correct Answers:

Pain relief
Sedation
Decreases myocardial demand .

Rationale :

🔶 Pain relief: Morphine binds to opioid receptors, reducing the perception of ischemic chest pain.

🔶Sedation: Provides anxiolysis and calming effects, decreasing stress-induced sympathetic activity.

🔶 Decreases myocardial demand: By vasodilation and reduced preload/afterload, it lessens cardiac workload and O₂ consumption.

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Medical-surgical Nursing 2 (NURSA 225 OIC- UNIVERSITY OF CHARLETON)

No.

1 :
When assisting with defibrillating an adult client who has gone into ventricular fibrillation, what must the nurse do?

3 :
The nurse is doing discharge teaching with a client who has coronary artery disease. The client asks why he has to take an aspirin every day if he doesn’t have any pain. What would be the nurse’s best response?

4 :
A nurse is describing the process by which blood is ejected into circulation as the chambers of the heart become smaller. How does the nurse categorize this action of the heart?

5 :
An older adult client’s assessment reveals the following data: Lying BP 144/82 mm Hg, sitting BP 121/69 mm Hg, standing BP 98/56 mm Hg.What nursing diagnosis should be identified in the client’s plan of care?

6 :
The patient’s cardiac rhythm suddenly changes on the monitor. There are no P waves, instead there are fibrillatory waves before each QRS complex. How would the nurse interpret the rhythm?

7 :
A client with angina has been prescribed nitroglycerin. Before administering the drug, what potential adverse effects should the nurse inform the client about?

8 :
The ED nurse is caring for a client who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform?

9 :
Aspirin is administered to the client experiencing an MI because of its:

10 :
A patient who had a myocardial infarction asks the nurse why they are receiving morphine. Which benefits of morphine should the nurse explain to this patient? (Select all that apply)

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Medical-surgical Nursing 2 (NURSA 225 OIC- UNIVERSITY OF CHARLETON)

No.

1 : When assisting with defibrillating an adult client who has gone into ventricular fibrillation, what must the nurse do?

3 : The nurse is doing discharge teaching with a client who has coronary artery disease. The client asks why he has to take an aspirin every day if he doesn’t have any pain. What would be the nurse’s best response?

4 : A nurse is describing the process by which blood is ejected into circulation as the chambers of the heart become smaller. How does the nurse categorize this action of the heart?

5 : An older adult client’s assessment reveals the following data: Lying BP 144/82 mm Hg, sitting BP 121/69 mm Hg, standing BP 98/56 mm Hg.What nursing diagnosis should be identified in the client’s plan of care?

6 : The patient’s cardiac rhythm suddenly changes on the monitor. There are no P waves, instead there are fibrillatory waves before each QRS complex. How would the nurse interpret the rhythm?

7 : A client with angina has been prescribed nitroglycerin. Before administering the drug, what potential adverse effects should the nurse inform the client about?

8 : The ED nurse is caring for a client who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform?

9 : Aspirin is administered to the client experiencing an MI because of its:

10 : A patient who had a myocardial infarction asks the nurse why they are receiving morphine. Which benefits of morphine should the nurse explain to this patient? (Select all that apply)

1 :
When assisting with defibrillating an adult client who has gone into ventricular fibrillation, what must the nurse do?

3 :
The nurse is doing discharge teaching with a client who has coronary artery disease. The client asks why he has to take an aspirin every day if he doesn’t have any pain. What would be the nurse’s best response?

4 :
A nurse is describing the process by which blood is ejected into circulation as the chambers of the heart become smaller. How does the nurse categorize this action of the heart?

5 :
An older adult client’s assessment reveals the following data: Lying BP 144/82 mm Hg, sitting BP 121/69 mm Hg, standing BP 98/56 mm Hg.What nursing diagnosis should be identified in the client’s plan of care?

6 :
The patient’s cardiac rhythm suddenly changes on the monitor. There are no P waves, instead there are fibrillatory waves before each QRS complex. How would the nurse interpret the rhythm?

7 :
A client with angina has been prescribed nitroglycerin. Before administering the drug, what potential adverse effects should the nurse inform the client about?

8 :
The ED nurse is caring for a client who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform?

9 :
Aspirin is administered to the client experiencing an MI because of its:

10 :
A patient who had a myocardial infarction asks the nurse why they are receiving morphine. Which benefits of morphine should the nurse explain to this patient? (Select all that apply)