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1.Blood pressure
2.Status of airway
3.Oxygen flow rate
4.Level of consciousness
2.
Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then
oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia
detection.
Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Evaluation
Content Area: Adult Health: Cardiovascular
Strategy(s): Strategic Words, ABCsAirway, Breathing, Circulation
Priority Concepts: Clinical Judgment, Perfusion
The nurse is caring for a client who has just had implantation of an automatic
internal cardioverter-defibrillator. The nurse immediately would assess which
item based on priority?
1.Anxiety level of the client and family
2.Presence of a Medic-Alert card for the client to carry
3.Knowledge of restrictions of postdischarge physical activity
4.Activation status of the device, heart rate cutoff, and number of shocks it is
programmed to deliver
4.
The nurse who is caring for the client after insertion of an automatic internal cardioverterdefibrillator needs to assess device settings, similar to after insertion of a permanent pacemaker.
Specifically, the nurse needs to know whether the device is activated, the heart rate cutoff above
which it will fire, and the number of shocks it is programmed to deliver. The remaining options
are also nursing interventions but are not the priority.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Adult Health: Cardiovascular
Strategy(s): Strategic Words, Maslow's Hierarchy of Needs Theory
Priority Concepts: Perfusion, Safety
1.Sinus dysrhythmia
2.Sinus tachycardia
3.Sinus bradycardia
4.Normal sinus rhythm
2.
Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval
and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus
tachycardia, the atrial and ventricular rates are greater than 100 beats/minute.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Adult Health: Cardiovascular
Strategy(s): Subject
Priority Concepts: Clinical Judgment, Perfusion
The nurse is assessing the neurovascular status of a client who returned to the
surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The
affected leg is warm, and the nurse notes redness and edema. The pedal pulse is
palpable and unchanged from admission. How should the nurse correctly
interpret the client's neurovascular status?
1.The neurovascular status is normal because of increased blood flow through
the leg.
2.The neurovascular status is moderately impaired, and the surgeon should be
called.
3.The neurovascular status is slightly deteriorating and should be monitored for
another hour.
4.The neurovascular status is adequate from an arterial approach, but venous
complications are arising.
1.
An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the
surgical extremity because of increased blood flow. The remaining options are incorrect
interpretations.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Adult Health: Cardiovascular
Strategy(s): Subject
Priority Concepts: Clinical Judgment, Perfusion