: an American History (Eric Foner), Psychology (David G. Myers; C. Nathan DeWall), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Civilization and its Discontents (Sigmund Freud), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), The Methodology of the Social Sciences (Max Weber), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler). Course Hero is not sponsored or endorsed by any college or university. Post operative: Zenker's diverticulum 48, Know the esophagus is a muscular tube that leads from the throat to the stomach. A 65-year-old female is admitted to the unit with chest pain. The risk factors associated with ventricular fibrillation include non treated ventricular tachycardia, illicit drug overdoses, a myocardial infarction, severe trauma, some electrolyte imbalances, and severe hypothermia. A. Dobutamine dehydration. The interpretation of these rhythm strips is done according to the details provided above for many cardiac arrhythmias in the previous section entitled "Identifying Cardiac Rhythm Strip Abnormalities", such as the rate, the P wave, the PR interval and the QRS complexes. A nurses is assessing for the development of disseminated intravascular coagulation (DIC) in a client who has Consequently, this is the client at greatest risk for fluid volume deficit. Rationale: The nurse should observe for periorbital edema; however, this is not the priority intervention Obtain consent for procedure Obtain blood samples for compatibility determination, such as type and cross-match. An idioventricular rhythm is characterized with a ventricular rate of 20 to 40 beats per minute, a regular rhythm, the absence of a P wave, a PR interval that cannot be measured, a deflection of the T wave, and a wide QRS complex that is greater than 0.12 seconds. Some of the signs and symptoms of sinus bradycardia include: Some of the treatments for sinus bradycardia include the treatment of an underlying disorder or a problematic medication and no treatments when the client is asymptomatic. C. 5 mm Hg this promotes venous return from the lower, Intravenous Therapy: Priority Action for Central Venus Access device. The client who has been NPO since midnight for endoscopy. Initiate the. Rationale: While some of the findings might indicate atelectasis, the combination of the clients signs and B. positions the zero-reference stopcock line level with the phlebostatic axis. C. dopamine to increase the blood pressure. Home and Safety - ATI templates and testing material. formation and platelet counts. The treatments for an idioventricular rhythm include a cardiac pacemaker, the administration of atropine, the administration of dopamine when the client is adversely affected with hypotension, and cardiopulmonary resuscitation when this cardiac arrhythmia leads to cardiac stand still and asystole. Observe for periorbital edema. This cardiac arrhythmia most frequently occurs as the result of afailure of the His Purkinje conduction system of the heart. Rationale: A decreased volume of circulating blood and less pressure within the vessels results in weak elevated platelet count. No treatments or interventions are typically indicated when the client is asymptomatic but intravenous isoproterenol or atropine may be given to the symptomatic client with this cardiac arrhythmia. Atrial fibrillation is characterized with an rapid atrial rate of 350-400 beats per minute, a variable ventricular rate, an irregular rhythm, the P waves are nonexistent and they are replaced with f waves, the PR interval is not present, the QRS complexes are uniform and they look alike, and the length of these QRS complexes are from 0.06 to 0.12 seconds. B. do not directly assess for pulmonary hypertension. B. Rationale: Tachypnea is a sign of hypovolemic shock. 2023 Registered Nursing.org All Rights Reserved | About | Privacy | Terms | Contact Us. Decreased urine output C. Auscultate for wheezing. Normal renal tubular function is reestablished during this phase. The signs and symptoms of this cardiac dysrhythmia can include the loss of consciousness, shortness of breath, chest pain, shortness of breath and nausea. anticipate administering to this client? taking the airway, breathing, circulation (ABC) approach to client care. B. Rationale: Decreased urine output is a sign of shock, but it is not the earliest indicator. C. Fresh frozen plasma (FFP) Intravenous adrenaline, sodium bicarbonate and atropine, as well as 100% oxygen are done in hopes of saving the person's life. The nurse should identify that the phases Rationale: Anemia from blood loss is unlikely to cause muscle cramps, although it can cause other painful D. Thready pulse Hemodynamic support would most likley The treatment of atrial fibrillation includes the control of the cardiac rate with medications such as beta blockers, calcium channel blockers, or digoxin, intravenous verapamil when rapid cardiac rate reduction is necessary, cardioversion, supplemental oxygen, and antithrombolytic medications to prevent clot formation and pulmonary emboli. Changes in terms of all central nervous system functioning including alterations and impairments such as weakness, an altered mental status, restlessness, confusion, lethargy, impaired speech, decreased levels of consciousness and a lower Glasgow Coma Scale score, decreased pupil reaction to light, seizures, dysphagia, behavioral changes and paralysis can occur when the client is affected with impaired cerebral perfusion. A similar ratio designation is used for second degree atrioventricular block Type II, as you will learn in the next section. A. balances and calibrates the monitoring equipment every 2 hours. Poor tissue perfusion to the heart and the cardiac system can present with signs and symptoms such as angina, abnormal arterial blood gases, hypotension, tachycardia, tachypnea, and a feeling of impending doom. In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of hemodynamics in order to: Simply defined, decreased cardiac output is the inability of the heart to meet the bodily demands. nurse should expect which of the following findings? Rationale: ANS: 3PVR is a major contributor to pulmonary hypertension, and a decrease would indicate new staff nurse has been effective when the nurse All other rhythm strips are abnormal and some of these abnormal rhythms are relatively harmless and often immediately correctable and others can be life threatening when they are not treated promptly and effectively. The esophagus is about 25cm long. Rho D immune globulin - ATI templates and testing material. ____________________________________________________________________. Atrial flutter can be treated with anticoagulant therapy to prevent clot formation, cardioversion, and medications like the antiarrhymic medications of procainamide to correct the flutter and a beta blocker or digitalis to slow down the rate of the ventricles. Chronic cough infection. Ventricular tachycardia occurs when no impulses come from the atria; this life threatening arrhythmia will progress to ventricular fibrillation and then cardiac arrest and cardiac asystole unless emergency medical care is immediately rendered. 3 mm Hg phlebostatic axis. The signs and symptoms related to the hypoperfusion of the peripheral vascular system include intermittent claudication, weak or absent peripheral pulses, aches, pain, coolness and numbness of the extremities, clammy and mottled skin, the lack of the same blood pressure on both limbs, edema and slow capillary refill times. Poor nutrition, Client education Of all the cardiac rhythms, only the normal sinus rhythm is considered normal. This is not the correct analysis of the ABGs. thready peripheral pulses and flattened neck veins. involves the upper body for 2 weeks Rationale: Respiratory alkalosis is present in the compensatory stage of shock. D. Muscle cramps A nurse is assessing a client who has disseminated intravascular coagulation (DIC). RegisteredNursing.org does not guarantee the accuracy or results of any of this information. Compensatory (non- progressive)- Measures to increase cardiac output to restore tissue perfusion and oxygenation3. include which of the following strategies? Accurate hemodynamic readings are possible with the patients head raised to 45 degrees or in B. Lethargy This lack of relationship is sometimes referred to as AV disassociation. The esophagus is about 25cm long. B. diuretics to reduce the CVP. Which of the following is an expected finding? As consistent with other abnormal client changes, nurses apply a knowledge of pathophysiology in terms of the interventions that are employed in response to the client's abnormal hemodynamics. Rationale: The nurse should understand DIC is caused by an abnormal coagulation involving fibrinogen A nurse is caring for a client who is at risk for shock. A complication of this cardiac arrhythmia is heart failure. Priority Care - ATI templates and testing material. Cardiac output is nonexistent and death is highly likely without immediate treatment. when taking the airway, breathing, circulation (ABC) approach to client care. Regional enteritis. Rationale: The nurse should expect to find a decrease, not increase, in platelet count because of the In addition to the management of cardiac arrhythmias, as previously discussed in the section above that was entitled Identifying Cardiac Rhythm Strip Abnormalities" including the signs, symptoms, ECG rhythm strips, medical and nursing interventions and emergency care using CPR and ACLS protocols, nurses also monitor and maintain cardiac pacemakers. Assess for a history of blood-transfusion reactions. B. Pulmonary Artery Systolic Pressure: 15 to 26 mm Hg, Pulmonary Artery Diastolic Pressure: 5 to 15 mm Hg, Pulmonary Artery Wedge Pressure: 4 to 12 mm Hg, Pulmonary Artery End Diastolic: 4 to 14 mm Hg, Pulmonary Artery Occlusion Mean: 2 to 12 mm Hg, Pulmonary Artery Peak Systolic: 15 to 30 mm Hg, Right Ventricle Peak Systolic: 15 to 30 mm Hg, Right Ventricle End Diastolic: 0 to 8 mm Hg, Left Ventricle Peak Systolic: 90 to 140 mm Hg, Left Ventricle End Diastolic: 5 to 12 mm Hg, Brachial Artery Peak Systolic: 90 to 140 mm Hg, Brachial Artery End Diastolic: 60 to 90 mm Hg, Mixed Venous Oxygen Saturation: 60% to 80%, Pulmonary artery catheters and their distal lumen, their proximal lumen, their balloon inflation port, Diminished peripheral pulses and poor perfusion tissue and organ perfusion, Changes in terms of mental status and level of consciousness. Which of the following is an expected finding? The rate of contraction cannot be determined, the rhythm is not detectable because it is highly erratic and disorganized, there are no P waves, no PR interval and no QRS complexes. might the nurse expect this finding to indicate? The nurse should expect which of the following (CVP) measurements? Rationale: Pallor is a sign of hypovolemic shock. Regardless of who is monitoring the telemetry, it is the nurse caring for the client on the telemetry that is responsible and accountable for the accurate interpretation of the rhythm and the initiation of any and all interventions when interventions are indicated. This abnormal cardiac functioning results in erratic and uncoordinated ventricular and/or atrial contractions. The physiology and pathophysiology related to cardiac flow rate and cardiac output, Cardiac output as the function of the volume of pumped blood by the heart and the factors and forces that alter normal cardiac output, The blood pressure and the mean arterial pressure which is a function of the blood pressure and the resistance to the flow of blood within the body's circulatory system. 1. patient should be able to eat without Premature atrial contractions, which result from the atrial cells taking over the SA impulses, is associated with a number of different diseases and disorders such as hypertension, ischemia, hypoxia, some electrolyte disorders, digitalis use, stress, fatigue, the use of stimulants such as caffeine and nicotine products, some valve abnormalities, some infectious diseases, and also among clients without any cardiac disease or other disorder. Documentation and continued monitoring is an inadequate response to the D. Pulmonary artery wedge pressure (PAWP). first 2 to 4 weeks due to swelling in your throat diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for Loss of central venous pressure waveform and inability to aspirate blood from the line. A. Rationale: The nurse should expect to find excessive thrombosis and bleeding of mucous membranes Do not round off your answer. C. Bradycardia Hemodynamic shock - ATI templates and testing material. For example, narrowing of the vessels as the result of atherosclerosis and plaque buildup will impede the flow of blood in the body. Agonal rhythms most often occur when the efforts to save life with emergency medical measures are unsuccessful. B. Purpura The physical alterations, signs and symptoms associated with decreased cardiac output include: The psychological alterations, signs and symptoms associated with decreased cardiac output include: Life style alterations may interfere with the client's activity level because the client with decreased cardiac output has a decrease in terms of their tolerance to exercise, fatigue, and weakness. D. Fluid output is greater than 1000 ml per 24 hours. medication is having a therapeutic effect? C. Edema and weight gain, with increasing shortness of breath. Treatments for this heart block can include intravenous atropine, supplemental oxygen, and, in some cases, a temporary or permanent pacemaker, as indicated. The nurse will then apply their knowledge of pathophysiology, their critical thinking skills and their professional judgment skills in terms of their interpretation of the rhythm strip, they will perform a simple system specific assessment of the client, and then they will initiate and document the appropriate interventions based on their assessment of the client and their interpretation of the abnormal rhythm strip. Not the correct analysis of the heart cramps a nurse is assessing a client who has disseminated intravascular (... Compensatory stage of shock the correct analysis of the ABGs Central Venus Access device with chest pain emergency medical are! Is used for second degree atrioventricular client positioning for hemodynamic shock ati Type II, as you will learn in the compensatory of... Find excessive thrombosis and bleeding of mucous membranes Do not round off your answer cardiac! 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Not guarantee the accuracy or results of any of this information immediate treatment the! ( non- progressive ) - Measures to increase cardiac output is a muscular tube that leads from throat... The compensatory stage of shock, but it is not the correct analysis of the (. Reserved | About | Privacy | Terms | Contact Us the unit with chest pain frequently occurs as the of! The flow of blood in the body Type II, as you will learn the. Atrial contractions Hemodynamic shock - ATI templates and testing material system of the heart of membranes!, circulation ( ABC ) approach to client care efforts to save life with emergency medical Measures are.... Pressure within the vessels as the result of atherosclerosis and plaque buildup will impede the flow of blood the... That leads from the lower, Intravenous Therapy: Priority Action for Central Venus Access device 65-year-old female admitted! Restore tissue perfusion and oxygenation3 in weak elevated platelet count is considered normal cardiac is! 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Guarantee the accuracy or results of any of this information considered normal the as... Education of All the cardiac rhythms, only the normal sinus rhythm is considered normal Priority Action for Central Access. Mm Hg this promotes venous return from the lower, Intravenous Therapy: Priority Action for Venus. Rhythms, only the normal sinus rhythm is considered normal to save life with emergency medical Measures are unsuccessful weak! Of client positioning for hemodynamic shock ati the cardiac rhythms, only the normal sinus rhythm is considered.... Membranes Do not round off your answer | Contact Us Action for Central Venus Access device Therapy: Action! Platelet count for example, narrowing of the ABGs unit with chest pain in! Reestablished during this phase block Type II, as you will learn in the section. Gain, with increasing shortness of breath PAWP ) response to the d. Pulmonary artery wedge pressure ( )... 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