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Exam 1

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  • 1. :Question -1 A client arrives in the emergency room complaining of chest pain that began 4 hours ago . A troponin T blood specimen is obtained , and the results indicate a level of 0.6 ng/mL . The nurse interprets that :this result indicates a :Options Normal level . 1 Low value that indicates possible . 2 gastritis Level that indicates a myocardial . 3 infarction Level that indicates the presence of . 4 possible angina :Answer . 3 :Question -2 A 22-year- old adult has a cholesterol blood test done at a screening clinic sponsored by a local health club. The nurse volunteering at the screening teaches the client that diet and exercise should be used as health measures to keep the total :cholesterol level below :Options mg/dL 80 . 1 mg/dL 200 . 2 mg/dL 250 . 3 mg/dL 300 . 4 :Answer . 2 :Rationale The nurse should counsel the client to keep the total cholesterol level under 200 mg/dL
  • 2. . This will aid in the prevention of atherosclerosis, which can lead to a number of cardiovascular disorders later in life. Options 3 and 4 are elevated values and place the client at risk for cardiovascular disease . Although option 1 is a low cholesterol level , option 2 identifies the realistic value to assist in preventing .cardiovascular disease :Question -3 A client is suspected of having a myocardial infarction. The nurse assesses for elevations in which of the following isoenzyme values reported with the creatine ?kinase level :Options MM . 1 MB . 2 BB . 3 MK . 4 :Answer . 2 :Rationale Creatine kinase (CK) is a cellular enzyme that can be fractionated into three isoenzymes. The MB band reflects CK from cardiac muscle. This is the level that elevates with myocardial infarction. The MM band reflects CK from skeletal muscle. The BB band reflects CK from the brain. There :is no MK band. Question A client is suspected of having a myocardial infarction. The nurse assesses for elevations in which of the following isoenzyme values reported with the creatine ?kinase level :Options
  • 3. MM . 1 MB . 2 BB . 3 MK . 4 . Answer:2 :Rationale Creatine kinase (CK) is a cellular enzyme that can be fractionated into three isoenzymes. The MB band reflects CK from cardiac muscle. This is the level that elevates with myocardial infarction. The MM band reflects CK from skeletal muscle. The BB band reflects CK from the brain. There .is no MK band :Question -4 A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium (Coumadin) has a prothrombin time of 35 seconds . Based on the prothrombin time , the nurse anticipates which of the ?following orders :Options Adding a dose of heparin sodium . 1 Holding the next dose of warfarin . 2 Increasing the next dose of warfarin . 3 Administering the next dose of warfarin . 4 :Answer . 2 :Rationale The normal prothrombin time (PT) is 9.6 to 11.8 seconds (male adult) or 9.5 to 11.3 seconds (female adult). A therapeutic PT level is 1.5 to 2.0 times higher than the normal level . Because the value of 35 seconds is high (and perhaps near the critical range), the nurse should
  • 4. anticipate that the client would not .receive further doses at this time :Question-5 The nurse checks the laboratory result for a serum digoxin level that was determined for a client earlier in the day and notes that the result is 2.4 ng/mL . Which of the following is the most important action on ?the part of the nurse :Options .Notify the physician . 1 .Check the client ’s last pulse rate . 2 Record the normal value on the client . 3 .’s flow sheet Administer the next dose of the . 4 .medication as scheduled :Answer . 1 :Rationale The normal therapeutic range for digoxin is 0.5 to 2.0 ng/mL . A level of 2.4 ng/mL exceeds the therapeutic range and indicates toxicity. The most important action is to notify the physician, who may give further orders about holding further doses of digoxin . Option 3 is incorrect because the level is not normal. The next dose should not be administered because the serum digoxin level exceeds the therapeutic range. Checking the client ’s last pulse rate is not incorrect but may have limited value in this situation. Depending on the time that has elapsed since the last assessment, a current assessment of the .client ’s status may be more useful :Question-6 A client is receiving a continuous intravenous infusion of heparin sodium to
  • 5. treat deep vein thrombosis. The client ’s activated partial thromboplastin (aPTT) time is 65 seconds . The client ’s baseline before the initiation of therapy was 30 seconds . The nurse anticipates that which ? action is needed :Options Discontinuing the heparin infusion . 1 Increasing the rate of the heparin . 2 infusion Decreasing the rate of the heparin . 3 infusion Leaving the rate of the heparin . 4 infusion as is :Answer . 4 :Rationale The normal activated partial thromboplastin time (aPTT) varies between 20 and 36 seconds , depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal . Thus , the client ’s aPTT is within the therapeutic range, and .the dose should remain unchanged :Question -7 A client with a history of cardiac disease is due for a morning dose of furosemide (Lasix). Which serum potassium level should be reported to the surgeon before administering the dose of furosemide? :Options mEq/L 3.2 . 1 mEq/L 3.8 . 2 mEq/L 4.2 . 3 mEq/L 4.8 . 4 :Answer
  • 6. . 1 :Rationale The normal serum potassium level in the adult is 3.5 to 5.1 mEq/L . Option 1 is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias . Options 2 , 3 , .and 4 are within the normal range :Question -8 A client with hypertension has been told to maintain a diet low in sodium. A nurse who is teaching this client about foods that are allowed would plan to include which ?food item in a list provided to the client :Options Tomato soup . 1 Boiled shrimp . 2 Instant oatmeal . 3 Summer squash . 4 :Answer . 4 :Rationale Foods that are lower in sodium include fruits and vegetables (option 4) , because they do not contain physiological saline . Highly processed or refined foods (options 1 and 3) are higher in sodium unless their food labels specifically state “low sodium. ”Saltwater fish and shellfish are high in .sodium :Question -9 A nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low- fat diet. The nurse
  • 7. develops a list of high-fat foods to avoid and includes which food item on the list? :Options Oranges . 1 Broccoli . 2 Cream cheese . 3 Broiled haddock . 4 :Answer . 3 :Rationale Fruits and vegetables tend to be lower in fat because they do not come from animal sources. Fish is also naturally lower in .fat. Cream cheese is a high-fat food :Question -10 The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium The nurse should teach the client to limit ?which of the following foods :Options Apples . 1 Bananas . 2 Smoked sausage . 3 Steamed vegetables . 4 :Answer . 3 :Rationale Smoked foods are high in sodium . Options 1 , 2 , and 4 are fruits and vegetables that are low in sodium :Question -11 A nurse is performing cardiopulmonary resuscitation (CPR) on an adult client. The nurse understands that when performing chest compressions, one should depress the :sternum
  • 8. :Options to 1 inch ¾ . 1 to ¾ inch ½ . 2 to 2 inches ½ 1 . 3 to 3 inches ½ 2 . 4 :Answer . 3 :Rationale When performing cardiopulmonary resuscitation (CPR) on an adult client , the sternum is depressed 1 ½ to 2 inches . Options 1 and 2 identify compression depths that would be ineffective in an adult . Option 4 identifies a depth that could :Question -12 A client with no history of cardiovascular disease comes to the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which of the following questions would best help a nurse discriminate pain caused by a noncardiac ?problem :Options “ ?Can you describe the pain to me” . 1 “ ?Have you ever had this pain before” . 2 Does the pain get worse when you” . 3 “ ?breathe in Can you rate the pain on a scale of 1” . 4 “ ?to 10 , with 10 being the worst :Answer . 3 :Rationale Chest pain is assessed by using the standard pain assessment parameters (e.g., characteristics, location , intensity , duration , precipitating and alleviating factors , and associated symptoms). Options 1 , 2 , and 4 may or may not help
  • 9. discriminate the origin of pain . Pain of pleuropulmonary origin usually worsens on .inspiration :Question -13 A client is admitted to an emergency room with chest pain that is being ruled out for myocardial infarction . Vital signs are as follows : at 11 AM , pulse (P) , 92 beats/min , respiratory rate (RR) , 24 breaths/min , blood pressure (BP) , 140/88 mm Hg ; 11:15 AM , P , 96 beats/min , RR , 26 breaths/min , BP , 128/82 mm Hg ; 11:30 AM , P , 104 beats/min , RR , 28 breaths/min , BP , 104/68 mm Hg ; 11:45 AM , P , 118 beats/min , RR , 32 breaths/min , BP , 88/58 mm Hg . The nurse should alert the physician because these changes are most consistent with which of ?the following complications :Options Cardiogenic shock . 1 Cardiac tamponade . 2 Pulmonary embolism . 3 Dissecting thoracic aortic aneurysm . 4 :Answer . 1 :Rationale Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle . Classic signs include hypotension, a rapid pulse that becomes weaker, decreased urine output, and cool, clammy skin. Respiratory rate increases as the body develops metabolic acidosis from shock. Cardiac tamponade is accompanied by distant, muffled heart sounds and prominent neck vessels. Pulmonary embolism presents suddenly with severe dyspnea accompanying
  • 10. the chest pain. Dissecting aortic aneurysms .usually are accompanied by back pain :Question -14 A client with myocardial infarction has been transferred from a coronary care unit to a general medical unit with cardiac monitoring via telemetry. A nurse plans to allow for which of the following client ?activities :Options Strict bed rest for 24 hours after . 1 transfer Bathroom privileges and self-care . 2 activities Ad lib activities because the client is . 3 monitored Unsupervised hallway ambulation with . 4 distances under 200 feet :Answer . 2 :Rationale On transfer from the coronary care unit, the client is allowed self-care activities and bathroom privileges. Supervised ambulation in the hall for brief distances is encouraged, with distances gradually .(increased (50 , 100 , 200 feet :Question -15 A client admitted to the hospital with chest pain and history of type II diabetes mellitus is scheduled for cardiac catheterization . Which of the following medications would need to be held for 48 ?hours before and after the procedure :Options Regular insulin . 1 (Glipizide (Glucotrol . 2 (Repaglinide (Prandin . 3
  • 11. (Metformin (Glucophage . 4 :Answer . 4 :Rationale Metformin (Glucophage) needs to be withheld 48 hours before and after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system, the client would be at increased risk for lactic acidosis. The medications in options 1 , 2 , and 3 do not need to be withheld 48 hours before and after cardiac . catheterization :Question .-16 A client is in sinus bradycardia with a heart rate of 45 beats/min , complains of dizziness , and has a blood pressure of 82/60 mm Hg . Which of the following should the nurse anticipate will be prescribed ? :Options .Defibrillate the client . 1 .(Administer digoxin (Lanoxin . 2 .Continue to monitor the client . 3 .Prepare for transcutaneous pacing . 4 :Answer . 4 :Rationale Hypotension and dizziness are signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the symptomatic client. Digoxin will further decrease the client ’s heart rate. Defibrillation is used for treatment of pulseless ventricular tachycardia and ventricular fibrillation. Continuing to
  • 12. monitor the client delays necessary .intervention :Question -17 A nurse notes bilateral + 2 edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago . The nurse would plan to do which ?of the following next :Options Order daily weights starting on the . 1 .following morning Review the intake and output records . 2 . for the last 2 days Request a sodium restriction of 1 g/day . 3 . from the physician Change the time of diuretic . 4 .administration from morning to evening :Answer . 2 :Rationale Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe .symptoms :Question -18 A nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which of the following disorders reported by the client is unlikely to play a role in exacerbating the heart failure? :Options Atrial fibrillation . 1 Nutritional anemia . 2 Peptic ulcer disease . 3
  • 13. Recent upper respiratory infection . 4 :Answer . 3 :Rationale Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget ’s disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, .and hypervolemia :Question -19 A nurse is preparing for the admission of a client with heart failure who is being sent directly to the hospital from the physician ’s office. The nurse would plan on having which of the following medications readily ?available for use :Options (Digoxin (Lanoxin . 1 (Verapamil (Calan . 2 (Propranolol (Inderal . 3 (Diltiazem (Cardizem . 4 :Answer . 1 :Rationale Digoxin exerts a positive inotropic effect on the heart while slowing the overall rate through a variety of mechanisms. Digoxin is the medication of choice to treat heart failure. Diltiazem and verapamil (calcium channel blockers) and propranolol (β- adrenergic blocker) have a negative inotropic effect and would worsen the .failing heart :Question -20 A nurse is preparing for the admission of a client with heart failure who is being sent
  • 14. directly to the hospital from the physician ’s office. The nurse would plan on having which of the following medications readily ?available for use :Options (Digoxin (Lanoxin . 1 (Verapamil (Calan . 2 (Propranolol (Inderal . 3 (Diltiazem (Cardizem . 4 :Answer . 1 :Rationale Digoxin exerts a positive inotropic effect on the heart while slowing the overall rate through a variety of mechanisms. Digoxin is the medication of choice to treat heart failure. Diltiazem and verapamil (calcium channel blockers) and propranolol (β- adrenergic blocker) have a negative inotropic effect and would worsen the .failing heart :Question -21 A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which of the following would the nurse anticipate when ?auscultating the client ’s breath sounds :Options Stridor . 1 Crackles . 2 Scattered rhonchi . 3 Diminished breath sounds . 4 :Answer . 2 :Rationale Pulmonary edema is characterized by extreme
  • 15. breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of .the upper airway :Question .-22 A client who has developed severe pulmonary edema would most likely exhibit which of ?the following :Options Mild anxiety . 1 Slight anxiety . 2 Extreme anxiety . 3 Moderate anxiety . 4 :Answer . 3 :Rationale Pulmonary edema causes the client to be extremely agitated and anxious. The client may complain of a sense of drowning, .suffocation, or smothering :Question -23 A client with pulmonary edema has been on diuretic therapy. The client has an order for additional furosemide (Lasix) in the amount of 40 mg intravenous push . Knowing that the client will also be started on digoxin (Lanoxin), the nurse should review ?which laboratory result :Options Sodium level . 1 Digoxin level . 2 Creatinine level . 3 Potassium level . 4 :Answer
  • 16. . 4 :Rationale The serum potassium level is measured in the client receiving digoxin and furosemide. Heightened digoxin effect leading to digoxin toxicity can occur in the client with hypokalemia. Hypokalemia also predisposes the client to ventricular .dysrhythmias :Question -24 A client with myocardial infarction is going into cardiogenic shock. Because of the risk of myocardial ischemia, for which of the following should the nurse carefully ?assess the client :Options Bradycardia . 1 Ventricular dysrhythmias . 2 Rising diastolic blood pressure . 3 Falling central venous pressure . 4 :Answer . 2 :Rationale Classic signs of cardiogenic shock as they relate to this question include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater . than 40% of the myocardium :Question -25 A nurse assesses the sternotomy incision of a client on the third day after cardiac surgery. The incision shows some slight “puffiness ”along the edges and is
  • 17. nonreddened, with no apparent drainage. Temperature is 99° F orally . The white blood cell count is 7500 cells/mm 3 . How ?should the nurse interpret these findings :Options Incision is slightly edematous but . 1 .shows no active signs of infection Incision shows early signs of . 2 infection, although the temperature is .nearly normal Incision shows early signs of . 3 infection, supported by an elevated white blood cell count. 4 . Incision shows no sign of infection, although the white blood .cell count is elevated :Answer . 1 :Rationale Sternotomy incision sites are assessed for signs and symptoms of infection, such as redness, swelling, induration , and drainage . Elevated temperature and white blood cell count after 3 to 4 days .postoperatively usually indicate infection :Question -26 A client who had cardiac surgery 24 hours ago has a urine output averaging 20 mL/hr for 2 hours . The client received a single bolus of 500 mL of intravenous fluid . Urine output for the subsequent hour was 25 mL . Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL and the serum creatinine level is 2.2 mg/dL . Based on these findings , the nurse would anticipate that the client is at risk for ?which of the following :Options
  • 18. Hypovolemia . 1 Acute renal failure . 2 Glomerulonephritis . 3 Urinary tract infection . 4 :Answer . 2 :Rationale The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal insult is signaled by decreased urine output and increased blood urea nitrogen and creatinine levels. The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, urinary tract infection, or .glomerulonephritis :Question -27 A nurse is preparing to ambulate a client on the third day after cardiac surgery. The nurse would plan to do which of the following to enable the client to best ?tolerate the ambulation :Options .Remove telemetry equipment . 1 .Provide the client with a walker . 2 Premedicate the client with an . 3 .analgesic Encourage the client to cough and deep . 4 .breathe :Answer . 3 :Rationale The nurse should encourage regular use of
  • 19. pain medication for the first 48 to 72 hours after cardiac surgery because analgesia will promote rest, decrease myocardial oxygen consumption resulting from pain, and allow better participation in activities such as coughing, deep breathing, and ambulation. Options 2 and 4 will not help in tolerating ambulation . Removal of telemetry equipment is .contraindicated unless prescribed :Question -28 The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second , and QRS complexes measure 0.06 second . The overall heart rate is 64 beats/min . Which of the following would be a correct interpretation based on these ?characteristics :Options Sinus bradycardia . 1 Sick sinus syndrome . 2 Normal sinus rhythm . 3 First-degree heart block . 4 :Answer . 3 :Rationale Normal sinus rhythm is defined as a regular rhythm , with an overall rate of 60 to 100 beats/min . The PR and QRS measurements are normal , measuring 0.12 to 0.20 second and .0.04 to 0.10 second , respectively :Question A client ’s electrocardiogram strip shows atrial and ventricular rates of 110 beats/min . The PR interval is 0.14 second , the QRS complex measures 0.08 second , and the PP and RR intervals are
  • 20. regular. How should the nurse correctly ?interpret this rhythm :Options Sinus arrhythmia . 1 Sinus tachycardia . 2 Sinus bradycardia . 3 Normal sinus rhythm . 4 :Answer . 2 :Rationale 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 higher than 100 beats/min :Question -30 A nurse notices frequent artifact on the electrocardiographic monitor for a client whose leads are connected by cable to a console at the bedside. The nurse examines the client to determine the cause. Which of the following items is unlikely to be ?responsible for the artifact :Options Frequent movement of the client . 1 Tightly secured cable connections . 2 Leads applied over hairy areas . 3 Leads applied to the limbs . 4 :Answer . 2 :Rationale Motion artifact, or “noise, ”can be caused
  • 21. by frequent client movement, electrode placement on limbs, and insufficient adhesion to the skin, such as placing electrodes over hairy areas of the skin. Electrode placement over bony prominences also should be avoided. Signal interference also can occur with electrode removal and .cable disconnection :Question -31 A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves , the QRS complexes are wide , and the ventricular rate is regular but over 100 beats/min . The nurse determines that the client is experiencing ?which of the following dysrhythmias :Options Sinus tachycardia . 1 Ventricular fibrillation . 2 Ventricular tachycardia . 3 Premature ventricular contractions . 4 :Answer . 3 :Rationale Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 second) , and typically a rate between 140 and 180 impulses/min . The rhythm is regular. Level of :Question -32 ?most concerned about with this dysrhythmia :Options It can develop into ventricular . 1 .fibrillation at any time It is almost impossible to convert to a . 2 .normal rhythm It is uncomfortable for the client, . 3
  • 22. .giving a sense of impending doom It produces a high cardiac output that . 4 quickly leads to cerebral and myocardial :ischemia. Answer . 1 :Rationale Ventricular tachycardia is a life- threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Clients frequently experience a feeling of impending doom. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (client awake), or defibrillation (loss of consciousness). Ventricular tachycardia can deteriorate .into ventricular fibrillation at any time :Question -33 A nurse is viewing the cardiac monitor in a client ’s room and notes that the client has just gone into ventricular tachycardia. The client is awake and alert and has good skin color. The nurse would prepare to do ?which of the following :Options .Immediately defibrillate . 1 .Prepare for pacemaker insertion . 2 Administer amiodarone (Cordarone) . 3 .intravenously Administer epinephrine (Adrenalin) . 4 .intravenously :Answer . 3 :Rationale First-line treatment of ventricular tachycardia in a client who is
  • 23. hemodynamically stable is the use of antidysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm (cardioversion is recommended for stable ventricular tachycardia). Defibrillation is used with pulseless ventricular tachycardia. Epinephrine would stimulate an already excitable ventricle and is .contraindicated :Question -34 A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs the client to do which of the following, if prescribed, during an episode ?of ventricular tachycardia :Options .Lie down flat in bed . 1 .Remove any metal jewelry . 2 .Breathe deeply, regularly, and easily . 3 Inhale deeply and cough forcefully . 4 . every 1 to 3 seconds :Answer . 4 :Rationale Cough cardiopulmonary resuscitation (CPR) sometimes is used in the client with unstable ventricular tachycardia. The nurse tells the client to use cough CPR, if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds . Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented . Options 1 , 2 , and 3 will .not assist in terminating the dysrhythmia
  • 24. :Question -35 A client has developed atrial fibrillation , with a ventricular rate of 150 beats/min . The nurse should assess the client for which associated signs or ?symptoms :Options Flat neck veins . 1 Nausea and vomiting . 2 Hypotension and dizziness . 3 Hypertension and headache . 4 :Answer . 3 :Rationale The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats/min is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of .breath, and distended neck veins :Question -36 A nurse is watching the cardiac monitor, and a client ’s rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret ?the client ’s heart rhythm :Options Atrial fibrillation . 1 Sinus tachycardia . 2 Ventricular fibrillation . 3 Ventricular tachycardia . 4 :Answer . 1 :Rationale
  • 25. Atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each QRS complex. The atria quiver, which can lead to thrombi formation :Question -37 A client with rapid rate atrial fibrillation asks a nurse why the physician is going to perform carotid sinus massage. Which of the following would be reflective of a correct explanation provided by the :nurse? Options .The vagus nerve slows the heart rate . 1 The diaphragmatic nerve slows the heart . 2 .rate The diaphragmatic nerve overdrives the . 3 .rhythm The vagus nerve increases the heart . 4 .rate, overdriving the rhythm :Answer . 1 :Rationale Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The others include inducing the gag reflex and asking the client to strain or bear down. Medication therapy often is needed as an adjunct to keep the rate down or maintain the normal rhythm . Options 2 , 3 , and 4 are . incorrect descriptions of this procedure :Question -38 A nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client ’s rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy
  • 26. lines of varying amplitude. How would the ?nurse correctly interpret this rhythm :Options Asystole . 1 Atrial fibrillation . 2 Ventricular fibrillation . 3 Ventricular tachycardia . 4 :Answer . 3 :Rationale Ventricular fibrillation is characterized by irregular chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical .chaos in the ventricles :Question -39 A nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client ’s rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How would the ?nurse correctly interpret this rhythm :Options Asystole . 1 Atrial fibrillation . 2 Ventricular fibrillation . 3 Ventricular tachycardia . 4 :Answer . 3 :Rationale Ventricular fibrillation is characterized by irregular chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical
  • 27. .chaos in the ventricles :Question -40 A client in ventricular fibrillation is about to be defibrillated. A nurse knows that to convert this rhythm effectively, the machine should be set at which of the following energy levels (in joules, J) for ?the first delivery :Options J 50 . 1 J 100 . 2 J 200 . 3 J 360 . 4 :Answer . 3 :Rationale The client may be defibrillated up to three times in succession . The energy levels used are 200 , 300 , and 360 J for the first , second , and third attempts , . respectively :Question -41 A nurse would evaluate that defibrillation of a client was most successful if which of ?the following observations was made :Options Arousable , sinus rhythm , BP 116/72 mm . 1 Hg Arousable , marked bradycardia , BP . 2 86/54 mm Hg Nonarousable , supraventricular . 3 tachycardia , BP 122/60 mm Hg Nonarousable , sinus rhythm , BP 88/60 . 4 mm Hg :Answer . 1
  • 28. :Rationale After defibrillation, the client requires continuous monitoring of electrocardiographic rhythm, hemodynamic status, and neurological status. Respiratory and metabolic acidosis develops during ventricular fibrillation because of lack of respiration and cardiac output. These can cause cerebral and cardiopulmonary complications. Arousable status, adequate blood pressure, and a sinus rhythm indicate successful response .to defibrillation :Question -42 A nurse is performing cardiopulmonary resuscitation on a client who has had a cardiac arrest. An automatic external defibrillator is available to treat the client. Which of the following activities will allow the nurse to assess the client ?’s cardiac rhythm :Options Hold the defibrillator paddles firmly . 1 .against the chest Apply adhesive patch electrodes to the . 2 .chest and move away from the client Apply standard electrocardiographic . 3 monitoring leads to the client and observe the rhythm. 4 . Connect standard electrocardiographic electrodes to a :transtelephonic monitoring device. Answer . 2 :Rationale The nurse or rescuer puts two large adhesive patch electrodes on the client ’s chest in the usual defibrillator positions. The nurse stops cardiopulmonary resuscitation and orders anyone near the
  • 29. client to move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds . The machine then indicates if . defibrillation is necessary :Question -43 A nurse employed in a cardiac unit determines that which of the following clients is the least likely to have implantation of an automatic internal ?(cardioverter-defibrillator (AICD :Options A client with syncopal episodes related . 1 to ventricular tachycardia A client with ventricular dysrhythmias . 2 despite medication therapy A client with an episode of cardiac . 3 arrest related to myocardial infarction A client with three episodes of cardiac . 4 arrest unrelated to myocardial infarction :Answer . 3 :Rationale An automatic internal cardioverter- defibrillator (AICD) detects and delivers an electrical shock to terminate life- threatening episodes of ventricular tachycardia and ventricular fibrillation. These devices are implanted in clients who are considered high risk, including those who have survived sudden cardiac death unrelated to myocardial infarction, those who are refractive to medication therapy, and those who have syncopal episodes .related to ventricular tachycardia :Question A nurse is caring for a client immediately after insertion of a permanent demand
  • 30. pacemaker via the right subclavian vein. Which of the following activities will assist with preventing dislodgement of the ?pacing catheter :Options Limiting movement and abduction of the . 1 left arm Limiting movement and abduction of the . 2 right arm Assisting the client to get out of bed . 3 and ambulate with a walker Having the physical therapist do active . 4 range-of-motion exercises to the right arm :Answer . 2 :Rationale In the first several hours after insertion of a permanent or a temporary pacemaker, the most common complication is pacing electrode dislodgement. The nurse helps prevent this complication by limiting the client ’s activities of the arm on the side .of the insertion site :Question -45 A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath and is visibly anxious. The nurse should immediately assess the client for signs and symptoms of ?which of the following :Options Pneumonia . 1 Pulmonary edema . 2 Pulmonary embolism . 3 Myocardial infarction . 4 :Answer . 3 :Rationale
  • 31. Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset, and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, .diaphoresis, and apprehension :Question -46 A client seeks treatment in a physician ’s office for unsightly varicose veins, and sclerotherapy is recommended. Before leaving the examining room, the client says to the nurse, “Can you tell me again how this sclerotherapy is done? ”Which of the following statements would reflect accurate ?teaching by the nurse :Options .The varicosity is surgically removed” . 1 “ The vein is tied off at the upper end” . 2 “ .to prevent stasis from occurring The vein is tied off at the lower end” . 3 “ .to prevent stasis from occurring An agent is injected into the vein to” . 4 damage the vein wall and close the vein “ .off :Answer . 4 :Rationale Sclerotherapy is the injection of a sclerosing agent into a varicosity. The agent damages the vessel and causes aseptic thrombosis, which results in vein closure. With no blood flow through the vessel, there is no distention. The surgical procedure for varicose veins is vein ligation and stripping. This procedure involves tying off the varicose vein and
  • 32. large tributaries and then removing the vein with hook and wires via multiple small .incisions in the leg :Question -47 A client is having a follow-up physician office visit after vein ligation and stripping. The client describes a sensation of “pins and needles ”in the affected leg. Which of the following would be an appropriate action by the nurse based on ?evaluation of the client ’s comment :Options Instruct the client to apply warm . 1 .packs .Report the complaint to the physician . 2 Reassure the client that this is only . 3 .temporary Advise the client to take acetaminophen . 4 .(Tylenol) until it is gone :Answer . 2 :Rationale Hypersensitivity or a sensation of “pins and needles ”in the surgical limb may indicate temporary or permanent nerve injury following surgery. The saphenous vein and saphenous nerve run close together in the distal third of the leg. Because complications from this surgery are relatively rare, this symptom should be .reported :Question -48 A 24-year- old man seeks medical attention for complaints of claudication in the arch of the foot . A nurse also notes superficial thrombophlebitis of the lower leg. For which risk factor should the nurse ?assess based on these clinical findings
  • 33. :Options Smoking history . 1 Recent exposure to allergens . 2 History of recent insect bites . 3 Familial tendency toward peripheral . 4 vascular disease :Answer . 1 :Rationale The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger ’s disease). This disorder is characterized by inflammation and thrombosis of smaller arteries and veins. It typically is found in young adult males who smoke. The cause is not known precisely but is suspected to have an autoimmune component :Question -49 A nurse has given instructions to the client with Raynaud ’s disease about self- management of the disease process. The nurse determines that the client needs further reinforcement of teaching if the ?client states which of the following :Options “ .Smoking cessation is important” . 1 .Moving to a warmer climate is needed” . 2 “ Sources of caffeine should be” . 3 “ .eliminated from the diet Taking nifedipine (Procardia) as” . 4 “ .prescribed will decrease vessel spasm :Answer . 2 :Rationale
  • 34. Raynaud ’s disease responds favorably to eliminating caffeine from the diet and cessation of smoking. Medications may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is important. However, moving to a warmer climate may not necessarily be beneficial because the symptoms still could occur with the use of air conditioning and during periods of cooler weather