Medical surgical Nursing critical care exam 3 Latest 2023, Exams of Nursing

Download Medical surgical Nursing critical care exam 3 Latest 2023 and more Exams Nursing in PDF only on Docsity! [Date] 2 1 Medical surgical Nursing critical care exam 3 Latest 2023 A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a possible complication of the insertion procedure? a. I can’t get rid of these hiccups A nurse is caring for a postoperative client 1 hr following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider? a. Urine output is 20 ml/hr A nurse is assessing a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect? a. Dyspnea on exertion A nurse is providing health teaching for a group of clients. Which of the following clients is at risk for developing peripheral artery disease? a. Client who has diabetes mellitus A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mm Hg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first? a. Elevate the head of the clients bed. A nurse is assessing a client who has a history of deep-vein thrombosis and is receiving warafin. The nurse should identify that which of the following findings indicates the medication is effective? a. INR 2.0 2 2 [Date] b. Spot of maximal impulse is D A nurse is caring for a client who was admitted for treatment of left-sided heart failure with intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and irregular heart rate. Which of the following actions should the nurse take first? a. Review serum electrolyte values A nurse is caring for a client who has a history of angina and is scheduled for exercise electrocardiography at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling? a. I smoked a cigarette this morning to calm my nerves about having the procedure. 5 2 [Date] following an open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated? a. Assisting with thrombolytic therapy A nurse is providing discharge teaching for a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider? a. Weight gain of 0.9 kg (2 ib) in 24 hr A nurse is providing teaching for a client who is 2 days postoperative following a heart transplant. Which of the following statements should the nurse include in the teaching? a. You might no longer be able to feel chest pain. A nurse is caring for a client who is receiving heparin therapy and develops hematuria. Which of the following actions should the nurse take if the client’s aPTT is 96 seconds? a. Stop the heparin infusion A nurse in an emergency room is assessing a client who has a bradydysrhythmia. Which of the following findings should the nurse monitor for? a. Confusion A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication? a. Valvular disease A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse should recognize that an increase in which of the following is diagnostic if a myocardial infarction (MI)? a. Creatine kinase-MB 6 2 [Date] A nurse is monitoring a clients ECG monitor and notes the clients rhythm has changed from normal sinus rhythm supraventricular tachycardia. The nurse should prepare to assist with which of the following interventions? a. Vagal stimulation A nurse is caring for a client who is 8hr postoperative following a coronary artery bypass graft (CABG). Which of the following client findings should the nurse report? a. Blood pressure 160/80 mm Hg A nurse is teaching a client who is teaching a client who is starting to take an ACE inhibitor to treat hypertension. The nurse should instruct the client to notify the provider if he experiences which of the following adverse effects? a. Persistent cough A nurse is providing teaching to a client who is postoperative following a CABG surgery and is receiving opioid medications to relieve discomfort. Aside from managing pain, which of the following desired effects of medication should the nurse identify as most important for the clients recovery? a. It facilitates the clients deep breathing A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic? a. Fatigue A nurse is caring for a client who reports an area of redness, warmth, tenderness, and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of these findings? a. Obtain a venous duplex ultrasound A nurse is caring for a client who came in the emergency room reporting chest pain. The provider suspects a myocardial infarction. While waiting for the 7 2 [Date] laboratory report the nurse reports the clients troponin level, the client asks what his blood tests will show. The nurse should explain that troponin is? a. A heart muscle protein that appears in the blood stream when there is damage to the heart. A nurse in the emergency department is caring for a client who reports chest pressure, indigestion, fatigue, and occasional SOB. Which of the laboratory tests will provide the most specific indications of whether or not the client has had an MI? a. Troponin I A nurse is assessing a clients wife how to take a blood pressure. Which of the following actions by the wife indicates a need for further instructions? a. Place the clients arm above the level of the heart Patient took 3 nitroglycerin before coming to the ER the nurse should expect (select all) a. Tightness in chest b. SOB c. Indigestion Manifestations of an acute MI (select all) a. Nausea b. Tachycardia c. Diaphoresis Myocardial infarction- give oxygen first A nurse is caring for a client who enters the emergency department for severe chest pain. Which of the following interventions should the nurse implement to determine if the client is experiencing a myocardial infarction? a. Perform a 12-lead ECG 10 2 [Date] a. Oliguria If you suspect an MI administer oxygen first A client with ventricular heart disease is at risk for developing left-sided heart failure. The nurse knows to monitor which of the following parameters to determine if the client has developed this disorder? a. Breath sounds A nurse is about to administer warfarin (Coumadin) to a client who has atrial fibrillation. When the client asks what this medication will do, which of the following is an appropriate nursing response? a. It prevents strokes in clients who have atrial fibrillation Troponin- a heart muscle protein that appears in the bloodstream when there is damage to the heart. A nurse is caring for a client who has been admitted with atrial fibrillation. Which of the following assessments will provide valuable client data to the nurse in relation to this diagnosis? a. Apical and radial pulse Afib- irregular pulse Cardiac tamponade- muffled heart tones A nurse enters an adult clients room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, Which of the following actions should the nurse take first? a. Summon the code team A nurse is caring for a client who has hypertension and is afraid to take medication. Which of the following statements uses reflection? a. You seem upset about your blood pressure. 11 2 [Date] A nurse is reviewing the following vital signs: heart rate 86/min, blood pressure 80/40 mm Hg, respirations 28/min with stridor, and temperature 101.5F which of the following actions should the nurse take next? a. Hold captopril (Capoten) To prevent DVT- place sequential compression devices bilaterally. A nurse is receiving a clients admission laboratory values. The client has thrombocytopenia with a platelet count of 34,000/mm3 Which of the following actions should the nurse take? a. Pad sharp surfaces to protect from injury A nurse is caring for a client who has a diagnosis of diabetes mellitus and hypertension and recently began taking propranolol (Inderal). When the client reports dizziness upon standing. The nurse should perform which of the following actions? a. Monitor blood pressure standing, sitting, lying. A nurse is planning care for a client who has thrombocytopenia. Which of the following findings is most appropriate for the nurse to monitor with this disease process? a. Ecchymosis A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicate understanding of the teaching? a. I must stop smoking b. I need to monitor my weight c. I am limiting my intake of fast food A nurse is monitoring the cardiac output of a client who has left-sided heart failure using pulse pressure analysis. Which of the following findings can compromise the reading? a. The client is experiencing premature atrial contractions 12 2 [Date] A nurse in the ICU is caring for a client who has heart failure and is receiving dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective? a. Increased urine output A nurse is caring for a client who is scheduled for an echocardiogram the following day. Which of the following instructions should the nurse include about the test? a. It requires lying quietly on one side A nurse is interpreting a client’s ECG strip. Which of the components of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization? a. QT interval A client who has history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? a. Antiplatelet aggregate A nurse interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave? a. Atrial depolarization A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client’s EKG should the nurse interpret as a sign of hypokalemia? a. Abnormally prominent U wave 15 2 [Date] A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a spike (pacemaker artifact) followed by a QRS complex. Which of the following actions should the nurse take? a. Document that depolarization has occurred. A nurse us teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching? a. I will wear clean graduated compression stockings everyday Chapter 31: Assessment of Cardiovascular System Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 16 2 [Date] 1. A 74-yr-old patient has just arrived in the emergency department. After assessment reveals a pulse deficit of 46 beats, the nurse will anticipate that the patient may require a. emergent cardioversion. b. a cardiac catheterization. c. hourly blood pressure (BP) checks. d. electrocardiographic (ECG) monitoring. ANS: D Pulse deficit is a difference between simultaneously obtained apical and radial pulses. It indicates that there may be a cardiac dysrhythmia that would best be detected with ECG monitoring. Frequent BP monitoring, cardiac catheterization, and emergent cardioversion are used for diagnosis and/or treatment of cardiovascular disorders but would not be as helpful in determining the immediate reason for the pulse deficit. DIF: Cognitive Level: Apply (application) REF: 668 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 2. The nurse is reviewing the 12-lead electrocardiograph (ECG) for a healthy 74-yr- old patient who is having an annual physical examination. What finding is of most concern to the nurse? a. A right bundle-branch block. c. The QRS duration is 0.13 seconds. b. The PR interval is 0.21 seconds. d. The heart rate (HR) is 41 beats/min. ANS: D The resting HR does not change with aging, so the decrease in HR requires further investigation. Bundle-branch block and slight increases in PR interval or QRS duration are common in older individuals because of increases in conduction time through the AV node, bundle of His, and bundle branches. DIF: Cognitive Level: Analyze (analysis) REF: 662 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 17 2 [Date] 3. During a physical examination of an older patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The best follow-up action for the nurse to take will be to a. ask about risk factors for atherosclerosis. b. determine family history of heart disease. c. assess for symptoms of left ventricular hypertrophy. d. auscultate carotid arteries for the presence of a bruit. ANS: C The PMI should be felt at the intersection of the fifth intercostal space and left midclavicular line. A PMI located outside these landmarks indicates possible cardiac enlargement, such as with left ventricular hypertrophy (LVH). The other assessments are part of a general cardiac assessment but do not represent follow-up for LVH. Cardiac enlargement is not necessarily associated with atherosclerosis or carotid artery disease. DIF: Cognitive Level: Analyze (analysis) REF: 667 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 4. To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the a. diaphragm of the stethoscope with the patient lying flat. b. bell of the stethoscope with the patient in the left lateral position. c. diaphragm of the stethoscope with the patient in a supine position. d. bell of the stethoscope with the patient sitting and leaning forward. ANS: B Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall. The diaphragm of the stethoscope is best to use for the higher pitched sounds such as S1 and S2. DIF: Cognitive Level: Apply (application) REF: 668 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 20 2 [Date] b. exercise more than usual while the monitor is in place. c. remove the electrodes when taking a shower or tub bath. d. keep a diary of daily activities while the monitor is worn. ANS: D The patient is instructed to keep a diary describing daily activities while Holter monitoring is being accomplished to help correlate any rhythm disturbances with patient activities. Patients are taught that they should not take a shower or bath during Holter monitoring and that they should continue with their usual daily activities. The recorder stores the information about the patient’s rhythm until the end of the testing, when it is removed and the data are analyzed. DIF: Cognitive Level: Apply (application) REF: 674 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 10. When auscultating over the patient’s abdominal aorta, the nurse hears a loud humming sound. The nurse documents this finding as a a. thrill. c. murmur. b. bruit. d. normal finding. ANS: B A bruit is the sound created by turbulent blood flow in an artery. Thrills are palpable vibrations felt when there is turbulent blood flow through the heart or in a blood vessel. A murmur is the sound caused by turbulent blood flow through the heart. Auscultating a bruit in an artery is not normal and indicates pathology. DIF: Cognitive Level: Understand (comprehension) REF: 667 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 11. The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. The laboratory test result most helpful in indicating myocardial damage will be a. myoglobin. c. homocysteine (Hcy) b. troponins T and I. d. creatine kinase-MB (CK-MB). 21 2 [Date] ANS: B Cardiac troponins start to elevate 4 to 6 hours after myocardial injury and are highly specific to myocardium. They are the preferred diagnostic marker for myocardial infarction. Myoglobin rises in response to myocardial injury within 30 to 60 minutes. It is rapidly cleared from the body, thus limiting its use in the diagnosis of myocardial infarction. Low-density lipoprotein cholesterol is useful in assessing cardiovascular risk but is not helpful in determining whether a patient is having an acute myocardial infarction. Creatine kinase (CK-MB) is specific to myocardial injury and infarction and increases 4 to 6 hours after the infarction occurs. It is often trended with troponin levels. Homocysteine (Hcy) is an amino acid that is produced during protein catabolism. Elevated Hcy levels can be either hereditary or acquired from dietary deficiencies of vitamin B6, cobalamin (vitamin B12), or folate. Elevated levels of Hcy have been linked to a higher risk of CVD, peripheral vascular disease, and stroke. DIF: Cognitive Level: Analyze (analysis) REF: 670 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 12. When assessing a newly admitted patient, the nurse notes a murmur along the left sternal border. To acquire more information about the murmur, which action will the nurse take? a. Palpate the peripheral pulses. b. Determine the timing of the sound. c. Find the point of maximal impulse. d. Compare apical and radial pulse rates. ANS: B Murmurs are caused by turbulent blood flow, such as occurs when blood flows through a damaged valve. Relevant information includes the position in which the murmur is heard best (e.g., sitting and leaning forward), the timing of the murmur in relation to the cardiac cycle (e.g., systole, diastole), and where on the thorax the murmur is heard best. The other information is important in the cardiac assessment but will not provide information that is relevant to the murmur. DIF: Cognitive Level: Apply (application) REF: 662 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 22 2 [Date] 13. The nurse hears a murmur between the S1 and S2 heart sounds at the patient’s left fifth intercostal space and midclavicular line. How will the nurse record this information? a. Systolic murmur heard at mitral area b. Systolic murmur heard at Erb’s point c. Diastolic murmur heard at aortic area d. Diastolic murmur heard at the point of maximal impulse ANS: A The S1 signifies the onset of ventricular systole. S2 signifies the onset of diastole. A murmur occurring between these two sounds is a systolic murmur. The mitral area is the intersection of the left fifth intercostal space and the midclavicular line. The other responses describe murmurs heard at different landmarks on the chest and/or during the diastolic phase of the cardiac cycle. DIF: Cognitive Level: Apply (application) REF: 663 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 14. A registered nurse (RN) is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student nurse a. presses on the skin over the tibia for 10 seconds to check for edema. b. palpates both carotid arteries simultaneously to compare pulse quality. c. documents a murmur heard along the right sternal border as a pulmonic murmur. d. places the patient in the left lateral position to check for the point of maximal impulse. ANS: B The carotid pulses should never be palpated at the same time to avoid vagal stimulation, dysrhythmias, and decreased cerebral blood flow. The other assessment techniques also need to be corrected. However, they are not dangerous to the patient. DIF: Cognitive Level: Analyze (analysis) REF: 666 TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 25 2 [Date] ANS: B The contrast dye used for the procedure is iodine based, so patients who have shellfish allergies will require treatment with medications such as corticosteroids and antihistamines before the angiogram. The other information is also communicated to the health care provider but will not require a change in the usual precardiac catheterization orders or medications. DIF: Cognitive Level: Analyze (analysis) REF: 677 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 20. A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which action included in the standard TEE orders will the nurse need to accomplish first? a. Start an IV line. c. Place the patient on NPO status. b. Start O2 per nasal cannula. d. Give lorazepam (Ativan) 1 mg IV. ANS: C The patient will need to be NPO for 6 hours preceding the TEE, so the nurse should place the patient on NPO status as soon as the order is received. The other actions also will need to be accomplished but not until just before or during the procedure. DIF: Cognitive Level: Analyze (analysis) REF: 671 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 21. The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four patients. Which nursing action can be delegated to the UAP? a. Teaching a patient about exercise electrocardiography b. Attaching ECG monitoring electrodes after a patient bathes c. Checking the catheter insertion site for a patient who is recovering from a coronary angiogram d. Monitoring a patient who has just returned to the unit after a transesophageal echocardiogram 26 2 [Date] ANS: B UAP can be educated in standardized lead placement for ECG monitoring. Assessment of patients who have had procedures where airway maintenance (transesophageal echocardiography) or bleeding (coronary angiogram) is a concern must be done by the registered nurse (RN). Patient teaching requires RN level education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 660 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 22. The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular unit. Which laboratory result is most important to communicate as soon as possible to the health care provider? a. High troponin I level b. Increased triglyceride level c. Very low homocysteine level d. Elevated high-sensitivity C-reactive protein level ANS: A The elevation in troponin I indicates that the patient has had an acute myocardial infarction. Further assessment and interventions are indicated. The other laboratory results are indicative of increased risk for coronary artery disease but are not associated with acute cardiac problems that need immediate intervention. DIF: Cognitive Level: Analyze (analysis) REF: 670 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 23. When the nurse is screening patients for possible peripheral arterial disease, indicate where the posterior tibial artery will be palpated. 27 2 [Date] a. 1 c. 3 b. 2 d. 4 ANS: C The posterior tibial site is located behind the medial malleolus of the tibia. DIF: Cognitive Level: Understand (comprehension) REF: 666 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity OTHER 1. While listening at the mitral area, the nurse notes abnormal heart sounds at the patient’s fifth intercostal space, midclavicular line. After listening to the audio clip, describe how the nurse will document the assessment finding. Click here to listen to the audio clip a. S3 gallop heard at the aortic area b. Systolic murmur noted at mitral area c. Diastolic murmur noted at tricuspid area d. Pericardial friction rub heard at the apex ANS: B 30 2 [Date] c. “The pain has gotten worse over the last week.” d. “The pain goes away after a nitroglycerin tablet.” ANS: D Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina. DIF: Cognitive Level: Understand (comprehension) REF: 712 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 5. After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective? a. “I can expect nausea as a side effect of nitroglycerin.” b. “I should only take nitroglycerin when I have chest pain.” c. “Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart.” d. “I will call an ambulance if I still have pain after taking three nitroglycerin 5 minutes apart.” ANS: D The emergency response system (ERS) should be activated when chest pain or other symptoms are not completely relieved after three sublingual nitroglycerin tablets taken 5 minutes apart. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset (e.g., nausea) is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis. DIF: Cognitive Level: Apply (application) REF: 716 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 6. Which statement made by a patient with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? a. “I will switch from whole milk to 1% milk.” 31 2 [Date] b. “I like salmon and I will plan to eat it more often.” c. “I can have a glass of wine with dinner if I want one.” d. “I will miss being able to eat peanut butter sandwiches.” ANS: D Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monounsaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. The other patient comments indicate a good understanding of the TLC diet. DIF: Cognitive Level: Apply (application) REF: 709 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 7. After the nurse teaches the patient about the use of carvedilol (Coreg) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? a. “Carvedilol will help my heart muscle work harder.” b. “It is important not to suddenly stop taking the carvedilol.” c. “I can expect to feel short of breath when taking carvedilol.” d. “Carvedilol will increase the blood flow to my heart muscle.” ANS: B Patients who have been taking 𝗉-adrenergic blockers can develop intense and frequent angina if the medication is suddenly discontinued. Carvedilol (Coreg) decreases myocardial contractility. Shortness of breath that occurs when taking 𝗉- adrenergic blockers for angina may be due to bronchospasm and should be reported to the health care provider. Carvedilol works by decreasing myocardial O2 demand, not by increasing blood flow to the coronary arteries. DIF: Cognitive Level: Apply (application) REF: 715 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 8. A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to best determine whether the patient has had an AMI? 32 2 [Date] a. Myoglobin c. C-reactive protein b. Homocysteine d. Cardiac-specific troponin ANS: D Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI) and are highly specific indicators for MI. Myoglobin is released within 2 hours of MI, but it lacks specificity and its use is limited. The other laboratory data are useful in determining the patient’s risk for developing coronary artery disease but are not helpful in determining whether an acute MI is in progress. DIF: Cognitive Level: Understand (comprehension) REF: 722 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 9. Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetal’s (variant) angina. When teaching the patient, the nurse will include the information that diltiazem will a. reduce heart palpitations. b. prevent coronary artery plaque. c. decrease coronary artery spasms. d. increase contractile force of the heart. ANS: C Prinzmetal’s angina is caused by coronary artery spasm. Calcium channel blockers (e.g., diltiazem, amlodipine [Norvasc]) are a first-line therapy for this type of angina. Lipid-lowering drugs help reduce atherosclerosis (i.e., plaque formation), and 𝗉-adrenergic blockers decrease sympathetic stimulation of the heart (i.e., palpitations). Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing O2 demand. DIF: Cognitive Level: Apply (application) REF: 713 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 10. The nurse suspects that the patient with stable angina is experiencing a side effect of the prescribed drug metoprolol (Lopressor) if the a. patient is restless and agitated. b. blood pressure is 90/54 mm Hg. 35 2 [Date] ANS: C Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction, so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information is not a factor in the decision about thrombolytic therapy. DIF: Cognitive Level: Apply (application) REF: 723 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 15. After an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse evaluates the patient’s response to the activity, which data would indicate that the exercise level should be decreased? a. O2 saturation drops from 99% to 95%. b. Heart rate increases from 66 to 98 beats/min. c. Respiratory rate goes from 14 to 20 breaths/min. d. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg. ANS: B A change in heart rate of more than 20 beats over the resting heart rate indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in O2 saturation, are normal responses to exercise. DIF: Cognitive Level: Apply (application) REF: 732 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 16. During the administration of the thrombolytic agent to a patient with an acute myocardial infarction, the nurse should stop the drug infusion if the patient experiences a. bleeding from the gums. b. increase in blood pressure. c. a decrease in level of consciousness. d. a nonsustained episode of ventricular tachycardia. ANS: C 36 2 [Date] The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of thrombolytic therapy. Some bleeding of the gums is an expected side effect of the therapy but not an indication to stop infusion of the thrombolytic medication. A decrease in blood pressure could indicate internal bleeding. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective. DIF: Cognitive Level: Apply (application) REF: 723 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 17. A patient recovering from a myocardial infarction (MI) develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take as focused follow-up on this symptom? a. Assess the feet for pedal edema. b. Palpate the radial pulses bilaterally. c. Auscultate for a pericardial friction rub. d. Check the heart monitor for dysrhythmias. ANS: C The patient’s symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient’s symptoms. DIF: Cognitive Level: Apply (application) REF: 721 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 18. In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective? a. “I will check my pulse rate before I take any nitroglycerin tablets.” b. “I will put the nitroglycerin patch on as soon as I get any chest pain.” c. “I will stop what I am doing and sit down before I put the nitroglycerin under my tongue.” d. “I will be sure to remove the nitroglycerin patch before taking any sublingual nitroglycerin.” 37 2 [Date] ANS: C The patient should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather than to treat acute pain and can be used concurrently with sublingual nitroglycerin. Although the nurse should check blood pressure before giving nitroglycerin, patients do not need to check the pulse rate before taking nitrates. DIF: Cognitive Level: Apply (application) REF: 716 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 19. Three days after experiencing a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with hygiene activities, saying, “I am too nervous about my heart to be alone while I get washed up.” Based on this information, which nursing diagnosis is appropriate? a. Activity intolerance related to weakness b. Anxiety related to change in health status c. Denial related to lack of acceptance of the MI d. Altered body image related to cardiac disease ANS: B The patient data indicate anxiety about the impact of the MI is a concern. The other nursing diagnoses may be appropriate for some patients after an MI, but the data for this patient do not support denial, activity intolerance, or altered body image. DIF: Cognitive Level: Apply (application) REF: 725 TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 20. When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that a. sudden cardiac death events rarely reoccur. b. additional diagnostic testing will be required. c. long-term anticoagulation therapy will be needed. d. limiting physical activity will prevent future SCD events. 40 2 [Date] a. Administer the medication at the patient’s usual bedtime. b. Have the patient take the colesevelam 1 hour before breakfast. c. Give the patient’s other medications 2 hours after colesevelam. d. Have the patient take the dose at the same time as the prescribed aspirin. ANS: C The bile acid sequestrants interfere with the absorption of many other drugs and giving other medications at the same time should be avoided. Taking an aspirin concurrently with the colesevelam may increase the incidence of gastrointestinal side effects such as heartburn. For maximum effect, colesevelam should be administered with meals. DIF: Cognitive Level: Apply (application) REF: 711 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 25. The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would include a. when cardiac rehabilitation will begin. b. the typical emotional responses to AMI. c. information regarding discharge medications. d. the pathophysiology of coronary artery disease. ANS: A Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this time, the patient’s anxiety level or denial will interfere with good understanding of complex information such as the pathophysiology of coronary artery disease. Teaching about discharge medications should be done closer to discharge. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional responses to myocardial infarction. DIF: Cognitive Level: Apply (application) REF: 726 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 41 2 [Date] 26. A patient who has recently started taking pravastatin (Pravachol) and niacin reports several symptoms to the nurse. Which information is most important to communicate to the health care provider? a. Generalized muscle aches and pains b. Dizziness with rapid position changes c. Nausea when taking the drugs before meals d. Flushing and pruritus after taking the drugs ANS: A Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute kidney injury and death in some patients who have taken the statin medications. These symptoms indicate that the pravastatin may need to be discontinued. The other symptoms are common side effects when taking niacin, and although the nurse should follow-up with the health care provider, they do not indicate that a change in medication is needed. DIF: Cognitive Level: Analyze (analysis) REF: 711 OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 27. A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of daily medications to the nurse. Which medication has the most immediate implications for the patient’s care? a. Captopril c. furosemide (Lasix) b. sildenafil (Viagra) d. warfarin (Coumadin) ANS: B The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using sildenafil because of the risk of severe hypotension caused by vasodilation. The other home medications should also be documented and reported to the health care provider but do not have as immediate an impact on decisions about the patient’s treatment. DIF: Cognitive Level: Analyze (analysis) REF: 716 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 42 2 [Date] 28. Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider? a. Complaints of incisional chest pain b. Pallor and weakness of the right hand c. Fine crackles heard at both lung bases d. Redness on both sides of the sternal incision ANS: B The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions such as prescribed calcium channel blockers or surgery. The other changes are expected or require nursing interventions. DIF: Cognitive Level: Analyze (analysis) REF: 729 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 29. When caring for a patient who has just arrived on the telemetry unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Give the scheduled aspirin and lipid-lowering medication. b. Perform the initial assessment of the catheter insertion site. c. Teach the patient about the usual postprocedure plan of care. d. Titrate the heparin infusion according to the agency protocol. ANS: A Administration of oral medications is within the scope of practice for LPNs/LVNs. The initial assessment of the patient, patient teaching, and titration of IV anticoagulant medications should be done by the registered nurse (RN). DIF: Cognitive Level: Apply (application) REF: 729 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 30. Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain? a. Inverted P wave c. ST-segment elevation b. Sinus tachycardia d. First-degree atrioventricular 45 2 [Date] Continued chest pain suggests that the thrombolytic therapy is not effective and that other interventions such as percutaneous coronary intervention may be needed. Bruising is a possible side effect of thrombolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST-segment elevation indicates that thrombolysis is occurring and perfusion is returning to the injured myocardium. An increase in troponin levels is expected with reperfusion and is related to the washout of cardiac biomarkers into the circulation as the blocked vessel is opened. DIF: Cognitive Level: Analyze (analysis) REF: 723 OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 35. The nurse obtains the following data when assessing a patient who experienced an ST-segment- elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? a. The troponin level is elevated. b. The patient denies having a heart attack. c. Bilateral crackles in the mid-lower lobes. d. Occasional premature atrial contractions (PACs). ANS: C The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme inhibitors for the patient. Elevation in troponin level at this time is expected. PACs are not life-threatening dysrhythmias. Denial is a common response in the immediate period after the MI. DIF: Cognitive Level: Analyze (analysis) REF: 720 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 36. A patient had a non–ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention included in the plan of care is appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Evaluation of the patient’s response to walking in the hallway b. Completion of the referral form for a home health nurse follow-up 46 2 [Date] c. Education of the patient about the pathophysiology of heart disease d. Reinforcement of teaching about the purpose of prescribed medications ANS: D LPN/LVN education and scope of practice include reinforcing education that has previously been done by the RN. Evaluating the patient’s response to exercise after a NSTEMI requires more education and should be done by the RN. Teaching and discharge planning and referral are skills that require RN education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 729 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 37. A patient who has chest pain is admitted to the emergency department (ED), and all of the following are ordered. Which one should the nurse arrange to be completed first? a. Chest x-ray c. Electrocardiogram (ECG) b. Troponin level d. Insertion of a peripheral IV ANS: C The priority for the patient is to determine whether an acute myocardial infarction (AMI) is occurring so that the appropriate therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion, and an ECG should be obtained as soon as possible. Troponin levels will increase after about 3 hours. Data from the chest x-ray may impact the patient’s care but are not helpful in determining whether the patient is experiencing a myocardial infarction. Peripheral access will be needed but not before the ECG. DIF: Cognitive Level: Analyze (analysis) REF: 719 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 38. After receiving change-of-shift report about the following four patients on the cardiac care unit, which patient should the nurse assess first? a. A 39-yr-old patient with pericarditis who is complaining of sharp, stabbing chest pain 47 2 [Date] b. A 56-yr-old patient with variant angina who is scheduled to receive nifedipine (Procardia) c. A 65-yr-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about today’s planned discharge d. A 59-yr-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI) ANS: D After PCI, the patient is at risk for hemorrhage from the arterial access site. The nurse should assess the patient’s blood pressure, pulses, and the access site immediately. The other patients should also be assessed as quickly as possible, but assessment of this patient has the highest priority. DIF: Cognitive Level: Analyze (analysis) REF: 718 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 39. To improve the physical activity level for a mildly obese 71-yr-old patient, which action should the nurse plan to take? a. Stress that weight loss is a major benefit of increased exercise. b. Determine what kind of physical activities the patient usually enjoys. c. Tell the patient that older adults should exercise for no more than 20 minutes at a time. d. Teach the patient to include a short warm-up period at the beginning of physical activity. ANS: B Because patients are more likely to continue physical activities that they already enjoy, the nurse will plan to ask the patient about preferred activities. The goal for older adults is 30 minutes of moderate activity on most days. Older adults should plan for a longer warm-up period. Benefits of exercises, such as improved activity tolerance, should be emphasized rather than aiming for significant weight loss in older mildly obese adults. DIF: Cognitive Level: Apply (application) REF: 708 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 50 2 [Date] a. Hyperglycemia c. Q waves on ECG b. Bilateral crackles d. Elevated troponin ANS: B Pulmonary congestion suggests that the patient may be developing heart failure, a complication of myocardial infarction (MI). Hyperglycemia is common after MI because of the inflammatory process that occurs with tissue necrosis. Troponin levels will be elevated for several days after MI. Q waves often develop with ST- segment-elevation MI. DIF: Cognitive Level: Analyze (analysis) REF: 720 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 51 2 [Date] Chapter 35: Dysrhythmias Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. To determine whether there is a delay in impulse conduction through the ventricles, the nurse will measure the duration of the patient’s a. P wave. c. PR interval. b. Q wave. d. QRS complex. ANS: D The QRS complex represents ventricular depolarization. The P wave represents the depolarization of the atria. The PR interval represents depolarization of the atria, atrioventricular node, bundle of His, bundle branches, and the Purkinje fibers. The Q wave is the first negative deflection following the P wave and should be narrow and short. DIF: Cognitive Level: Understand (comprehension) REF: 759 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use? a. Count the number of large squares in the R-R interval and divide by 300. b. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes. c. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10. d. Calculate the number of small squares between one QRS complex and the next and divide into 1500. ANS: C This is the quickest way to determine the ventricular rate for a patient with a regular rhythm. All the other methods are accurate, but take longer. DIF: Cognitive Level: Analyze (analysis) REF: 759 52 2 [Date] TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of beats/min. a. 15 to 20 c. 40 to 60 b. 20 to 40 d. 60 to 100 ANS: C If the sinoatrial (SA) node fails to discharge, the atrioventricular (AV) node will automatically discharge at the normal rate of 40 to 60 beats/minute. The slower rates are typical of the bundle of His and Purkinje system and may be seen with failure of both the SA and AV node to discharge. The normal SA node rate is 60 to 100 beats/min. DIF: Cognitive Level: Understand (comprehension) REF: 760 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, and QRS complex wide and distorted, and QRS duration of 0.18 second. The nurse interprets the patient’s cardiac rhythm as a. atrial flutter. c. ventricular fibrillation. b. sinus tachycardia. d. ventricular tachycardia. ANS: D The absence of P waves, wide QRS, rate greater than 150 beats/min, and the regularity of the rhythm indicate ventricular tachycardia. Atrial flutter is usually regular, has a narrow QRS configuration, and has flutter waves present representing atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration. DIF: Cognitive Level: Apply (application) REF: 764 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 55 2 [Date] 9. A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. Teaching for this patient would include information about a. anticoagulant therapy. c. emergency cardioversion. b. permanent pacemakers. d. IV adenosine (Adenocard). ANS: A Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant treatment for 3 weeks before attempting cardioversion. This is done to prevent embolization of clots from the atria. Cardioversion may be done after several weeks of anticoagulation therapy. Adenosine is not used to treat atrial fibrillation. Pacemakers are routinely used for patients with bradydysrhythmias. Information does not indicate that the patient has a slow heart rate. DIF: Cognitive Level: Apply (application) REF: 766 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 10. Which information will the nurse include when teaching a patient who is scheduled for a radiofrequency catheter ablation for treatment of atrial flutter? a. The procedure prevents or minimizes the risk for sudden cardiac death. b. The procedure uses cold therapy to stop the formation of the flutter waves. c. The procedure uses electrical energy to destroy areas of the conduction system. d. The procedure stimulates the growth of new conduction pathways between the atria. ANS: C Radiofrequency catheter ablation therapy uses electrical energy to “burn” or ablate areas of the conduction system as definitive treatment of atrial flutter (i.e., restore normal sinus rhythm) and tachydysrhythmias. All other statements regarding the procedure are incorrect. DIF: Cognitive Level: Apply (application) REF: 765 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 56 2 [Date] 11. The nurse knows that discharge teaching about the management of a new permanent pacemaker has been most effective when the patient states a. “It will be several weeks before I can return to my usual activities.” b. “I will avoid cooking with a microwave oven or being near one in use.” c. “I will notify the airlines when I make a reservation that I have a pacemaker.” d. “I won’t lift the arm on the pacemaker side until I see the health care provider.” ANS: D The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The patient should notify airport security about the presence of a pacemaker before going through the metal detector, but there is no need to notify the airlines when making a reservation. Microwave oven use does not affect the pacemaker. The insertion procedure involves minor surgery that will have a short recovery period. DIF: Cognitive Level: Apply (application) REF: 775 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 12. Which intervention by a new nurse who is caring for a patient who has just had an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more teaching about the care of patients with ICDs? a. The nurse administers amiodarone (Cordarone) to the patient. b. The nurse helps the patient fill out the application for obtaining a Medic Alert device. c. The nurse encourages the patient to do active range of motion exercises for all extremities. d. The nurse teaches the patient that sexual activity can be resumed when the incision is healed. ANS: C The patient should avoid moving the arm on the ICD insertion site until healing has occurred to prevent displacement of the ICD leads. The other actions by the new nurse are appropriate for this patient. 57 2 [Date] DIF: Cognitive Level: Apply (application) REF: 772 TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment 13. Which action should the nurse perform when preparing a patient with supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm Hg? a. Turn the synchronizer switch to the “off” position. b. Give a sedative before cardioversion is implemented. c. Set the defibrillator/cardioverter energy to 360 joules. d. Provide assisted ventilations with a bag-valve-mask device. ANS: B When a patient has a nonemergency cardioversion, sedation is used just before the procedure. The synchronizer switch is turned “on” for cardioversion. The initial level of joules for cardioversion is low (e.g., 50). Assisted ventilations are not indicated for this patient. DIF: Cognitive Level: Apply (application) REF: 772 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 14. A 20-yr-old patient has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. Blood pressure (BP) is 114/54 mm Hg, and the student denies any health problems. What action by the nurse is most appropriate? a. Allow the student to participate on the soccer team. b. Refer the student to a cardiologist for further testing. c. Tell the student to stop playing immediately if any dyspnea occurs. d. Obtain more detailed information about the student’s family health history. ANS: A In an aerobically trained individual, sinus bradycardia is normal. The student’s normal BP and negative health history indicate that there is no need for a cardiology referral or for more detailed information about the family’s health history. Dyspnea during an aerobic activity such as soccer is normal. 60 2 [Date] b. Give atropine sulfate 1 mg IV per agency dysrhythmia protocol. c. Call the health care provider before giving scheduled metoprolol (Lopressor). d. Document the patient’s rhythm and assess the patient’s response to the rhythm. ANS: C The patient has progressive first-degree atrioventricular (AV) block, and the 𝗉- blocker should be held until discussing the drug with the health care provider. Documentation and assessment are appropriate but not fully adequate responses. The patient with first-degree AV block usually is asymptomatic and a pacemaker is not indicated. Atropine is sometimes used for symptomatic bradycardia, but there is no indication that this patient is symptomatic. DIF: Cognitive Level: Analyze (analysis) REF: 767 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 20. A patient develops sinus bradycardia at a rate of 32 beats/min, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which action should the nurse take next? a. Recheck the heart rhythm and BP in 5 minutes. b. Have the patient perform the Valsalva maneuver. c. Give the scheduled dose of diltiazem (Cardizem). d. Apply the transcutaneous pacemaker (TCP) pads. ANS: D The patient is experiencing symptomatic bradycardia and treatment with TCP is appropriate. Continued monitoring of the rhythm and BP is an inadequate response. Calcium channel blockers will further decrease the heart rate and the diltiazem should be held. The Valsalva maneuver will further decrease the rate. DIF: Cognitive Level: Apply (application) REF: 775 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 61 2 [Date] 21. A 19-yr-old student comes to the student health center at the end of the semester complaining that, “My heart is skipping beats.” An electrocardiogram (ECG) shows occasional unifocal premature ventricular contractions (PVCs). What action should the nurse take next? a. Insert an IV catheter for emergency use. b. Start supplemental O2 at 2 to 3 L/min via nasal cannula. c. Ask the patient about current stress level and caffeine use. d. Have the patient taken to the nearest emergency department (ED). ANS: C In a patient with a normal heart, occasional PVCs are a benign finding. The timing of the PVCs suggests stress or caffeine as possible etiologic factors. The patient is hemodynamically stable, so there is no indication that the patient needs supplemental O2, an IV, or to be seen in the ED. DIF: Cognitive Level: Apply (application) REF: 768 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 22. The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first? a. A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due b. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating c. A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago d. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due ANS: D The frequent firing of the ICD indicates that the patient’s ventricles are very irritable and the priority is to assess the patient and give the amiodarone. The other patients can be seen after the amiodarone is given. DIF: Cognitive Level: Analyze (analysis) REF: 773 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective 62 2 [Date] Care Environment 23. A patient who is on the telemetry unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first? a. Obtain a 12-lead electrocardiogram (ECG). b. Notify the health care provider of the change in rhythm. c. Give supplemental O2 at 2 to 3 L/min via nasal cannula. d. Assess the patient’s vital signs including O2 saturation. ANS: C Because this patient has dyspnea and chest pain in association with the new rhythm, the nurse’s initial actions should be to address the patient’s airway, breathing, and circulation (ABC) by starting with O2 administration. The other actions are also important and should be implemented rapidly. DIF: Cognitive Level: Analyze (analysis) REF: 765 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 24. A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic, and has no palpable pulses. What action should the nurse take next? a. Perform synchronized cardioversion. b. Start cardiopulmonary resuscitation (CPR). c. Give atropine per agency dysrhythmia protocol. d. Provide supplemental O2 via non-rebreather mask. ANS: B The patient’s clinical manifestations indicate pulseless electrical activity, and the nurse should immediately start CPR. The other actions would not be of benefit to this patient. DIF: Cognitive Level: Apply (application) REF: 763 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 65 2 [Date] DIF: Cognitive Level: Apply (application) REF: 768 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 29. A patient who is complaining of a “racing” heart and feeling “anxious” comes to the emergency department. The nurse places the patient on a heart monitor and obtains the following electrocardiographic (ECG) tracing. Which action should the nurse take next? a. Prepare to perform electrical cardioversion. b. Have the patient perform the Valsalva maneuver. c. Obtain the patient’s vital signs including O2 saturation. d. Prepare to give a 𝗉-blocker medication to slow the heart rate. ANS: C The patient has sinus tachycardia, which may have multiple etiologies such as pain, dehydration, anxiety, and myocardial ischemia. Further assessment is needed before determining the treatment. Vagal stimulation or 𝗉-blockade may be used after further assessment of the patient. Electrical cardioversion is used for some tachydysrhythmias but would not be used for sinus tachycardia. DIF: Cognitive Level: Analyze (analysis) REF: 763 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 66 2 [Date] 1. When analyzing an electrocardiographic (ECG) rhythm strip of a patient with a regular heart rhythm, the nurse counts 30 small blocks from one R wave to the next. The nurse calculates the patient’s heart rate as . ANS: 50 There are 1500 small blocks in a minute, and the nurse will divide 1500 by 30. DIF: Cognitive Level: Apply (application) REF: 759 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity OTHER 1. When preparing to defibrillate a patient, in which order will the nurse perform the following steps? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Turn the defibrillator on. b. Deliver the electrical charge. c. Select the appropriate energy level. d. Place the hands-free, multifunction defibrillator pads on the patient’s chest. e. Check the location of other staff and call out “all clear.” ANS: A, C, D, E, B This order will result in rapid defibrillation without endangering hospital staff. DIF: Cognitive Level: Analyze (analysis) REF: 771 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 67 2 [Date]