NUR 2502 MULTIDIMENSIONAL CARE
III EXAM 2 COMPREHENSIVE REVIEW
QUESTIONS AND ANSWERS
1. A nurse is caring for a patient who develops ventricular fibrillation (VF) on the cardiac
monitor. Which action should the nurse take first?
A. Begin high-quality chest compressions while preparing for defibrillation.
B. Administer a bolus of amiodarone 300 mg IV push.
C. Perform immediate synchronized cardioversion at 100 Joules.
D. Assess the patient’s carotid pulse for a full 10 seconds.
Answer: A
Conceptual Explanation: Ventricular fibrillation is a pulseless rhythm requiring
immediate CPR and defibrillation. Synchronized cardioversion is for rhythms with a pulse
(like SVT or VT with a pulse). Amiodarone is secondary to defibrillation and epinephrine.
2. A patient with atrial fibrillation is prescribed warfarin. Which laboratory value should the
nurse monitor to determine the effectiveness of the therapy?
A. Activated Partial Thromboplastin Time (aPTT)
,B. International Normalized Ratio (INR)
C. Platelet count
D. Serum potassium levels
Answer: B
Conceptual Explanation: INR is the standard monitoring tool for warfarin therapy, usually
targeting a range of 2.0 to 3.0 for atrial fibrillation. aPTT is used for heparin monitoring.
3. The nurse notes a ‘Failure to Capture’ on the ECG of a patient with a permanent
pacemaker. Which assessment finding is most concerning?
A. Pacer spikes present followed by a QRS complex.
B. A heart rate of 72 beats per minute.
C. Pacer spikes present without a subsequent QRS complex.
D. The patient reporting a hiccuping sensation.
Answer: C
Conceptual Explanation: Failure to capture occurs when the pacemaker delivers a
stimulus (spike) but the heart muscle does not depolarize (no QRS). This leads to
bradycardia or asystole.
4. A patient is in the early stages of hypovolemic shock. Which clinical manifestation should
the nurse expect to find first?
A. Profound hypotension and cold, clammy skin.
, B. Decreased urinary output less than 10 mL/hr.
C. Increased heart rate and mild tachypnea.
D. Lethargy and loss of consciousness.
Answer: C
Conceptual Explanation: Tachycardia is one of the earliest compensatory mechanisms in
hypovolemic shock to maintain cardiac output, often accompanied by slight increases in
respiratory rate.
5. During the emergent phase of a burn injury, which electrolyte imbalance is most likely to
occur due to cellular destruction?
A. Hyperkalemia
B. Hypernatremia
C. Hypokalemia
D. Hypocalcemia
Answer: A
Conceptual Explanation: Massive cellular damage during the emergent phase of burns
causes potassium to leak out of the cells into the extracellular fluid, resulting in
hyperkalemia.
III EXAM 2 COMPREHENSIVE REVIEW
QUESTIONS AND ANSWERS
1. A nurse is caring for a patient who develops ventricular fibrillation (VF) on the cardiac
monitor. Which action should the nurse take first?
A. Begin high-quality chest compressions while preparing for defibrillation.
B. Administer a bolus of amiodarone 300 mg IV push.
C. Perform immediate synchronized cardioversion at 100 Joules.
D. Assess the patient’s carotid pulse for a full 10 seconds.
Answer: A
Conceptual Explanation: Ventricular fibrillation is a pulseless rhythm requiring
immediate CPR and defibrillation. Synchronized cardioversion is for rhythms with a pulse
(like SVT or VT with a pulse). Amiodarone is secondary to defibrillation and epinephrine.
2. A patient with atrial fibrillation is prescribed warfarin. Which laboratory value should the
nurse monitor to determine the effectiveness of the therapy?
A. Activated Partial Thromboplastin Time (aPTT)
,B. International Normalized Ratio (INR)
C. Platelet count
D. Serum potassium levels
Answer: B
Conceptual Explanation: INR is the standard monitoring tool for warfarin therapy, usually
targeting a range of 2.0 to 3.0 for atrial fibrillation. aPTT is used for heparin monitoring.
3. The nurse notes a ‘Failure to Capture’ on the ECG of a patient with a permanent
pacemaker. Which assessment finding is most concerning?
A. Pacer spikes present followed by a QRS complex.
B. A heart rate of 72 beats per minute.
C. Pacer spikes present without a subsequent QRS complex.
D. The patient reporting a hiccuping sensation.
Answer: C
Conceptual Explanation: Failure to capture occurs when the pacemaker delivers a
stimulus (spike) but the heart muscle does not depolarize (no QRS). This leads to
bradycardia or asystole.
4. A patient is in the early stages of hypovolemic shock. Which clinical manifestation should
the nurse expect to find first?
A. Profound hypotension and cold, clammy skin.
, B. Decreased urinary output less than 10 mL/hr.
C. Increased heart rate and mild tachypnea.
D. Lethargy and loss of consciousness.
Answer: C
Conceptual Explanation: Tachycardia is one of the earliest compensatory mechanisms in
hypovolemic shock to maintain cardiac output, often accompanied by slight increases in
respiratory rate.
5. During the emergent phase of a burn injury, which electrolyte imbalance is most likely to
occur due to cellular destruction?
A. Hyperkalemia
B. Hypernatremia
C. Hypokalemia
D. Hypocalcemia
Answer: A
Conceptual Explanation: Massive cellular damage during the emergent phase of burns
causes potassium to leak out of the cells into the extracellular fluid, resulting in
hyperkalemia.
