PNR 408 TEST #2 UPDATED ACTUAL QUESTIONS AND CORRECT ANSWERS

PNR 408 TEST #2 UPDATED ACTUAL QUESTIONS AND
CORRECT ANSWERS

Question:
1. The nurse is caring for a client admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol
misuse who has a serum amylase level of 280 units/L and a serum lipase level of 310 units/L. To which of
the following diagnoses does the nurse attribute these findings?
Answer:
Alcohol Misuse

Question:
2. The health care provider prescribes lactulose for a client with hepatic encephalopathy. Which of the
following assessment parameters should the nurse monitor for effectiveness of this medication?
Answer:
Decreased ammonia levels

Question:
3. The family of a client newly diagnosed with hepatitis A asks the nurse what they can do to prevent
becoming ill themselves. Which of the following responses by the nurse is most appropriate?
Answer:
"An injection of immune globulin will need to be given to prevent or minimize the effects from this
exposure."

Question:
4. The nurse is planning care for a client with cirrhosis. Which of the following nursing diagnoses is
priority?
Answer:
Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume

Question:
5. Normal serum bilirubin levels lie between:
Answer:
5.1 and 17 mcmol/L

Question:
6. Which if the following is a possible cause of loss of capture in a pacemaker?
Answer:
Battery depletion

Question:
7. A patient in the coronary care unit develops ventricular fibrillation. The first action of the nurse should
take is to:
Answer:
Initiate cardiopulmonary resuscitation

,Question:
8. A patient has a diagnosis of acute myocardial infraction, and his cardiac rhythm is sinus bradycardia
with six to eight premature ventricular contractions (PVCs) per minute. The pattern that the nurse
recognize as the most characteristic of PVC is:
Answer:
A wide, distorted QRS complex

Question:
9. A patient's cardiac rhythm is sinus bradycardia with a heart rate of 34 beats/minute. If the bradycardia is
symptomatic, the nurse would expect the patient to exhibit:
Answer:
Shortness of breath

Question:
10. When computing a heart rate from the ECG tracing, the nurse counts 15 of the small blocks between
the R waves of a client whose rhythm is regular. From these data, which of the following rates should the
nurse calculate as the client's heart rate?
Answer:
100 beats/minute

Question:
11. Which of the following statements best describes the electrical activity of the heart represented by
measuring the PR interval on the ECG?
Answer:
The length of time for the electrical impulse to travel from the SA node to the Purkinje fibres

Question:
12. The nurse obtains a 6-second rhythm strip and charts the following analysis: atrial rate 70, regular;
ventricular rate 40, regular; QRS 0.04 second; no relationship between P waves and QRS complexes; atria
and ventricles beating independently of each other. Which of the following descriptions is a correct
interpretation of this rhythm strip?
Answer:
Third-degree heart block

Question:
13. The nurse is caring for a client who is 24 hours postpacemaker insertion. Which of the following
nursing interventions is most appropriate at this time?
Answer:
Assessing the incision for any redness, swelling, or discharge

Question:
14. The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P
waves. Instead there are fine, wavy lines between the QRS complexes. The QRS complexes measure 0.08
second (narrow), but they occur irregularly with a rate of 120 beats/minute. Which of the following
rhythms should the nurse identify from this data?
Answer:
Atrial fibrillation

, Question:
15. A client has sought care following a syncopal episode of unknown etiology. Which of the following
nursing actions should the nurse prioritize in the client's subsequent diagnostic workup?
Answer:
Preparing to assist with a head-upright tilt-table test

Question:
16. For which of the following dysrhythmias is defibrillation primarily indicated?
Answer:
Ventricular fibrillation

Question:
17. The nurse is caring for a client in asystole. Which of the following drug treatments is the client most
likely to receive?
Answer:
Atropine and epinephrine

Question:
18. The nurse is caring for a client with ventricular tachycardia. Which of the following ECG
characteristics is consistent with a diagnosis of ventricular tachycardia (VT)?
Answer:
Rate 200 beats/minute; P wave not visible

Question:
19. The community health nurse is planning health-promotion teaching targeted at preventing coronary
artery disease (CAD). Which of the following individuals would the nurse select as the highest priority for
this intervention?
Answer:
White male

Question:
20. For which of the following antilipemic medications would the nurse question an order in a client with
cirrhosis of the liver?
Answer:
Atorvastatin

Question:
21. The nurse is planning emergent care for a client with a suspected myocardial infarction (MI). Which of
the following actions should the nurse include in the emergency care for this client?
Answer:
Oxygen, nitroglycerin, acetylsalisylic acid, and morphine sulphate

Question:
22. The nurse is caring for a postoperative client who underwent coronary artery bypass graft (CABG)
surgery. Which of the following common complication should the nurse monitor in the client?
Answer:
Atrial dysrhythmias