NUR 504 EXAM 1 TESTBANK 2025
QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS
A nurse assesses a client's electrocardiograph tracing and observes that not all
QRS complexes are preceded by a P wave. How would the nurse interpret this
observation?
a. The client has hyperkalemia causing irregular QRS complexes.
b. Ventricular tachycardia is overriding the normal atrial rhythm.
c. The client's chest leads are not making sufficient contact with the skin.
d. Ventricular and atrial depolarizations are initiated from different sites. -
ANSWERS ANS: D
Normal rhythm shows one P wave preceding each QRS complex, indicating that all
depolarization is initiated at the sinoatrial node. QRS complexes without a P wave
indicate a
different source of initiation of depolarization. This finding on an
electrocardiograph tracing is
not an indication of hyperkalemia, ventricular tachycardia, or disconnection of
leads.
A nurse cares for a client who has a heart rate averaging 56 beats/min with no
adverse symptoms. Which activity modification would the nurse suggest to avoid
further slowing of the heart rate?
a. "Make certain that your bath water is warm."
b. "Avoid straining while having a bowel movement."
c. "Limit your intake of caffeinated drinks to one a day."
,d. "Avoid strenuous exercise such as running." - ANSWERS ANS: B
Bearing down strenuously during a bowel movement is one type of Valsalva
maneuver, which
stimulates the vagus nerve and results in slowing of the heart rate. Such a
response is not
desirable in a person who has bradycardia. The other instructions are not
appropriate for this
condition.
A nurse is assessing clients on a medical-surgical unit. Which client would the
nurse identify
as being at greatest risk for atrial fibrillation?
a. A 45-year-old who takes an aspirin daily.
b. A 50-year-old who is post coronary artery bypass graft surgery.
c. A 78-year-old who had a carotid endarterectomy.
d. An 80-year-old with chronic obstructive pulmonary disease. - ANSWERS
ANS: B
Atrial fibrillation occurs commonly in clients with cardiac disease. Other risk
factors include
hypertension (HTN), previous ischemic stroke, transient ischemic attack (TIA) or
other
thromboembolic event, diabetes mellitus, heart failure, obesity, hyperthyroidism,
chronic
kidney disease, excessive alcohol use, and mitral valve disease. The other
conditions do not
place these clients at higher risk for atrial fibrillation.
,A nurse assesses a client with atrial fibrillation. Which manifestation would alert
the nurse to the possibility of a serious complication from this condition?
a. Sinus tachycardia
b. Speech alterations
c. Fatigue
d. Dyspnea with activity - ANSWERS ANS: B
Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic
events
includes changes in mentation, speech, sensory function, and motor function.
Clients with
atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a
nonspecific
complaint. Clients with atrial fibrillation often have dyspnea as a result of the
decreased
cardiac output caused by the rhythm disturbance.
A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which
medication would the nurse expect to find on this client's medication
administration record to prevent a common complication of this condition?
a. Sotalol
b. Warfarin
c. Atropine
d. Lidocaine - ANSWERS ANS: B
Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for
emboli are
treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol,
atropine, and
, lidocaine are not appropriate for preventing this complication.
A nurse administers prescribed adenosine to a client. Which response would the
nurse assess for as the expected therapeutic response?
a. Decreased intraocular pressure
b. Increased heart rate
c. Short period of asystole
d. Hypertensive crisis - ANSWERS ANS: C
Clients usually respond to adenosine with a short period of asystole, bradycardia
with long
pauses, nausea, or vomiting. Adenosine has no impact on intraocular pressure nor
does it
cause increased heart rate or hypertensive crisis.
A telemetry nurse assesses a client who has a heart rate of 35 beats/min on the
cardiac monitor. Which assessment would the nurse complete next?
a. Pulmonary auscultation
b. Pulse strength and amplitude
c. Level of consciousness
d. Mobility and gait stability - ANSWERS ANS: C
A heart rate of 40 beats/min or less could have hemodynamic consequences. The
client is at
risk for inadequate cerebral perfusion. The nurse would assess for level of
consciousness,
dizziness, confusion, syncope, chest pain, shortness of breath. Although the other
assessments
QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS
A nurse assesses a client's electrocardiograph tracing and observes that not all
QRS complexes are preceded by a P wave. How would the nurse interpret this
observation?
a. The client has hyperkalemia causing irregular QRS complexes.
b. Ventricular tachycardia is overriding the normal atrial rhythm.
c. The client's chest leads are not making sufficient contact with the skin.
d. Ventricular and atrial depolarizations are initiated from different sites. -
ANSWERS ANS: D
Normal rhythm shows one P wave preceding each QRS complex, indicating that all
depolarization is initiated at the sinoatrial node. QRS complexes without a P wave
indicate a
different source of initiation of depolarization. This finding on an
electrocardiograph tracing is
not an indication of hyperkalemia, ventricular tachycardia, or disconnection of
leads.
A nurse cares for a client who has a heart rate averaging 56 beats/min with no
adverse symptoms. Which activity modification would the nurse suggest to avoid
further slowing of the heart rate?
a. "Make certain that your bath water is warm."
b. "Avoid straining while having a bowel movement."
c. "Limit your intake of caffeinated drinks to one a day."
,d. "Avoid strenuous exercise such as running." - ANSWERS ANS: B
Bearing down strenuously during a bowel movement is one type of Valsalva
maneuver, which
stimulates the vagus nerve and results in slowing of the heart rate. Such a
response is not
desirable in a person who has bradycardia. The other instructions are not
appropriate for this
condition.
A nurse is assessing clients on a medical-surgical unit. Which client would the
nurse identify
as being at greatest risk for atrial fibrillation?
a. A 45-year-old who takes an aspirin daily.
b. A 50-year-old who is post coronary artery bypass graft surgery.
c. A 78-year-old who had a carotid endarterectomy.
d. An 80-year-old with chronic obstructive pulmonary disease. - ANSWERS
ANS: B
Atrial fibrillation occurs commonly in clients with cardiac disease. Other risk
factors include
hypertension (HTN), previous ischemic stroke, transient ischemic attack (TIA) or
other
thromboembolic event, diabetes mellitus, heart failure, obesity, hyperthyroidism,
chronic
kidney disease, excessive alcohol use, and mitral valve disease. The other
conditions do not
place these clients at higher risk for atrial fibrillation.
,A nurse assesses a client with atrial fibrillation. Which manifestation would alert
the nurse to the possibility of a serious complication from this condition?
a. Sinus tachycardia
b. Speech alterations
c. Fatigue
d. Dyspnea with activity - ANSWERS ANS: B
Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic
events
includes changes in mentation, speech, sensory function, and motor function.
Clients with
atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a
nonspecific
complaint. Clients with atrial fibrillation often have dyspnea as a result of the
decreased
cardiac output caused by the rhythm disturbance.
A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which
medication would the nurse expect to find on this client's medication
administration record to prevent a common complication of this condition?
a. Sotalol
b. Warfarin
c. Atropine
d. Lidocaine - ANSWERS ANS: B
Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for
emboli are
treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol,
atropine, and
, lidocaine are not appropriate for preventing this complication.
A nurse administers prescribed adenosine to a client. Which response would the
nurse assess for as the expected therapeutic response?
a. Decreased intraocular pressure
b. Increased heart rate
c. Short period of asystole
d. Hypertensive crisis - ANSWERS ANS: C
Clients usually respond to adenosine with a short period of asystole, bradycardia
with long
pauses, nausea, or vomiting. Adenosine has no impact on intraocular pressure nor
does it
cause increased heart rate or hypertensive crisis.
A telemetry nurse assesses a client who has a heart rate of 35 beats/min on the
cardiac monitor. Which assessment would the nurse complete next?
a. Pulmonary auscultation
b. Pulse strength and amplitude
c. Level of consciousness
d. Mobility and gait stability - ANSWERS ANS: C
A heart rate of 40 beats/min or less could have hemodynamic consequences. The
client is at
risk for inadequate cerebral perfusion. The nurse would assess for level of
consciousness,
dizziness, confusion, syncope, chest pain, shortness of breath. Although the other
assessments
