NCLEX MED SURG ACTUAL TEST EXAM 1 NEWEST
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The nurse notices ventricular tachycardia on the heart monitor.
The nurse's first action should be to:
Determine patient responsiveness and presence of a pulse.
Determine whether the patient has a pulse. If no pulse is
present, provide emergent basic and advanced life-support
interventions, including defibrillation. If a pulse is present and
the blood pressure is stable, the patient can be treated with
intravenous amiodarone or lidocaine. Cardioversion is used as
an emergency measure in patients who become
hemodynamically unstable but continue to have a pulse. It may
also be used in nonemergency situations, such as when a
patient has asymptomatic VT.
,The patient has a temporary transvenous, demand-type
ventricular pacemaker. The rate on the pacemaker is set at 60
beats/min. Which of the following situations would be of
concern?
A pacemaker spike is seen on the T wave of the preceding beat.
Failure to sense manifests as pacer spikes that fall earlier than
the programmed rate. This can cause an artificial R-on-T
phenomenon similar to when a PVC occurs during the T wave,
and ventricular tachycardia may occur.
,The patient is complaining of midsternal chest discomfort and
nausea. The nurse calls for a 12-lead ECG and notices that the ST
segment is newly elevated in two related leads. The nurse
should:
Call the provider because the ST segment may indicate
myocardial injury.
A displacement in the ST segment can indicate myocardial
ischemia or injury. If ST displacement is noted and is a new finding,
a 12-lead ECG is performed and the provider notified. The patient
is assessed for signs and symptoms of myocardial ischemia.
, The nurse is interpreting the rhythm strip of a patient and
measures the QRS complex as being three small boxes in width.
The nurse interprets this width as:
0.12 seconds.
ECG paper contains a standardized grid in which the horizontal
axis measures time and the vertical axis measures voltage or
amplitude. Larger boxes are circumscribed by darker lines and
the smaller boxes by lighter lines. The larger boxes contain 5
smaller boxes on the horizontal line and 5 on the vertical line
for a total of 25 per large box. Horizontally, the smaller boxes
denote 0.04 seconds each or 40 milliseconds; the larger box
contains five smaller boxes and thus equals
0.20 seconds or 200 milliseconds. Along the uppermost aspect
of the ECG paper are vertical hash marks that occur every 15
large boxes. The area between these marks equals 3 seconds.
The patient is admitted with a heart rate of 144 beats/min and a
blood pressure of 88/42 mm Hg. The patient complains of
generalized weakness and fatigue. He states, "Just let me sleep."
The nurse determines that the presence of the patient's
symptoms is due to:
Decreased cardiac output.
The fast heart rhythm may cause a decrease in cardiac output
because of the shorter filling time for the ventricles. Vulnerable
populations are those with ischemic heart disease who are
VERSION 1 WITH COMPLETE QUESTIONS AND
CORRECT DETAILED ANSWERS||VERIFIED 100%
(RATIONALES) ALREADY GRADED A+ (Verified
Answers) Already Graded A+ | Guaranteed
Success!! | Newest Exam | Just Released
The nurse notices ventricular tachycardia on the heart monitor.
The nurse's first action should be to:
Determine patient responsiveness and presence of a pulse.
Determine whether the patient has a pulse. If no pulse is
present, provide emergent basic and advanced life-support
interventions, including defibrillation. If a pulse is present and
the blood pressure is stable, the patient can be treated with
intravenous amiodarone or lidocaine. Cardioversion is used as
an emergency measure in patients who become
hemodynamically unstable but continue to have a pulse. It may
also be used in nonemergency situations, such as when a
patient has asymptomatic VT.
,The patient has a temporary transvenous, demand-type
ventricular pacemaker. The rate on the pacemaker is set at 60
beats/min. Which of the following situations would be of
concern?
A pacemaker spike is seen on the T wave of the preceding beat.
Failure to sense manifests as pacer spikes that fall earlier than
the programmed rate. This can cause an artificial R-on-T
phenomenon similar to when a PVC occurs during the T wave,
and ventricular tachycardia may occur.
,The patient is complaining of midsternal chest discomfort and
nausea. The nurse calls for a 12-lead ECG and notices that the ST
segment is newly elevated in two related leads. The nurse
should:
Call the provider because the ST segment may indicate
myocardial injury.
A displacement in the ST segment can indicate myocardial
ischemia or injury. If ST displacement is noted and is a new finding,
a 12-lead ECG is performed and the provider notified. The patient
is assessed for signs and symptoms of myocardial ischemia.
, The nurse is interpreting the rhythm strip of a patient and
measures the QRS complex as being three small boxes in width.
The nurse interprets this width as:
0.12 seconds.
ECG paper contains a standardized grid in which the horizontal
axis measures time and the vertical axis measures voltage or
amplitude. Larger boxes are circumscribed by darker lines and
the smaller boxes by lighter lines. The larger boxes contain 5
smaller boxes on the horizontal line and 5 on the vertical line
for a total of 25 per large box. Horizontally, the smaller boxes
denote 0.04 seconds each or 40 milliseconds; the larger box
contains five smaller boxes and thus equals
0.20 seconds or 200 milliseconds. Along the uppermost aspect
of the ECG paper are vertical hash marks that occur every 15
large boxes. The area between these marks equals 3 seconds.
The patient is admitted with a heart rate of 144 beats/min and a
blood pressure of 88/42 mm Hg. The patient complains of
generalized weakness and fatigue. He states, "Just let me sleep."
The nurse determines that the presence of the patient's
symptoms is due to:
Decreased cardiac output.
The fast heart rhythm may cause a decrease in cardiac output
because of the shorter filling time for the ventricles. Vulnerable
populations are those with ischemic heart disease who are
