HESI Med Surg 1
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The nurse observes ventricular B.
fibrillation on telemetry and, on Start cardiopulmonary resuscitation.
entering the client's bathroom, finds
the client unconscious on the floor. Rationale:
Which intervention should the nurse Ventricular fibrillation is a life-threatening
implement first? dysrhythmia, and CPR should be started
A. immediately (B). (A and C) are appropriate, but CPR
Administer an antidysrhythmic is the priority action. The client is dying, and (D)
medication. does not address the seriousness of this situation.
B.
Start cardiopulmonary resuscitation.
C.
Defibrillate the client at 200 J.
D.
Assess the client's pulse oximetry.
,The nurse assesses a client who has D.
been prescribed furosemide (Lasix) Presence of a U wave
for cardiac disease. Which
electrocardiographic change would Rationale:
be a concern for a client taking a A U wave (D) is a positive deflection following the T
diuretic? wave and is often present with hypokalemia (low
A. potassium level). (A, B, and C) are all signs of
Tall, spiked T waves hyperkalemia.
B.
A prolonged QT interval
C.
A widening QRS complex
D.
Presence of a U wave
A 43-year-old homeless, B.
malnourished female client with a Magnesium sulfate
history of alcoholism is transferred to
the ICU. She is placed on telemetry, Rationale:
and the rhythm strip shown is Because the client has chronic alcoholism, she is
obtained. The nurse palpates a heart likely to have hypomagnesemia. (B) is the
rate of 160 beats/min, and the client's recommended drug for torsades de pointes, which
blood pressure is 90/54 mm Hg. is a form of polymorphic ventricular tachycardia
Based on these findings, which IV (VT) usually associated with a prolonged QT
medication should the nurse interval that occurs with hypomagnesemia. (A and
administer? D) increase the QT interval, which can cause the
A. torsades to worsen. (C) is the antiarrhythmic of
Amiodarone (Cordarone) choice in most cases of drug-induced
B. monomorphic VT, not torsades.
Magnesium sulfate
C.
Lidocaine (Xylocaine)
D.
Procainamide (Pronestyl)
,When developing a discharge D.
teaching plan for a client after the The client states that changes in the pulse and
insertion of a permanent pacemaker, feelings of dizziness are significant changes.
the nurse writes a goal of "The client
will verbalize symptoms of Rationale:
pacemaker failure." Which behavior Changes in pulse rate and/or rhythm may indicate
indicates that the goal has been pacer failure. Feelings of dizziness may be caused
met? by a decreased heart rate, leading to decreased
A. cardiac output (D). The rate of a pacemaker is not
The client demonstrates the changed by a client, although the client may be
procedures to change the rate of the familiar with this procedure as explained by his
pacemaker using a magnet. health care provider (A). (B) is an important step in
B. preparing the client for discharge but does not
The client carries a card in his wallet demonstrate knowledge of the symptoms of pacer
stating the type and serial number of failure. (C) indicates symptoms of possible
the pacemaker. incisional infection or irritation but do not indicate
C. pacer failure.
The client tells the nurse that it is
important to report redness and
tenderness at the insertion site.
D.
The client states that changes in the
pulse and feelings of dizziness are
significant changes.
, The nurse teaches a client with type B
2 diabetes nutritional strategies to Salmon
decrease obesity. Which food item(s)
chosen by the client indicates C
understanding of the teaching? Broccoli
(Select all that apply.)
A. E.
White bread Banana
B.
Salmon Rationale:
C. (B, C, and E) provide fresh fruits, lean meats and
Broccoli fish, vegetables, whole grains, and low-fat dairy
D. products. All are recommended by the American
Whole milk Diabetes Association (ADA) and are a part of the
E. My Plate guidelines recommended by the U.S.
Banana Department of Agriculture (USDA). Whole milk (D)
is high in fat and is not recommended by ADA.
White bread is milled, a process that removes the
essential nutrients. It should be avoided for weight
loss and is a poor choice for the client with
diabetes (A).
Leave the first rating
Save
Terms in this set (57) Hide definitions
The nurse observes ventricular B.
fibrillation on telemetry and, on Start cardiopulmonary resuscitation.
entering the client's bathroom, finds
the client unconscious on the floor. Rationale:
Which intervention should the nurse Ventricular fibrillation is a life-threatening
implement first? dysrhythmia, and CPR should be started
A. immediately (B). (A and C) are appropriate, but CPR
Administer an antidysrhythmic is the priority action. The client is dying, and (D)
medication. does not address the seriousness of this situation.
B.
Start cardiopulmonary resuscitation.
C.
Defibrillate the client at 200 J.
D.
Assess the client's pulse oximetry.
,The nurse assesses a client who has D.
been prescribed furosemide (Lasix) Presence of a U wave
for cardiac disease. Which
electrocardiographic change would Rationale:
be a concern for a client taking a A U wave (D) is a positive deflection following the T
diuretic? wave and is often present with hypokalemia (low
A. potassium level). (A, B, and C) are all signs of
Tall, spiked T waves hyperkalemia.
B.
A prolonged QT interval
C.
A widening QRS complex
D.
Presence of a U wave
A 43-year-old homeless, B.
malnourished female client with a Magnesium sulfate
history of alcoholism is transferred to
the ICU. She is placed on telemetry, Rationale:
and the rhythm strip shown is Because the client has chronic alcoholism, she is
obtained. The nurse palpates a heart likely to have hypomagnesemia. (B) is the
rate of 160 beats/min, and the client's recommended drug for torsades de pointes, which
blood pressure is 90/54 mm Hg. is a form of polymorphic ventricular tachycardia
Based on these findings, which IV (VT) usually associated with a prolonged QT
medication should the nurse interval that occurs with hypomagnesemia. (A and
administer? D) increase the QT interval, which can cause the
A. torsades to worsen. (C) is the antiarrhythmic of
Amiodarone (Cordarone) choice in most cases of drug-induced
B. monomorphic VT, not torsades.
Magnesium sulfate
C.
Lidocaine (Xylocaine)
D.
Procainamide (Pronestyl)
,When developing a discharge D.
teaching plan for a client after the The client states that changes in the pulse and
insertion of a permanent pacemaker, feelings of dizziness are significant changes.
the nurse writes a goal of "The client
will verbalize symptoms of Rationale:
pacemaker failure." Which behavior Changes in pulse rate and/or rhythm may indicate
indicates that the goal has been pacer failure. Feelings of dizziness may be caused
met? by a decreased heart rate, leading to decreased
A. cardiac output (D). The rate of a pacemaker is not
The client demonstrates the changed by a client, although the client may be
procedures to change the rate of the familiar with this procedure as explained by his
pacemaker using a magnet. health care provider (A). (B) is an important step in
B. preparing the client for discharge but does not
The client carries a card in his wallet demonstrate knowledge of the symptoms of pacer
stating the type and serial number of failure. (C) indicates symptoms of possible
the pacemaker. incisional infection or irritation but do not indicate
C. pacer failure.
The client tells the nurse that it is
important to report redness and
tenderness at the insertion site.
D.
The client states that changes in the
pulse and feelings of dizziness are
significant changes.
, The nurse teaches a client with type B
2 diabetes nutritional strategies to Salmon
decrease obesity. Which food item(s)
chosen by the client indicates C
understanding of the teaching? Broccoli
(Select all that apply.)
A. E.
White bread Banana
B.
Salmon Rationale:
C. (B, C, and E) provide fresh fruits, lean meats and
Broccoli fish, vegetables, whole grains, and low-fat dairy
D. products. All are recommended by the American
Whole milk Diabetes Association (ADA) and are a part of the
E. My Plate guidelines recommended by the U.S.
Banana Department of Agriculture (USDA). Whole milk (D)
is high in fat and is not recommended by ADA.
White bread is milled, a process that removes the
essential nutrients. It should be avoided for weight
loss and is a poor choice for the client with
diabetes (A).
