Rasmussen MDC III Final Exam Test Bank |
Advanced Multidimensional Care 3 Complete
Cardiovascular & Hematology Q&As | Verified
Solutions Bundle
,Question 1
A nurse walks into a client’s room and discovers that the client is unresponsive and has no
pulse. Which action should the nurse take first?
A. Administer oxygen via bag-valve mask.
B. Initiate CPR and hit the code blue button.
C. Deliver a shock using the automated external defibrillator (AED).
D. Check the blood glucose level.
Answer: B. Initiate CPR and hit the code blue button.
Explanation: In an unresponsive, pulseless client, the immediate priority is to activate the
emergency response system (code blue) and start cardiopulmonary resuscitation (CPR) to
maintain perfusion to vital organs. Bag-mask ventilation is performed if the client has a
pulse but is not breathing. Defibrillation occurs as soon as the AED/defibrillator arrives
and analyzes a shockable rhythm.
Question 2
The nurse is reviewing an electrocardiogram (ECG) for a client and notes an irregular
rhythm, an atrial rate of 450 beats per minute, and absent P waves. Which dysrhythmia
should the nurse document?
A. Supraventricular Tachycardia (SVT)
B. Ventricular Fibrillation (V-Fib)
,C. Atrial Fibrillation (A-Fib)
D. Second-Degree Heart Block
Answer: C. Atrial Fibrillation (A-Fib).
Explanation: Atrial fibrillation is characterized by an extremely rapid atrial impulse rate
(typically 350 to 600 times per minute), no identifiable P waves, and an irregularly
irregular ventricular response due to chaotic atrial electrical activity. SVT exhibits a
regular rhythm with a rapid rate but distinguishable characteristics, while V-Fib presents
as chaotic waves without any recognizable QRS complexes.
Question 3
A client with supraventricular tachycardia (SVT) has a heart rate of 220 beats per minute.
The client is alert and hemodynamically stable. Which non-pharmacological intervention
should the nurse coach the client to perform first?
A. Carotid sinus massage
B. Administration of intravenous Adenosine
C. Bearing down as if having a bowel movement (Valsalva maneuver)
D. Synchronized cardioversion
Answer: C. Bearing down as if having a bowel movement (Valsalva maneuver).
Explanation: For a hemodynamically stable client experiencing SVT, vagal maneuvers—
such as the Valsalva maneuver (asking the patient to bear down)—are the first-line, non-
invasive action to help slow conduction through the AV node. Adenosine is the first-line
pharmacological treatment if vagal maneuvers fail. Carotid massage is strictly performed
by a healthcare provider, not coached by the nurse. Cardioversion is reserved for unstable
clients.
Question 4
The nurse is preparing a client for a scheduled electrical cardioversion to treat unstable atrial
fibrillation. Which nursing safety priority must be implemented immediately before
delivering the shock?
A. Stop and remove the client's supplemental oxygen source.
B. Infuse a rapid bolus of 0.9% Normal Saline.
C. Position the client in a high Fowler's position.
D. Administer a dose of oral Digoxin.
, Answer: A. Stop and remove the client's supplemental oxygen source.
Explanation: To prevent fire or explosion hazards during electrical cardioversion or
defibrillation, oxygen must be turned off and moved away from the immediate bedside area
where the shock paddles or pads deliver electrical current. High Fowler's position is used
for acute respiratory distress but not during cardioversion, where the client is typically
supine.
Question 5
The nurse is completing a physical assessment on a client admitted with a history of left-
sided heart failure. Which clinical manifestation should the nurse expect to find?
A. Jugular venous distension (JVD)
B. Dependent pitting edema in the lower extremities
C. Pink, frothy sputum and dyspnea
D. Hepatomegaly and right upper quadrant pain
Answer: C. Pink, frothy sputum and dyspnea.
Explanation: Left-sided heart failure results in pulmonary congestion due to backup of
blood into the lungs. This manifests as shortness of breath (SOB), crackles, cough, and
classic pink, frothy sputum from severe pulmonary edema. JVD, pitting edema, and
hepatomegaly are systemic manifestations associated with right-sided heart failure.
Question 6
A client is admitted with right-sided heart failure secondary to chronic pulmonary disease.
Which structural diagnostic finding and common clinical intervention does the nurse
anticipate?
A. Echocardiogram showing left ventricular hypertrophy; managed with antibiotics
B. Echocardiogram showing right ventricular enlargement; managed with fluid restrictions
and diuretics
C. Electrocardiogram showing ST elevation; managed with thrombolytic therapy
D. Cardiac catheterization showing coronary artery stenosis; managed with a mechanical
valve
Answer: B. Echocardiogram showing right ventricular enlargement; managed with fluid
restrictions and diuretics.
Explanation: Right-sided heart failure leads to systemic venous congestion, weight gain,
Advanced Multidimensional Care 3 Complete
Cardiovascular & Hematology Q&As | Verified
Solutions Bundle
,Question 1
A nurse walks into a client’s room and discovers that the client is unresponsive and has no
pulse. Which action should the nurse take first?
A. Administer oxygen via bag-valve mask.
B. Initiate CPR and hit the code blue button.
C. Deliver a shock using the automated external defibrillator (AED).
D. Check the blood glucose level.
Answer: B. Initiate CPR and hit the code blue button.
Explanation: In an unresponsive, pulseless client, the immediate priority is to activate the
emergency response system (code blue) and start cardiopulmonary resuscitation (CPR) to
maintain perfusion to vital organs. Bag-mask ventilation is performed if the client has a
pulse but is not breathing. Defibrillation occurs as soon as the AED/defibrillator arrives
and analyzes a shockable rhythm.
Question 2
The nurse is reviewing an electrocardiogram (ECG) for a client and notes an irregular
rhythm, an atrial rate of 450 beats per minute, and absent P waves. Which dysrhythmia
should the nurse document?
A. Supraventricular Tachycardia (SVT)
B. Ventricular Fibrillation (V-Fib)
,C. Atrial Fibrillation (A-Fib)
D. Second-Degree Heart Block
Answer: C. Atrial Fibrillation (A-Fib).
Explanation: Atrial fibrillation is characterized by an extremely rapid atrial impulse rate
(typically 350 to 600 times per minute), no identifiable P waves, and an irregularly
irregular ventricular response due to chaotic atrial electrical activity. SVT exhibits a
regular rhythm with a rapid rate but distinguishable characteristics, while V-Fib presents
as chaotic waves without any recognizable QRS complexes.
Question 3
A client with supraventricular tachycardia (SVT) has a heart rate of 220 beats per minute.
The client is alert and hemodynamically stable. Which non-pharmacological intervention
should the nurse coach the client to perform first?
A. Carotid sinus massage
B. Administration of intravenous Adenosine
C. Bearing down as if having a bowel movement (Valsalva maneuver)
D. Synchronized cardioversion
Answer: C. Bearing down as if having a bowel movement (Valsalva maneuver).
Explanation: For a hemodynamically stable client experiencing SVT, vagal maneuvers—
such as the Valsalva maneuver (asking the patient to bear down)—are the first-line, non-
invasive action to help slow conduction through the AV node. Adenosine is the first-line
pharmacological treatment if vagal maneuvers fail. Carotid massage is strictly performed
by a healthcare provider, not coached by the nurse. Cardioversion is reserved for unstable
clients.
Question 4
The nurse is preparing a client for a scheduled electrical cardioversion to treat unstable atrial
fibrillation. Which nursing safety priority must be implemented immediately before
delivering the shock?
A. Stop and remove the client's supplemental oxygen source.
B. Infuse a rapid bolus of 0.9% Normal Saline.
C. Position the client in a high Fowler's position.
D. Administer a dose of oral Digoxin.
, Answer: A. Stop and remove the client's supplemental oxygen source.
Explanation: To prevent fire or explosion hazards during electrical cardioversion or
defibrillation, oxygen must be turned off and moved away from the immediate bedside area
where the shock paddles or pads deliver electrical current. High Fowler's position is used
for acute respiratory distress but not during cardioversion, where the client is typically
supine.
Question 5
The nurse is completing a physical assessment on a client admitted with a history of left-
sided heart failure. Which clinical manifestation should the nurse expect to find?
A. Jugular venous distension (JVD)
B. Dependent pitting edema in the lower extremities
C. Pink, frothy sputum and dyspnea
D. Hepatomegaly and right upper quadrant pain
Answer: C. Pink, frothy sputum and dyspnea.
Explanation: Left-sided heart failure results in pulmonary congestion due to backup of
blood into the lungs. This manifests as shortness of breath (SOB), crackles, cough, and
classic pink, frothy sputum from severe pulmonary edema. JVD, pitting edema, and
hepatomegaly are systemic manifestations associated with right-sided heart failure.
Question 6
A client is admitted with right-sided heart failure secondary to chronic pulmonary disease.
Which structural diagnostic finding and common clinical intervention does the nurse
anticipate?
A. Echocardiogram showing left ventricular hypertrophy; managed with antibiotics
B. Echocardiogram showing right ventricular enlargement; managed with fluid restrictions
and diuretics
C. Electrocardiogram showing ST elevation; managed with thrombolytic therapy
D. Cardiac catheterization showing coronary artery stenosis; managed with a mechanical
valve
Answer: B. Echocardiogram showing right ventricular enlargement; managed with fluid
restrictions and diuretics.
Explanation: Right-sided heart failure leads to systemic venous congestion, weight gain,
