NSG 4100 Nclex Questions Exam 3|
100% VERIFIED
A chaotic small, irregular, disorganized cardiac pattern suddenly appears on a
client's cardiac monitor. Which is the nurse's first action?
1.Check the blood pressure.
2.Call the health care provider (HCP).
3.Check the client and the chest leads.
4.Initiate cardiopulmonary resuscitation (CPR). - ----ANS:3
Rationale:This type of pattern on the cardiac monitor indicates either
ventricular fibrillation or lead displacement. The first action of the nurse is
always to check the client and the chest leads. If the client is nonresponsive
and the leads are not the problem, CPR would be the next choice, along with
designating another person to contact the HCP.
A chest x-ray report for a client indicates the presence of a left apical
pneumothorax. The nurse would assess the status of breath sounds in that
area by placing the stethoscope in which location?
1.Just under the left clavicle
2.Midsternum, 1 inch to the left
3.Over the fifth intercostal space
4.Midsternum, 1 inch to the right - ----ANS:1
Rationale:The apex of the lung is the rounded, uppermost part of the lung.
Therefore, the nurse would place the stethoscope just under the left clavicle.
All of the other options are incorrect locations for assessing the left apex.
A client admitted to the hospital with coronary artery disease complains of
dyspnea at rest. The nurse caring for the client uses which item as the best
means to monitor respiratory status on an ongoing basis?
1.Apnea monitor
2.Oxygen flowmeter
3.Telemetry cardiac monitor
4.Oxygen saturation monitor - ----ANS:4
Rationale:Dyspnea in the cardiac client often is accompanied by hypoxemia.
Hypoxemia can be detected by an oxygen saturation monitor, especially if it is
,used continuously. An apnea monitor detects apnea episodes, such as when
the client has stopped breathing briefly. An oxygen flowmeter is part of the
setup for delivering oxygen therapy. Cardiac monitors detect dysrhythmias.
A client being admitted to the coronary care unit from the emergency
department has a stat prescription to receive a dose of intravenous
procainamide followed by a continuous infusion. Based on this prescription,
the nurse should assess for which condition?
1.Dyspnea
2.Bradycardia
3.Hypertension
4.Ventricular ectopy - ----ANS:4
Rationale:Procainamide is an antidysrhythmic medication used to treat
ventricular dysrhythmias unresponsive to lidocaine. The other options are not
indications for giving this medication.
A client develops atrial fibrillation with a ventricular rate of 140 beats/minute
and signs of decreased cardiac output. Which medication should the nurse
anticipate administering first?
1.Warfarin
2.Lidocaine
3.Metoprolol
4.Atropine sulfate - ----ANS:3
Rationale:Beta blockers such as metoprolol slow conduction of impulses
through the atrioventricular node and decrease the heart rate. In rapid atrial
fibrillation, the goal first is to slow the ventricular rate and improve the cardiac
output and then attempt to restore normal sinus rhythm. Atropine sulfate will
further increase the heart rate and will further decrease the cardiac output.
Although warfarin is administered to clients with atrial fibrillation to prevent
clots from forming in the atria, it will have no effect in decreasing the
ventricular rate or restoring normal sinus rhythm. Lidocaine is useful only in
suppressing ventricular dysrhythmias.
A client has been treated for pleural effusion with a thoracentesis. The nurse
determines that this procedure has been effective if the nurse notes which
assessment finding?
1.Absence of dyspnea
,2.Increased severity of cough
3.Dull percussion notes over lung tissue
4.Decreased tactile fremitus over lung tissue - ----ANS:1
Rationale:The client who has undergone thoracentesis should experience
relief of the signs and symptoms experienced before the procedure. Typical
signs and symptoms of pleural effusion include dry, nonproductive cough;
dyspnea (usually on exertion); decreased or absent tactile fremitus; and dull or
flat percussion notes on respiratory assessment.
A client has developed uncontrolled atrial fibrillation with a ventricular rate of
150 beats/min. What manifestation should the nurse observe for when
performing the client's focused assessment?
1.Flat neck veins
2.Nausea and vomiting
3.Hypotension and dizziness
4.Clubbed fingertips and headache - ----ANS:3
Rationale:The client with uncontrolled atrial fibrillation with a ventricular rate
greater than 100 beats/min is at risk for low cardiac output due to loss of atrial
kick. The nurse assesses the client for palpitations, chest pain or discomfort,
hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness
of breath, and distended neck veins.
A client has experienced pulmonary embolism. The nurse should assess for
which symptom, which is most commonly reported?
1. Hot, flushed feeling
2. Sudden chills and fever
3. Chest pain that occurs suddenly
4. Dyspnea when deep breaths are taken - ----ANS:3
The most common initial symptom in pulmonary embolism is chest pain that is
sudden in onset. The next most commonly reported symptom is dyspnea,
which is accompanied by an increased respiratory rate. Other typical
symptoms of pulmonary embolism include apprehension and restlessness,
tachycardia, cough, and cyanosis.
A client has experienced pulmonary embolism. The nurse should assess for
which symptom, which is most commonly reported?
, 1.Hot, flushed feeling
2.Sudden chills and fever
3.Chest pain that occurs suddenly
4.Dyspnea when deep breaths are taken - ----ANS:3
Rationale:The most common initial symptom in pulmonary embolism is chest
pain that is sudden in onset. The next most commonly reported symptom is
dyspnea, which is accompanied by an increased respiratory rate. Other typical
symptoms of pulmonary embolism include apprehension and restlessness,
tachycardia, cough, and cyanosis.
A client has frequent bursts of ventricular tachycardia on the cardiac monitor.
What should the nurse be most concerned about with this dysrhythmia?
1.It can develop into ventricular fibrillation at any time.
2.It is almost impossible to convert to a normal rhythm.
3.It is uncomfortable for the client, giving a sense of impending doom.
4.It produces a high cardiac output that quickly leads to cerebral and
myocardial ischemia. - ----ANS:1
Rationale:Ventricular tachycardia is a life-threatening dysrhythmia that results
from an irritable ectopic focus that takes over as the pacemaker for the heart.
The low cardiac output that results can lead quickly to cerebral and myocardial
ischemia. Clients frequently experience a feeling of impending doom.
Ventricular tachycardia is treated with antidysrhythmic medications,
cardioversion (if the client is awake), or defibrillation (loss of consciousness).
Ventricular tachycardia can deteriorate into ventricular fibrillation at any time.
A client has frequent runs of ventricular tachycardia. The health care provider
has prescribed flecainide. What is the best nursing action related to the effects
of this medication while the client is hospitalized?
1.Monitor the client's urinary output.
2.Assess the client for neurological changes.
3.Keep the call bell within the client's reach.
4.Monitor vital signs and cardiac rhythm frequently. - ----ANS:4
Rationale:Flecainide is an antidysrhythmic medication that slows conduction
and decreases excitability, conduction velocity, and automaticity. The nurse
needs to monitor the client's vital signs for changes and cardiac rhythm for the
development of a new or a worsening dysrhythmia. The remaining options are
components of standard care.
100% VERIFIED
A chaotic small, irregular, disorganized cardiac pattern suddenly appears on a
client's cardiac monitor. Which is the nurse's first action?
1.Check the blood pressure.
2.Call the health care provider (HCP).
3.Check the client and the chest leads.
4.Initiate cardiopulmonary resuscitation (CPR). - ----ANS:3
Rationale:This type of pattern on the cardiac monitor indicates either
ventricular fibrillation or lead displacement. The first action of the nurse is
always to check the client and the chest leads. If the client is nonresponsive
and the leads are not the problem, CPR would be the next choice, along with
designating another person to contact the HCP.
A chest x-ray report for a client indicates the presence of a left apical
pneumothorax. The nurse would assess the status of breath sounds in that
area by placing the stethoscope in which location?
1.Just under the left clavicle
2.Midsternum, 1 inch to the left
3.Over the fifth intercostal space
4.Midsternum, 1 inch to the right - ----ANS:1
Rationale:The apex of the lung is the rounded, uppermost part of the lung.
Therefore, the nurse would place the stethoscope just under the left clavicle.
All of the other options are incorrect locations for assessing the left apex.
A client admitted to the hospital with coronary artery disease complains of
dyspnea at rest. The nurse caring for the client uses which item as the best
means to monitor respiratory status on an ongoing basis?
1.Apnea monitor
2.Oxygen flowmeter
3.Telemetry cardiac monitor
4.Oxygen saturation monitor - ----ANS:4
Rationale:Dyspnea in the cardiac client often is accompanied by hypoxemia.
Hypoxemia can be detected by an oxygen saturation monitor, especially if it is
,used continuously. An apnea monitor detects apnea episodes, such as when
the client has stopped breathing briefly. An oxygen flowmeter is part of the
setup for delivering oxygen therapy. Cardiac monitors detect dysrhythmias.
A client being admitted to the coronary care unit from the emergency
department has a stat prescription to receive a dose of intravenous
procainamide followed by a continuous infusion. Based on this prescription,
the nurse should assess for which condition?
1.Dyspnea
2.Bradycardia
3.Hypertension
4.Ventricular ectopy - ----ANS:4
Rationale:Procainamide is an antidysrhythmic medication used to treat
ventricular dysrhythmias unresponsive to lidocaine. The other options are not
indications for giving this medication.
A client develops atrial fibrillation with a ventricular rate of 140 beats/minute
and signs of decreased cardiac output. Which medication should the nurse
anticipate administering first?
1.Warfarin
2.Lidocaine
3.Metoprolol
4.Atropine sulfate - ----ANS:3
Rationale:Beta blockers such as metoprolol slow conduction of impulses
through the atrioventricular node and decrease the heart rate. In rapid atrial
fibrillation, the goal first is to slow the ventricular rate and improve the cardiac
output and then attempt to restore normal sinus rhythm. Atropine sulfate will
further increase the heart rate and will further decrease the cardiac output.
Although warfarin is administered to clients with atrial fibrillation to prevent
clots from forming in the atria, it will have no effect in decreasing the
ventricular rate or restoring normal sinus rhythm. Lidocaine is useful only in
suppressing ventricular dysrhythmias.
A client has been treated for pleural effusion with a thoracentesis. The nurse
determines that this procedure has been effective if the nurse notes which
assessment finding?
1.Absence of dyspnea
,2.Increased severity of cough
3.Dull percussion notes over lung tissue
4.Decreased tactile fremitus over lung tissue - ----ANS:1
Rationale:The client who has undergone thoracentesis should experience
relief of the signs and symptoms experienced before the procedure. Typical
signs and symptoms of pleural effusion include dry, nonproductive cough;
dyspnea (usually on exertion); decreased or absent tactile fremitus; and dull or
flat percussion notes on respiratory assessment.
A client has developed uncontrolled atrial fibrillation with a ventricular rate of
150 beats/min. What manifestation should the nurse observe for when
performing the client's focused assessment?
1.Flat neck veins
2.Nausea and vomiting
3.Hypotension and dizziness
4.Clubbed fingertips and headache - ----ANS:3
Rationale:The client with uncontrolled atrial fibrillation with a ventricular rate
greater than 100 beats/min is at risk for low cardiac output due to loss of atrial
kick. The nurse assesses the client for palpitations, chest pain or discomfort,
hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness
of breath, and distended neck veins.
A client has experienced pulmonary embolism. The nurse should assess for
which symptom, which is most commonly reported?
1. Hot, flushed feeling
2. Sudden chills and fever
3. Chest pain that occurs suddenly
4. Dyspnea when deep breaths are taken - ----ANS:3
The most common initial symptom in pulmonary embolism is chest pain that is
sudden in onset. The next most commonly reported symptom is dyspnea,
which is accompanied by an increased respiratory rate. Other typical
symptoms of pulmonary embolism include apprehension and restlessness,
tachycardia, cough, and cyanosis.
A client has experienced pulmonary embolism. The nurse should assess for
which symptom, which is most commonly reported?
, 1.Hot, flushed feeling
2.Sudden chills and fever
3.Chest pain that occurs suddenly
4.Dyspnea when deep breaths are taken - ----ANS:3
Rationale:The most common initial symptom in pulmonary embolism is chest
pain that is sudden in onset. The next most commonly reported symptom is
dyspnea, which is accompanied by an increased respiratory rate. Other typical
symptoms of pulmonary embolism include apprehension and restlessness,
tachycardia, cough, and cyanosis.
A client has frequent bursts of ventricular tachycardia on the cardiac monitor.
What should the nurse be most concerned about with this dysrhythmia?
1.It can develop into ventricular fibrillation at any time.
2.It is almost impossible to convert to a normal rhythm.
3.It is uncomfortable for the client, giving a sense of impending doom.
4.It produces a high cardiac output that quickly leads to cerebral and
myocardial ischemia. - ----ANS:1
Rationale:Ventricular tachycardia is a life-threatening dysrhythmia that results
from an irritable ectopic focus that takes over as the pacemaker for the heart.
The low cardiac output that results can lead quickly to cerebral and myocardial
ischemia. Clients frequently experience a feeling of impending doom.
Ventricular tachycardia is treated with antidysrhythmic medications,
cardioversion (if the client is awake), or defibrillation (loss of consciousness).
Ventricular tachycardia can deteriorate into ventricular fibrillation at any time.
A client has frequent runs of ventricular tachycardia. The health care provider
has prescribed flecainide. What is the best nursing action related to the effects
of this medication while the client is hospitalized?
1.Monitor the client's urinary output.
2.Assess the client for neurological changes.
3.Keep the call bell within the client's reach.
4.Monitor vital signs and cardiac rhythm frequently. - ----ANS:4
Rationale:Flecainide is an antidysrhythmic medication that slows conduction
and decreases excitability, conduction velocity, and automaticity. The nurse
needs to monitor the client's vital signs for changes and cardiac rhythm for the
development of a new or a worsening dysrhythmia. The remaining options are
components of standard care.
