NUR 265
Nur265 Exam 1 Questions with Correct Answers
2025
A nurse assesses a client's electrocardiograph tracing and observes that not all QRS
complexes are preceded by a P wave. How should 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. -Correct Answer
✔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 is assessing clients on a medical-surgical unit. Which client should 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 -Correct Answer ✔ANS: B
Atrial fibrillation occurs commonly in clients with cardiac disease and is a common
occurrence after coronary artery bypass graft surgery. The other conditions do not place
these clients at higher risk for atrial fibrillation.
A nurse assesses a client with atrial fibrillation. Which manifestation should 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 -Correct Answer ✔ANS: B
NUR 265
,NUR 265
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 should the nurse expect to find on this client's medication administration
record to prevent a common complication of this condition?
a.
Sotalol (Betapace)
b.
Warfarin (Coumadin)
c.
Atropine (Sal-Tropine)
d.
Lidocaine (Xylocaine) -Correct Answer ✔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 this complication.
A nurse cares for a client with an intravenous temporary pacemaker for bradycardia.
The nurse observes the presence of a pacing spike but no QRS complex on the client's
electrocardiogram. Which action should the nurse take next?
a.
Administer intravenous diltiazem (Cardizem).
b.
Assess vital signs and level of consciousness.
c.
Administer sublingual nitroglycerin.
d.
Assess capillary refill and temperature. -Correct Answer ✔ANS: B
In temporary pacing, the wires are threaded onto the epicardial surface of the heart and
exit through the chest wall. The pacemaker spike should be followed immediately by a
QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of
capture. If there is no capture, then there is no ventricular depolarization and
contraction. The nurse should assess for cardiac output via vital signs and level of
consciousness. The other interventions would not determine if the client is tolerating the
loss of capture.
A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority
intervention should the nurse perform prior to defibrillating this client?
a.
Make sure the defibrillator is set to the synchronous mode.
b.
Administer 1 mg of intravenous epinephrine.
NUR 265
, NUR 265
c.
Test the equipment by delivering a smaller shock at 100 joules.
d.
Ensure that everyone is clear of contact with the client and the bed. -Correct Answer
✔ANS: D
To avoid injury, the rescuer commands that all personnel clear contact with the client or
the bed and ensures their compliance before delivery of the shock. A precordial thump
can be delivered when no defibrillator is available. Defibrillation is done in asynchronous
mode. Equipment should not be tested before a client is defibrillated because this is an
emergency procedure; equipment should be checked on a routine basis. Epinephrine
should be administered after defibrillation.
After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse
assesses the client's understanding. Which statement by the client indicates a correct
understanding of the teaching?
a.
"I should wear a snug-fitting shirt over the ICD."
b.
"I will avoid sources of strong electromagnetic fields."
c.
"I should participate in a strenuous exercise program."
d.
"Now I can discontinue my antidysrhythmic medication." -Correct Answer ✔ANS: B
The client being discharged with an ICD is instructed to avoid strong sources of
electromagnetic fields. Clients should avoid tight clothing, which could cause irritation
over the ICD generator. The client should be encouraged to exercise but should not
engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff
point because the ICD can discharge inappropriately. The client should continue all
prescribed medications.
A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation.
Which action should the nurse take prior to the initiation of cardioversion?
a.
Administer intravenous adenosine.
b.
Turn off oxygen therapy.
c.
Ensure a tongue blade is available.
d.
Position the client on the left side. -Correct Answer ✔ANS: B
For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent
fire. The other interventions are not appropriate for a cardioversion. The client should be
placed in a supine position.
A nurse assesses a client with tachycardia. Which clinical manifestation requires
immediate intervention by the nurse?
NUR 265
Nur265 Exam 1 Questions with Correct Answers
2025
A nurse assesses a client's electrocardiograph tracing and observes that not all QRS
complexes are preceded by a P wave. How should 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. -Correct Answer
✔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 is assessing clients on a medical-surgical unit. Which client should 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 -Correct Answer ✔ANS: B
Atrial fibrillation occurs commonly in clients with cardiac disease and is a common
occurrence after coronary artery bypass graft surgery. The other conditions do not place
these clients at higher risk for atrial fibrillation.
A nurse assesses a client with atrial fibrillation. Which manifestation should 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 -Correct Answer ✔ANS: B
NUR 265
,NUR 265
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 should the nurse expect to find on this client's medication administration
record to prevent a common complication of this condition?
a.
Sotalol (Betapace)
b.
Warfarin (Coumadin)
c.
Atropine (Sal-Tropine)
d.
Lidocaine (Xylocaine) -Correct Answer ✔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 this complication.
A nurse cares for a client with an intravenous temporary pacemaker for bradycardia.
The nurse observes the presence of a pacing spike but no QRS complex on the client's
electrocardiogram. Which action should the nurse take next?
a.
Administer intravenous diltiazem (Cardizem).
b.
Assess vital signs and level of consciousness.
c.
Administer sublingual nitroglycerin.
d.
Assess capillary refill and temperature. -Correct Answer ✔ANS: B
In temporary pacing, the wires are threaded onto the epicardial surface of the heart and
exit through the chest wall. The pacemaker spike should be followed immediately by a
QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of
capture. If there is no capture, then there is no ventricular depolarization and
contraction. The nurse should assess for cardiac output via vital signs and level of
consciousness. The other interventions would not determine if the client is tolerating the
loss of capture.
A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority
intervention should the nurse perform prior to defibrillating this client?
a.
Make sure the defibrillator is set to the synchronous mode.
b.
Administer 1 mg of intravenous epinephrine.
NUR 265
, NUR 265
c.
Test the equipment by delivering a smaller shock at 100 joules.
d.
Ensure that everyone is clear of contact with the client and the bed. -Correct Answer
✔ANS: D
To avoid injury, the rescuer commands that all personnel clear contact with the client or
the bed and ensures their compliance before delivery of the shock. A precordial thump
can be delivered when no defibrillator is available. Defibrillation is done in asynchronous
mode. Equipment should not be tested before a client is defibrillated because this is an
emergency procedure; equipment should be checked on a routine basis. Epinephrine
should be administered after defibrillation.
After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse
assesses the client's understanding. Which statement by the client indicates a correct
understanding of the teaching?
a.
"I should wear a snug-fitting shirt over the ICD."
b.
"I will avoid sources of strong electromagnetic fields."
c.
"I should participate in a strenuous exercise program."
d.
"Now I can discontinue my antidysrhythmic medication." -Correct Answer ✔ANS: B
The client being discharged with an ICD is instructed to avoid strong sources of
electromagnetic fields. Clients should avoid tight clothing, which could cause irritation
over the ICD generator. The client should be encouraged to exercise but should not
engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff
point because the ICD can discharge inappropriately. The client should continue all
prescribed medications.
A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation.
Which action should the nurse take prior to the initiation of cardioversion?
a.
Administer intravenous adenosine.
b.
Turn off oxygen therapy.
c.
Ensure a tongue blade is available.
d.
Position the client on the left side. -Correct Answer ✔ANS: B
For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent
fire. The other interventions are not appropriate for a cardioversion. The client should be
placed in a supine position.
A nurse assesses a client with tachycardia. Which clinical manifestation requires
immediate intervention by the nurse?
NUR 265
