ECC- FINAL EXAM QUESTIONS & ANSWERS
What would you do if this was occurring with a transcutaneous pacemaker? - Answer -
Adjust the sensitivty
A pt with ST-elevation myocardial infarction (STEMI) suddenly develops a 3rd degree
heart block with a rate of 38 bpm. BP is 62/38. Skin is cool, moist, and pale. After
ensuring a patent airway and adequate ventilation , the nurses priority intervention
would be the: - Answer -Anticipation of transcutaneous pacemaker
A pt in hypertensive crisis has an intial BP of 220/120. An hour after initiating treatment,
the pts blood pressure is 170/108. What should the nurse report during interdisciplinary
rounds? - Answer -Blood pressure decreased an ideal amount
A newly admitted develops positive JVD, HR 168, BP 84/78, and muffled heart tones.
What is your assessment of the situation - Answer -Cardiac tamponade
Which of the following represents right heart failure? - Answer -Positive jugular vein
distention, peripheral edema, S3 heart sound
A pt has heart failure. What education will you provide upon discharge ? - Answer -
1500 mg/day sodium diet
Daily weights
Which intervention should be performed first for the above rhythm ? - Answer -
Defibrillation
Which of the following are symptoms of aortic stenosis? - Answer -Pulmonary edema
The ECG monitor indicates a patient is in ventricular tachycardia. The patient is awake,
alert, anxious, and complains of chest pain. Vitals: HR 190, BP 80/40, Respirations 24,
O2 sat 92% on 2 liters nasal cannula. Which of the following interventions should the
nurse anticipate? - Answer -Synchronized cardioversion
Which 2 of the following would be indicative of dilated cardiomyopathy ? - Answer -
Bilateral lower extremity edema
15% ejection fraction (EF)
Patients on heart rate controlling medications (e.g. calcium channel blockers , beta
blockers, amiodarone) - Answer -May not compensate well for shock
Rhabdomyolysis has just been diagnosed on your pt. Which of the following
complications can develop due to this diagnosis? - Answer -Renal failure
, A pt is admitted with the diagnosis of sepsis. Currently they are anxious with vitals: HR
125, BP 80/55, RR 24,O2 sat 94% on 6 liters via nasal cannula (just increased last
hour). Which findings indicate organ dysfunction? - Answer -HR 125
Sepsis induced hypotension
Increased need for supplemental oxygen
After having an appropriate response to administration of IV naloxone (narcan), an
overdose patient has again become unresponsive. This status change is most likely
caused by: - Answer -Longer half life of the offending substance over that of naloxone
(narcane)
The nurse suspects a pt is developing sepsis from the following vitals signs: T:101.3F,
P-107. R-24, BP-88/30, O2 sat 94%. After notifying the physician, which of the following
actions receives the HIGHEST priority? - Answer -Obtain blood cultures , administering
antibiotic therapy, and a fluid bolus (30ml/kg)
An 80kg, hemodynamicaly stable, patient with pyelonephritis , has a urine output of 0.3
ml/kg/hr for the last 4 hours and the above results. What do these findings indicate? -
Answer -Systemic inflammatory response syndrome
What occurs at the cellular level to cause the lactic acid to increase? - Answer -
Anaerobic metabolism
A pt has absent lung sounds in the left lobe, tracheal deviation, SpO2:81%, RR:36,
HR:132, & BP:82/68. What shock state is present? - Answer -Obstructive shock
A patient with a history of alcohol abuse is started on CIWA protocol. The nurse finds
the patient sleeping when it is time for the patients scheduled IV Ativan. What is the
most important action? - Answer -Wake and assess the patient
A pt has severed spinal cord at the level of C-4 and has developed neurogenic shock.
Which of the following would be an expected finding? - Answer -Vasodilation
The physician ordered hypertonic saline infusion. What do you anticipate is the optimal
speed to correct a serum sodium of 113? No more than: - Answer -0.5 mEq/L per hour
A patient is lethargic with the following vitals:HR 51, BP 90/55, RR 12, TEMP 95.8F.
Which of the following is MOST likely the cause? - Answer -Hypothyroidism
The point of care glucose for a patient is 450 and the ABG showed pH 7.2 with sodium
bicarbonate of 9. The patient is lethargic with fruity breath. What treatment
recommendations would you share with the physician ? - Answer -Fluid bolus and
intravenous insulin
A patient being treated for diabetic ketoacidosis (DKA) received 3L isotonic fluid bolus,
10 units regular insulin IV push, and started on an insulin drip in the emergency
What would you do if this was occurring with a transcutaneous pacemaker? - Answer -
Adjust the sensitivty
A pt with ST-elevation myocardial infarction (STEMI) suddenly develops a 3rd degree
heart block with a rate of 38 bpm. BP is 62/38. Skin is cool, moist, and pale. After
ensuring a patent airway and adequate ventilation , the nurses priority intervention
would be the: - Answer -Anticipation of transcutaneous pacemaker
A pt in hypertensive crisis has an intial BP of 220/120. An hour after initiating treatment,
the pts blood pressure is 170/108. What should the nurse report during interdisciplinary
rounds? - Answer -Blood pressure decreased an ideal amount
A newly admitted develops positive JVD, HR 168, BP 84/78, and muffled heart tones.
What is your assessment of the situation - Answer -Cardiac tamponade
Which of the following represents right heart failure? - Answer -Positive jugular vein
distention, peripheral edema, S3 heart sound
A pt has heart failure. What education will you provide upon discharge ? - Answer -
1500 mg/day sodium diet
Daily weights
Which intervention should be performed first for the above rhythm ? - Answer -
Defibrillation
Which of the following are symptoms of aortic stenosis? - Answer -Pulmonary edema
The ECG monitor indicates a patient is in ventricular tachycardia. The patient is awake,
alert, anxious, and complains of chest pain. Vitals: HR 190, BP 80/40, Respirations 24,
O2 sat 92% on 2 liters nasal cannula. Which of the following interventions should the
nurse anticipate? - Answer -Synchronized cardioversion
Which 2 of the following would be indicative of dilated cardiomyopathy ? - Answer -
Bilateral lower extremity edema
15% ejection fraction (EF)
Patients on heart rate controlling medications (e.g. calcium channel blockers , beta
blockers, amiodarone) - Answer -May not compensate well for shock
Rhabdomyolysis has just been diagnosed on your pt. Which of the following
complications can develop due to this diagnosis? - Answer -Renal failure
, A pt is admitted with the diagnosis of sepsis. Currently they are anxious with vitals: HR
125, BP 80/55, RR 24,O2 sat 94% on 6 liters via nasal cannula (just increased last
hour). Which findings indicate organ dysfunction? - Answer -HR 125
Sepsis induced hypotension
Increased need for supplemental oxygen
After having an appropriate response to administration of IV naloxone (narcan), an
overdose patient has again become unresponsive. This status change is most likely
caused by: - Answer -Longer half life of the offending substance over that of naloxone
(narcane)
The nurse suspects a pt is developing sepsis from the following vitals signs: T:101.3F,
P-107. R-24, BP-88/30, O2 sat 94%. After notifying the physician, which of the following
actions receives the HIGHEST priority? - Answer -Obtain blood cultures , administering
antibiotic therapy, and a fluid bolus (30ml/kg)
An 80kg, hemodynamicaly stable, patient with pyelonephritis , has a urine output of 0.3
ml/kg/hr for the last 4 hours and the above results. What do these findings indicate? -
Answer -Systemic inflammatory response syndrome
What occurs at the cellular level to cause the lactic acid to increase? - Answer -
Anaerobic metabolism
A pt has absent lung sounds in the left lobe, tracheal deviation, SpO2:81%, RR:36,
HR:132, & BP:82/68. What shock state is present? - Answer -Obstructive shock
A patient with a history of alcohol abuse is started on CIWA protocol. The nurse finds
the patient sleeping when it is time for the patients scheduled IV Ativan. What is the
most important action? - Answer -Wake and assess the patient
A pt has severed spinal cord at the level of C-4 and has developed neurogenic shock.
Which of the following would be an expected finding? - Answer -Vasodilation
The physician ordered hypertonic saline infusion. What do you anticipate is the optimal
speed to correct a serum sodium of 113? No more than: - Answer -0.5 mEq/L per hour
A patient is lethargic with the following vitals:HR 51, BP 90/55, RR 12, TEMP 95.8F.
Which of the following is MOST likely the cause? - Answer -Hypothyroidism
The point of care glucose for a patient is 450 and the ABG showed pH 7.2 with sodium
bicarbonate of 9. The patient is lethargic with fruity breath. What treatment
recommendations would you share with the physician ? - Answer -Fluid bolus and
intravenous insulin
A patient being treated for diabetic ketoacidosis (DKA) received 3L isotonic fluid bolus,
10 units regular insulin IV push, and started on an insulin drip in the emergency
