PNR 408 TEST #2 WITH COMPLETE
SOLUTIONS
The nurse is caring for a client admitted with diabetes mellitus, malnutrition,
osteomyelitis, and alcohol misuse who has a serum amylase level of 280 units/L and
a serum lipase level of 310 units/L. To which of the following diagnoses does the
nurse attribute these findings? - ANSWER-Alcohol Misuse
The health care provider prescribes lactulose for a client with hepatic
encephalopathy. Which of the following assessment parameters should the nurse
monitor for effectiveness of this medication? - ANSWER-Decreased ammonia levels
The family of a client newly diagnosed with hepatitis A asks the nurse what they can
do to prevent becoming ill themselves. Which of the following responses by the
nurse is most appropriate? - ANSWER-"An injection of immune globulin will need to
be given to prevent or minimize the effects from this exposure."
A patient has a diagnosis of acute myocardial infraction, and his cardiac rhythm is
sinus bradycardia with six to eight premature ventricular contractions (PVCs) per
minute. The pattern that the nurse recognize as the most characteristic of PVC is: -
ANSWER-A wide, distorted QRS complex
A patient's cardiac rhythm is sinus bradycardia with a heart rate of 34 beats/minute.
If the bradycardia is symptomatic, the nurse would expect the patient to exhibit: -
ANSWER-Shortness of breath
When computing a heart rate from the ECG tracing, the nurse counts 15 of the small
blocks between the R waves of a client whose rhythm is regular. From these data,
which of the following rates should the nurse calculate as the client's heart rate? -
ANSWER-100 beats/minute
The nurse is planning care for a client with cirrhosis. Which of the following nursing
diagnoses is priority? - ANSWER-Ineffective breathing pattern related to pressure on
diaphragm and reduced lung volume
Normal serum bilirubin levels lie between: - ANSWER-5.1 and 17 mcmol/L
Which if the following is a possible cause of loss of capture in a pacemaker? -
ANSWER-Battery depletion
A patient in the coronary care unit develops ventricular fibrillation. The first action of
the nurse should take is to: - ANSWER-Initiate cardiopulmonary resuscitation
Which of the following statements best describes the electrical activity of the heart
represented by measuring the PR interval on the ECG? - ANSWER-The length of
time for the electrical impulse to travel from the SA node to the Purkinje fibres
, The nurse obtains a 6-second rhythm strip and charts the following analysis: atrial
rate 70, regular; ventricular rate 40, regular; QRS 0.04 second; no relationship
between P waves and QRS complexes; atria and ventricles beating independently of
each other. Which of the following descriptions is a correct interpretation of this
rhythm strip? - ANSWER-Third-degree heart block
The nurse is caring for a client who is 24 hours postpacemaker insertion. Which of
the following nursing interventions is most appropriate at this time? - ANSWER-
Assessing the incision for any redness, swelling, or discharge
The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes.
There are no P waves. Instead there are fine, wavy lines between the QRS
complexes. The QRS complexes measure 0.08 second (narrow), but they occur
irregularly with a rate of 120 beats/minute. Which of the following rhythms should the
nurse identify from this data? - ANSWER-Atrial fibrillation
A client has sought care following a syncopal episode of unknown etiology. Which of
the following nursing actions should the nurse prioritize in the client's subsequent
diagnostic workup? - ANSWER-Preparing to assist with a head-upright tilt-table test
For which of the following dysrhythmias is defibrillation primarily indicated? -
ANSWER-Ventricular fibrillation
The nurse is caring for a client in asystole. Which of the following drug treatments is
the client most likely to receive? - ANSWER-Atropine and epinephrine
The nurse is caring for a client with ventricular tachycardia. Which of the following
ECG characteristics is consistent with a diagnosis of ventricular tachycardia (VT)? -
ANSWER-Rate 200 beats/minute; P wave not visible
The community health nurse is planning health-promotion teaching targeted at
preventing coronary artery disease (CAD). Which of the following individuals would
the nurse select as the highest priority for this intervention? - ANSWER-White male
For which of the following antilipemic medications would the nurse question an order
in a client with cirrhosis of the liver? - ANSWER-Atorvastatin
The nurse is planning emergent care for a client with a suspected myocardial
infarction (MI). Which of the following actions should the nurse include in the
emergency care for this client? - ANSWER-Oxygen, nitroglycerin, acetylsalisylic
acid, and morphine sulphate
The nurse is caring for a postoperative client who underwent coronary artery bypass
graft (CABG) surgery. Which of the following common complication should the nurse
monitor in the client? - ANSWER-Atrial dysrhythmias
A client was admitted to the emergency department 24 hours earlier with symptoms
of chest pain that were subsequently attributed to ST-segment-elevation myocardial
infarction (STEMI). Which of the following complications of MI should the nurse
anticipate? - ANSWER-Cardiac dysrhythmias
SOLUTIONS
The nurse is caring for a client admitted with diabetes mellitus, malnutrition,
osteomyelitis, and alcohol misuse who has a serum amylase level of 280 units/L and
a serum lipase level of 310 units/L. To which of the following diagnoses does the
nurse attribute these findings? - ANSWER-Alcohol Misuse
The health care provider prescribes lactulose for a client with hepatic
encephalopathy. Which of the following assessment parameters should the nurse
monitor for effectiveness of this medication? - ANSWER-Decreased ammonia levels
The family of a client newly diagnosed with hepatitis A asks the nurse what they can
do to prevent becoming ill themselves. Which of the following responses by the
nurse is most appropriate? - ANSWER-"An injection of immune globulin will need to
be given to prevent or minimize the effects from this exposure."
A patient has a diagnosis of acute myocardial infraction, and his cardiac rhythm is
sinus bradycardia with six to eight premature ventricular contractions (PVCs) per
minute. The pattern that the nurse recognize as the most characteristic of PVC is: -
ANSWER-A wide, distorted QRS complex
A patient's cardiac rhythm is sinus bradycardia with a heart rate of 34 beats/minute.
If the bradycardia is symptomatic, the nurse would expect the patient to exhibit: -
ANSWER-Shortness of breath
When computing a heart rate from the ECG tracing, the nurse counts 15 of the small
blocks between the R waves of a client whose rhythm is regular. From these data,
which of the following rates should the nurse calculate as the client's heart rate? -
ANSWER-100 beats/minute
The nurse is planning care for a client with cirrhosis. Which of the following nursing
diagnoses is priority? - ANSWER-Ineffective breathing pattern related to pressure on
diaphragm and reduced lung volume
Normal serum bilirubin levels lie between: - ANSWER-5.1 and 17 mcmol/L
Which if the following is a possible cause of loss of capture in a pacemaker? -
ANSWER-Battery depletion
A patient in the coronary care unit develops ventricular fibrillation. The first action of
the nurse should take is to: - ANSWER-Initiate cardiopulmonary resuscitation
Which of the following statements best describes the electrical activity of the heart
represented by measuring the PR interval on the ECG? - ANSWER-The length of
time for the electrical impulse to travel from the SA node to the Purkinje fibres
, The nurse obtains a 6-second rhythm strip and charts the following analysis: atrial
rate 70, regular; ventricular rate 40, regular; QRS 0.04 second; no relationship
between P waves and QRS complexes; atria and ventricles beating independently of
each other. Which of the following descriptions is a correct interpretation of this
rhythm strip? - ANSWER-Third-degree heart block
The nurse is caring for a client who is 24 hours postpacemaker insertion. Which of
the following nursing interventions is most appropriate at this time? - ANSWER-
Assessing the incision for any redness, swelling, or discharge
The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes.
There are no P waves. Instead there are fine, wavy lines between the QRS
complexes. The QRS complexes measure 0.08 second (narrow), but they occur
irregularly with a rate of 120 beats/minute. Which of the following rhythms should the
nurse identify from this data? - ANSWER-Atrial fibrillation
A client has sought care following a syncopal episode of unknown etiology. Which of
the following nursing actions should the nurse prioritize in the client's subsequent
diagnostic workup? - ANSWER-Preparing to assist with a head-upright tilt-table test
For which of the following dysrhythmias is defibrillation primarily indicated? -
ANSWER-Ventricular fibrillation
The nurse is caring for a client in asystole. Which of the following drug treatments is
the client most likely to receive? - ANSWER-Atropine and epinephrine
The nurse is caring for a client with ventricular tachycardia. Which of the following
ECG characteristics is consistent with a diagnosis of ventricular tachycardia (VT)? -
ANSWER-Rate 200 beats/minute; P wave not visible
The community health nurse is planning health-promotion teaching targeted at
preventing coronary artery disease (CAD). Which of the following individuals would
the nurse select as the highest priority for this intervention? - ANSWER-White male
For which of the following antilipemic medications would the nurse question an order
in a client with cirrhosis of the liver? - ANSWER-Atorvastatin
The nurse is planning emergent care for a client with a suspected myocardial
infarction (MI). Which of the following actions should the nurse include in the
emergency care for this client? - ANSWER-Oxygen, nitroglycerin, acetylsalisylic
acid, and morphine sulphate
The nurse is caring for a postoperative client who underwent coronary artery bypass
graft (CABG) surgery. Which of the following common complication should the nurse
monitor in the client? - ANSWER-Atrial dysrhythmias
A client was admitted to the emergency department 24 hours earlier with symptoms
of chest pain that were subsequently attributed to ST-segment-elevation myocardial
infarction (STEMI). Which of the following complications of MI should the nurse
anticipate? - ANSWER-Cardiac dysrhythmias
