Science Medicine Surgery
Nur265 Exam 1
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NUR 265 Exam 1 NUR 265 Exam 1 Galen Advanced Medsurg Nur265 E... 265 Exa
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A nurse assesses a client's electrocardiograph tracing and ANS: D
observes that not all QRS complexes are preceded by a Normal rhythm shows one P wave preceding each QRS complex, indicating that
P wave. How should the nurse interpret this observation? all depolarization is initiated at the sinoatrial node. QRS complexes without a P
a. wave indicate a different source of initiation of depolarization. This finding on an
The client has hyperkalemia causing irregular QRS electrocardiograph tracing is not an indication of hyperkalemia, ventricular
complexes. tachycardia, or disconnection of leads.
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.
,A nurse is assessing clients on a medical-surgical unit. ANS: B
Which client should the nurse identify as being at Atrial fibrillation occurs commonly in clients with cardiac disease and is a common
greatest risk for atrial fibrillation? occurrence after coronary artery bypass graft surgery. The other conditions do
a. not place these clients at higher risk for atrial fibrillation.
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
A nurse assesses a client with atrial fibrillation. Which ANS: B
manifestation should alert the nurse to the possibility of a Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic
serious complication from this condition? events includes changes in mentation, speech, sensory function, and motor
a. function. Clients with atrial fibrillation often have a rapid ventricular response as a
Sinus tachycardia result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have
b. dyspnea as a result of the decreased cardiac output caused by the rhythm
Speech alterations disturbance.
c.
Fatigue
d.
Dyspnea with activity
A nurse evaluates prescriptions for a client with chronic ANS: B
atrial fibrillation. Which medication should the nurse Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for
expect to find on this client's medication administration emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin.
record to prevent a common complication of this Sotalol, atropine, and lidocaine are not appropriate for this complication.
condition?
a.
Sotalol (Betapace)
b.
Warfarin (Coumadin)
c.
Atropine (Sal-Tropine)
d.
Lidocaine (Xylocaine)
, A nurse cares for a client with an intravenous temporary ANS: B
pacemaker for bradycardia. The nurse observes the In temporary pacing, the wires are threaded onto the epicardial surface of the
presence of a pacing spike but no QRS complex on the heart and exit through the chest wall. The pacemaker spike should be followed
client's electrocardiogram. Which action should the nurse immediately by a QRS complex. Pacing spikes seen without subsequent QRS
take next? complexes imply loss of capture. If there is no capture, then there is no ventricular
a. depolarization and contraction. The nurse should assess for cardiac output via
Administer intravenous diltiazem (Cardizem). vital signs and level of consciousness. The other interventions would not
b. determine if the client is tolerating the loss of capture.
Assess vital signs and level of consciousness.
c.
Administer sublingual nitroglycerin.
d.
Assess capillary refill and temperature.
A nurse prepares to defibrillate a client who is in ANS: D
ventricular fibrillation. Which priority intervention should To avoid injury, the rescuer commands that all personnel clear contact with the
the nurse perform prior to defibrillating this client? client or the bed and ensures their compliance before delivery of the shock. A
a. precordial thump can be delivered when no defibrillator is available. Defibrillation
Make sure the defibrillator is set to the synchronous is done in asynchronous mode. Equipment should not be tested before a client is
mode. defibrillated because this is an emergency procedure; equipment should be
b. checked on a routine basis. Epinephrine should be administered after
Administer 1 mg of intravenous epinephrine. defibrillation.
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.
After teaching a client who has an implantable ANS: B
cardioverter-defibrillator (ICD), a nurse assesses the The client being discharged with an ICD is instructed to avoid strong sources of
client's understanding. Which statement by the client electromagnetic fields. Clients should avoid tight clothing, which could cause
indicates a correct understanding of the teaching? irritation over the ICD generator. The client should be encouraged to exercise but
a. should not engage in strenuous activities that cause the heart rate to meet or
"I should wear a snug-fitting shirt over the ICD." exceed the ICD cutoff point because the ICD can discharge inappropriately. The
b. client should continue all prescribed medications.
"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."
A nurse assists with the cardioversion of a client ANS: B
experiencing acute atrial fibrillation. Which action should For safety during cardioversion, the nurse should turn off any oxygen therapy to
the nurse take prior to the initiation of cardioversion? prevent fire. The other interventions are not appropriate for a cardioversion. The
a. client should be placed in a supine position.
Administer intravenous adenosine.
b.
Turn off oxygen therapy.
c.
Ensure a tongue blade is available.
d.
Position the client on the left side.
Nur265 Exam 1
Leave the first rating
Students also studied
Flashcard sets Study guides
NUR 265 Exam 1 NUR 265 Exam 1 Galen Advanced Medsurg Nur265 E... 265 Exa
54 terms 107 terms 95 terms 50 terms
keykey88 Preview ttrusl0517 Preview Ana00010 Preview jade
Terms in this set (54) Hide definitions
A nurse assesses a client's electrocardiograph tracing and ANS: D
observes that not all QRS complexes are preceded by a Normal rhythm shows one P wave preceding each QRS complex, indicating that
P wave. How should the nurse interpret this observation? all depolarization is initiated at the sinoatrial node. QRS complexes without a P
a. wave indicate a different source of initiation of depolarization. This finding on an
The client has hyperkalemia causing irregular QRS electrocardiograph tracing is not an indication of hyperkalemia, ventricular
complexes. tachycardia, or disconnection of leads.
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.
,A nurse is assessing clients on a medical-surgical unit. ANS: B
Which client should the nurse identify as being at Atrial fibrillation occurs commonly in clients with cardiac disease and is a common
greatest risk for atrial fibrillation? occurrence after coronary artery bypass graft surgery. The other conditions do
a. not place these clients at higher risk for atrial fibrillation.
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
A nurse assesses a client with atrial fibrillation. Which ANS: B
manifestation should alert the nurse to the possibility of a Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic
serious complication from this condition? events includes changes in mentation, speech, sensory function, and motor
a. function. Clients with atrial fibrillation often have a rapid ventricular response as a
Sinus tachycardia result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have
b. dyspnea as a result of the decreased cardiac output caused by the rhythm
Speech alterations disturbance.
c.
Fatigue
d.
Dyspnea with activity
A nurse evaluates prescriptions for a client with chronic ANS: B
atrial fibrillation. Which medication should the nurse Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for
expect to find on this client's medication administration emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin.
record to prevent a common complication of this Sotalol, atropine, and lidocaine are not appropriate for this complication.
condition?
a.
Sotalol (Betapace)
b.
Warfarin (Coumadin)
c.
Atropine (Sal-Tropine)
d.
Lidocaine (Xylocaine)
, A nurse cares for a client with an intravenous temporary ANS: B
pacemaker for bradycardia. The nurse observes the In temporary pacing, the wires are threaded onto the epicardial surface of the
presence of a pacing spike but no QRS complex on the heart and exit through the chest wall. The pacemaker spike should be followed
client's electrocardiogram. Which action should the nurse immediately by a QRS complex. Pacing spikes seen without subsequent QRS
take next? complexes imply loss of capture. If there is no capture, then there is no ventricular
a. depolarization and contraction. The nurse should assess for cardiac output via
Administer intravenous diltiazem (Cardizem). vital signs and level of consciousness. The other interventions would not
b. determine if the client is tolerating the loss of capture.
Assess vital signs and level of consciousness.
c.
Administer sublingual nitroglycerin.
d.
Assess capillary refill and temperature.
A nurse prepares to defibrillate a client who is in ANS: D
ventricular fibrillation. Which priority intervention should To avoid injury, the rescuer commands that all personnel clear contact with the
the nurse perform prior to defibrillating this client? client or the bed and ensures their compliance before delivery of the shock. A
a. precordial thump can be delivered when no defibrillator is available. Defibrillation
Make sure the defibrillator is set to the synchronous is done in asynchronous mode. Equipment should not be tested before a client is
mode. defibrillated because this is an emergency procedure; equipment should be
b. checked on a routine basis. Epinephrine should be administered after
Administer 1 mg of intravenous epinephrine. defibrillation.
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.
After teaching a client who has an implantable ANS: B
cardioverter-defibrillator (ICD), a nurse assesses the The client being discharged with an ICD is instructed to avoid strong sources of
client's understanding. Which statement by the client electromagnetic fields. Clients should avoid tight clothing, which could cause
indicates a correct understanding of the teaching? irritation over the ICD generator. The client should be encouraged to exercise but
a. should not engage in strenuous activities that cause the heart rate to meet or
"I should wear a snug-fitting shirt over the ICD." exceed the ICD cutoff point because the ICD can discharge inappropriately. The
b. client should continue all prescribed medications.
"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."
A nurse assists with the cardioversion of a client ANS: B
experiencing acute atrial fibrillation. Which action should For safety during cardioversion, the nurse should turn off any oxygen therapy to
the nurse take prior to the initiation of cardioversion? prevent fire. The other interventions are not appropriate for a cardioversion. The
a. client should be placed in a supine position.
Administer intravenous adenosine.
b.
Turn off oxygen therapy.
c.
Ensure a tongue blade is available.
d.
Position the client on the left side.
