HESI Med Surg 1 Exam | Questions with 100% Correct Answers | Verified | Latest Update

1. The nurse observes ventricular fibrillation on telemetry and, on entering the client's bathroom, finds the client unconscious on the floor. Which interven- tion should the nurse implement first? A. Administer an antidysrhythmic medication. B. Start cardiopulmonary resuscitation. C. Defibrillate the client at 200 J. D. Assess the client's pulse oximetry. ANS : B. Start cardiopulmonary resuscitation. Rationale: Ventricular fibrillation is a life-threatening dysrhythmia, and CPR should be started immediately (B). (A and C) are appropriate, but CPR is the priority action. The client is dying, and (D) does not address the seriousness of this situation. 2. The nurse assesses a client who has been prescribed furosemide (Lasix) for cardiac disease. Which electrocardiographic change would be a concern for a client taking a diuretic? A. Tall, spiked T waves B. A prolonged QT interval C. A widening QRS complex D. Presence of a U wave ANS : D. Presence of a U wave Rationale: A U wave (D) is a positive deflection following the T wave and is often present with hypokalemia (low potassium level). (A, B, and C) are all signs of hyperkalemia.