NRS220 Chapter 22 Questions With Complete Solutions
A 28-year-old client presents to the emergency department,
stating severe restlessness and anxiety. Upon assessment, the
client's heart rate is 118 bpm and regular, the client's pupils are
dilated, and the client appears excitable. Which action should
the nurse take next?
Place the client on supplemental oxygen.
Prepare to administer a calcium channel blocker.
Question the client about alcohol and substance use.
Instruct the client to hold the breath and bear down. Correct
Answer Question the client about alcohol and substance use.
The client is experiencing sinus tachycardia. Since the client's
findings of tachycardia, dilated pupils, restlessness, anxiety, and
excitability can indicate cocaine use, the nurse should question
the client about alcohol use and substance use. This information
will direct the client's plan of care. Causes of tachycardia
include medications that stimulate the sympathetic response,
stimulants, and substance use. The treatment goals for sinus
tachycardia is usually determined by the severity of symptoms
and directed at identifying and abolishing its cause. The other
interventions may be implemented, but determining the cause of
the tachycardia is essential.
A 62-year-old client with atrial fibrillation and a CHA2DS2-
VASC score of 3 is being discharged home today. Based on this
score, which additional medications or medications would be
prescribed for this client?
No antithrombotic therapy, oral anticoagulant or aspirin
,Warfarin, direct thrombin inhibitor, or factor Xa inhibitor
Antiarrhythmic agents and aspirin
Low molecular weight heparin or intravenous heparin Correct
Answer Warfarin, direct thrombin inhibitor, or factor Xa
inhibitor
Clients with atrial fibrillation are assessed for the risk of stroke
using the mnemonic CHA2DS2-VASC with age, sex, and
medical history determining a score. With a score of zero,
clients may choose no antithrombotic therapy. With a score of 1,
the client may choose no therapy, oral anticoagulant or aspirin.
With a score of 2 or greater in males or 3 or greater in females,
clients may choose warfarin, direct thrombin, or factor Xa
inhibitor. Heparin can be used as a short-term or immediate
anticoagulation medication and is not used as part of this scoring
process. And intravenous heparin is not typically used in a home
setting for prevention. The antiarrhythmic medication treats
atrial fibrillation and is not part of the scoring process.
A cardiac care nurse is caring for a client who is experiencing
positive chronotropy. What effect should the nurse prepare for?
Initiation of a new dysrhythmia
Resolution of ventricular tachycardia
Increased heart rate
Exacerbation of an existing dysrhythmia Correct Answer
Increased heart rate
A client admitted to the telemetry unit has a serum potassium
level of 6.6 mEq/L. Which electrocardiographic (ECG)
, characteristic is commonly associated with this laboratory
finding?
Peaked T waves
Occasional U waves
Prolonged QT interval
Flattened P waves Correct Answer Peaked T waves
A client asks the nurse what causes the heart to be an effective
pump. The nurse informs the client that this is due to the:
inherent rhythmicity of cardiac muscle tissue.
inherent electrons in muscle tissue.
sufficient blood pressure.
inherent rhythmicity of all muscle tissue. Correct Answer
inherent rhythmicity of cardiac muscle tissue.
A client has had an implantable cardioverter defibrillator
inserted. What should the nurse be sure to include in the
education of this client prior to discharge? (Select all that apply.)
The client will have to schedule monthly chest x-rays to make
sure the device is patent.
Avoid magnetic fields such as metal detection booths.
Record events that trigger a shock sensation.
Call for emergency assistance if feeling dizzy.
The client may have a throbbing pain that is normal Correct
Answer Avoid magnetic fields such as metal detection booths.
Call for emergency assistance if feeling dizzy.
Record events that trigger a shock sensation.
A client is 2 days postoperative after having a permanent
pacemaker inserted. The nurse observes that the client is having
continuous hiccups as the client states, "I thought this was
A 28-year-old client presents to the emergency department,
stating severe restlessness and anxiety. Upon assessment, the
client's heart rate is 118 bpm and regular, the client's pupils are
dilated, and the client appears excitable. Which action should
the nurse take next?
Place the client on supplemental oxygen.
Prepare to administer a calcium channel blocker.
Question the client about alcohol and substance use.
Instruct the client to hold the breath and bear down. Correct
Answer Question the client about alcohol and substance use.
The client is experiencing sinus tachycardia. Since the client's
findings of tachycardia, dilated pupils, restlessness, anxiety, and
excitability can indicate cocaine use, the nurse should question
the client about alcohol use and substance use. This information
will direct the client's plan of care. Causes of tachycardia
include medications that stimulate the sympathetic response,
stimulants, and substance use. The treatment goals for sinus
tachycardia is usually determined by the severity of symptoms
and directed at identifying and abolishing its cause. The other
interventions may be implemented, but determining the cause of
the tachycardia is essential.
A 62-year-old client with atrial fibrillation and a CHA2DS2-
VASC score of 3 is being discharged home today. Based on this
score, which additional medications or medications would be
prescribed for this client?
No antithrombotic therapy, oral anticoagulant or aspirin
,Warfarin, direct thrombin inhibitor, or factor Xa inhibitor
Antiarrhythmic agents and aspirin
Low molecular weight heparin or intravenous heparin Correct
Answer Warfarin, direct thrombin inhibitor, or factor Xa
inhibitor
Clients with atrial fibrillation are assessed for the risk of stroke
using the mnemonic CHA2DS2-VASC with age, sex, and
medical history determining a score. With a score of zero,
clients may choose no antithrombotic therapy. With a score of 1,
the client may choose no therapy, oral anticoagulant or aspirin.
With a score of 2 or greater in males or 3 or greater in females,
clients may choose warfarin, direct thrombin, or factor Xa
inhibitor. Heparin can be used as a short-term or immediate
anticoagulation medication and is not used as part of this scoring
process. And intravenous heparin is not typically used in a home
setting for prevention. The antiarrhythmic medication treats
atrial fibrillation and is not part of the scoring process.
A cardiac care nurse is caring for a client who is experiencing
positive chronotropy. What effect should the nurse prepare for?
Initiation of a new dysrhythmia
Resolution of ventricular tachycardia
Increased heart rate
Exacerbation of an existing dysrhythmia Correct Answer
Increased heart rate
A client admitted to the telemetry unit has a serum potassium
level of 6.6 mEq/L. Which electrocardiographic (ECG)
, characteristic is commonly associated with this laboratory
finding?
Peaked T waves
Occasional U waves
Prolonged QT interval
Flattened P waves Correct Answer Peaked T waves
A client asks the nurse what causes the heart to be an effective
pump. The nurse informs the client that this is due to the:
inherent rhythmicity of cardiac muscle tissue.
inherent electrons in muscle tissue.
sufficient blood pressure.
inherent rhythmicity of all muscle tissue. Correct Answer
inherent rhythmicity of cardiac muscle tissue.
A client has had an implantable cardioverter defibrillator
inserted. What should the nurse be sure to include in the
education of this client prior to discharge? (Select all that apply.)
The client will have to schedule monthly chest x-rays to make
sure the device is patent.
Avoid magnetic fields such as metal detection booths.
Record events that trigger a shock sensation.
Call for emergency assistance if feeling dizzy.
The client may have a throbbing pain that is normal Correct
Answer Avoid magnetic fields such as metal detection booths.
Call for emergency assistance if feeling dizzy.
Record events that trigger a shock sensation.
A client is 2 days postoperative after having a permanent
pacemaker inserted. The nurse observes that the client is having
continuous hiccups as the client states, "I thought this was
