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Test Bank RN 231 - Test Bank

Test Bank
Course

Advanced Medical /Surgical Nursing 2 €“ Theory (RN231)

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Academic year: 2020/2021
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Carrington College

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Detailed Answer Key RN 231 Quiz I 1. A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the EKG should the nurse interpret as a sign of hypokalemia? A. Abnormally prominent U wave Rationale: Although U waves are rare, their presence can be associated with hypokalemia, hypertension and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip for a flattened T wave, prolonged PR interval, prominent U wave, or ST depression. B. Elevated ST segment Rationale: The nurse should identify ST depression as an indication of hypokalemia. C. Wide QRS Rationale: The nurse should identify a widened QRS as an indication of hyperkalemia. D. Inverted P wave Rationale: Inverted P waves are associated with junctional rhythms. 2. Interpret the following ECG rhythm strip. Spell out your answer, abbreviations not acceptable. Third degree heart block 3. Interpret the following ECG rhythm strip. See waveform below. Spell out your answer, abbreviations not acceptable. Created Page 1 Detailed Answer Key RN 231 Quiz I Junctional tachycardia 4. Interpret the following ECG rhythm strip. Spell out your answer, abbreviations not acceptable. Torsades de Pointes 5. A client is being treated for a myocardial infarction that occured less than six hours ago. The cardiologist suspects occlusion of the RCA. The nurse is likely to find that the ECG on admission exhibits which findings? A. SVT, ST depression in inferior leads, shortened P waves. B. Atrial fibrillation, T wave inversion in anterior leads, irregular intervals. C. Sinus bradycardia, Q waves and ST elevation in inferior leads, QRS lengthening. D. Ventricular tachycardia, flattened T waves, interval elongated and regular. 6. A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation? Created Page 2 Detailed Answer Key RN 231 Quiz I 8. A nurse is caring for a client who is on warfarin therapy for atrial fibrillation. The INR is 5. Which of the following medications should the nurse prepare to administer? A. Epinephrine Rationale: Epinephrine treats anaphylaxis or cardiac arrest. It does not reverse the effects of warfarin. B. Atropine Rationale: Atropine treats bradycardia. It does not reverse the effects of warfarin. C. Protamine Rationale: Protamine reverses the effects of heparin, not warfarin. D. Vitamin K Rationale: Vitamin K reverses the effects of warfarin. 9. A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect? A. Slow Rationale: Atrial fibrillation is an abnormal cardiac rhythm in which the atria are unable to effectively contract because of multiple rapid stimuli causing the atria to depolarize in an organized manner. The atrial rate can range from 300 to 600 bpm, with the ventricular rate being 120 to 200 bpm. B. Not palpable Rationale: The contraction is not normal in the client who has atrial fibrillation. The atria quiver rather than contract, and the ventricles contract in a rapid, chaotic fashion. The ventricular response provides the client with a palpable pulse, although it may be difficult to count the rate. C. Irregular Rationale: With atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions and thus an irregular pulse. D. Bounding Rationale: With atrial fibrillation, the amplitude of the pulse is highly variable. There is a decrease in ventricular filling, resulting in varying stroke volumes. 10. A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following? A. To convert atrial fibrillation to sinus rhythm Rationale: Created Page 4 Detailed Answer Key RN 231 Quiz I Antidysrhythmic medications such as diltiazem are used to slow the ventricular rate for clients who have atrial fibrillation. B. To dissolve clots in the bloodstream Rationale: Thrombolytic medications, such as alteplase, are used to remove thrombi that have already formed. C. To slow the response of the ventricles to the fast atrial impulses Rationale: such as carvedilol slow the heart rate. D. To reduce the risk of stroke in clients who have atrial fibrillation Rationale: Clients who have atrial fibrillation are at an increased risk for thrombus formation and subsequent embolization to the brain. Anticoagulants, such as dabigatran, help prevent thrombus formation. 11. A nurse is assisting with obtaining an electrocardiogram (ECG) for a client who has atrial fibrillation. Which of the following actions should the nurse take? (Select all that apply.) A. Keep the client NPO after midnight. B. Inspect the electrode pads. C. Wash the skin with plain water before placing the electrodes. D. Instruct the client not talk during the test. E. Administer an analgesic prior to the procedure. Rationale: Keep the client NPO after midnight is incorrect. The client will not receive anesthesia for to the test, so he does not need to follow a food or fluid restriction prior to the test. Inspect the electrode pads is correct. The gel is necessary to promote electrical conduction between the skin and the therefore, the nurse should inspect the electrode pads to check that the gel is present. Wash the skin with plain water before placing the electrodes is incorrect. The nurse should wipe the skin with alcohol where she will place the electrodes to ensure the skin is free of oils. Instruct the client not talk during the test is correct. The nurse should instruct the client to lie quietly and not to talk or move to prevent the recording of artifact. Administer an analgesic prior to the procedure is incorrect. The client does not need to receive an analgesic prior to the test because the test is noninvasive and does cause any discomfort. 12. A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the priority? Created Page 5 Detailed Answer Key RN 231 Quiz I B. Pulmonary embolism Rationale: Altered atrial contractions can cause blood pooling and thrombus formation. The client is at risk for developing a pulmonary embolism or embolic stroke. The client should monitor and report immediately manifestations, such as shortness of breath, or neurological changes. C. Peripheral vascular disease Rationale: The client who has atrial fibrillation is at risk for developing heart failure because of decrease ventricular filling and decreased cardiac output. D. Hypertension Rationale: A client who has hypertension is at risk for developing atrial fibrillation. 15. A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm? A. The P wave falls before the QRS complex. Rationale: The nurse should recognize that in normal sinus rhythm the P wave, representing atrial depolarization, falls before the QRS wave. B. The T wave is in the inverted position. Rationale: In normal sinus rhythm, the T wave is upright. C. The interval measures 0 seconds. Rationale: In normal sinus rhythm, the interval has a constant duration between 0 and 0 seconds. D. The QRS duration is 0 seconds. Rationale: In normal sinus rhythm, a QRS has a constant duration between 0 and 0 seconds. 16. A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client feeling reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the apical pulse? A. Bounding pulsations Rationale: Decreased stroke volume is associated with PVCs, so the pulse can feel weak or absent. There is a slightly increased stroke volume in the beat following a PVC, but the pulse will not feel bounding. B. Irregular pulsations Rationale: PVCs are early ventricular depolarizations with a pause immediately afterwards. That pause in the usual heart rhythm results in an irregular force and rate on palpation of a peripheral pulse and an irregular beat on auscultation of the apical pulse. PVCs have a wide variety of causes. Created Page 7 Detailed Answer Key RN 231 Quiz I Clients typically perceive them as and can feel lightheaded if they occur frequently. C. Tachycardia Rationale: PVCs do not increase the heart rate but can be considered a warning of ventricular tachycardia in clients who have acute myocardial infarction. D. Bradycardia Rationale: PVCs do not decrease the heart rate. 17. A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify? A. Serum cardiac enzyme levels Rationale: A permanent pacemaker is not a contraindication for the measurement of cardiac enzymes. B. MRI of the chest Rationale: A permanent pacemaker is a contraindication for MRI of the chest. The magnets in the machine can create electromagnetic interference and cause the pacemaker to malfunction. C. Physical therapy Rationale: A permanent pacemaker is not a contraindication for physical therapy. D. diet Rationale: A permanent pacemaker is not a contraindication for a diet. Limiting sodium intake is a general recommendation for clients who have cardiovascular problems. 18. A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip? A. Pacemaker spikes after each QRS complex Rationale: This indicates improper functioning. B. Pacemaker spikes before each P wave Rationale: This is seen with an atrial pacemaker. C. Pacemaker spikes before each QRS complex Rationale: The pacemaker fires, showing a spike on the monitor strip, which stimulates the ventricle, and the QRS complex appears, indicating that depolarization has occurred. D. Pacemaker spikes with each T wave Rationale: Created Page 8 Detailed Answer Key RN 231 Quiz I hypoxia, with classic manifestations of weakness, fatigue, and dizziness. D. Sneezing Rationale: Some types of pacemaker malfunction can cause prolonged hiccuping, not sneezing, due to phrenic nerve and diaphragmatic stimulation. 21. A nurse is providing teaching to a client who has a permanent pacemaker and has just had the initial pacemaker check. Which of the following client statements should the nurse recognize as an understanding of the teaching? A. will take my pulse Rationale: The nurse should instruct the client to monitor his pulse daily to ensure proper pacemaker functioning. Any slowing or increasing in the set heart rate should be reported to the provider. B. pacemaker can be checked from home using the Rationale: The initial pacemaker check is performed at the clinic. Following this initial examination, pacemaker checks can happen remotely from the home. Using a telephone transmitting device, the client can transmit basic information electronically from the pacemaker to the clinic. The client will return to the clinic annually for a more thorough pacemaker check. C. pacemaker will need reprogramming if I stand too close to a microwave Rationale: Although a client who has a pacemaker should avoid exposure to transmission towers and arc welders, it is safe for the client to use home appliances. D. next pacemaker check will be when the batteries need to be Rationale: Pacemaker checks are scheduled periodically to monitor pacemaker function and battery life. Pacemaker batteries typically last 6 to 12 years. Clients who have pacemaker checks should schedule several checks each year (either at the clinic or telephone). Clients should be seen in the clinic at least annually for a pacemaker check. 22. A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions? A. Defibrillation Rationale: Defibrillation is performed to correct cardiac arrhythmias including VT. In cardiac emergencies, defibrillation should be performed immediately after identifying the client is experiencing an arrhythmia. The client in the question is awake and reporting sudden heart palpitations. There is no indication the client is unstable. B. Elective cardioversion Rationale: Elective cardioversion is the priority intervention when the client is awake and responsive. Ventricular tachycardia might not be an immediate threat to the client, but it does require intervention to prevent cardiac impairment. C. CPR Rationale: Created Page 10 Detailed Answer Key RN 231 Quiz I The nurse should assess the airway, breathing, circulation, level of consciousness, and oxygenation level prior to beginning CPR. Because this client is awake and in a stable VT rhythm, the nurse should not initiate CPR. D. Radiofrequency catheter ablation Rationale: Radiofrequency catheter ablation is a procedure used to destroy the area of the heart (irritable focus) that causes the VT. It is used to treat clients who have repeated episodes of stable VT, but it is not used in initial treatment. 23. A nurse is caring for a client who has infective endocarditis. Which of the following manifestations is the priority for the nurse to monitor for? A. Anorexia Rationale: Anorexia is a manifestation associated with infective however, another manifestation is a greater risk to the client, and therefore the priority. B. Dyspnea Rationale: When using the airway, breathing, circulation (ABC) approach to client care, the nurse determines the priority manifestation to monitor for is dyspnea. Dyspnea can be an indication of heart failure, or a pulmonary infarction due to embolization. C. Fever Rationale: Fever is a manifestation associated with infective however, another manifestation is a greater risk to the client, and therefore the priority. D. Malaise Rationale: Malaise is a manifestation associated with infective however, another manifestation is a greater risk to the client, and therefore the priority. 24. A nurse is assessing a client who has infective endocarditis. Which of the following findings should be the priority for the nurse to report to the provider? A. Splinter hemorrhages to the nails Rationale: Fine lines, called splinter hemorrhages, are an expected finding in the client who has infective endocarditis. B. Dyspnea Rationale: The client who has infective endocarditis and develops dyspnea, tachycardia, or a cough might be developing heart failure or experiencing pulmonary emboli, two complications of the infection. C. Fever Rationale: Clients who have infective endocarditis might experience intermittent fevers, even after Created Page 11 Detailed Answer Key RN 231 Quiz I The nurse should assess the client for decreased ability to tolerate activity because the presence of varicose veins and edema can be painful and present a feeling of fullness in the legs. However, another diagnosis is the priority. D. Impaired skin integrity Rationale: The nurse should address the presence of venous stasis ulcers and edema because these factors can lead to infection, increased tissue breakdown, and delayed healing. However, another diagnosis is the priority. 27. A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make? A. takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic Rationale: Heparin and warfarin are both anticoagulants that decrease the clotting ability of the blood and help prevent thrombosis formation in the blood vessels. However, these medications work in different ways to achieve therapeutic coagulation and must be given together until therapeutic levels of anticoagulation can be achieved warfarin alone, which is usually within 1 to 5 days. When the PT and INR are within therapeutic range, the heparin can be discontinued. B. will call the provider to get a prescription for discontinuing the IV heparin Rationale: Discontinuing the IV heparin is not indicated at this time. C. heparin and warfarin work together to dissolve the Rationale: Neither medication dissolves clots that have already formed. D. IV heparin increases the effects of the warfarin and decreases the length of your hospital Rationale: Neither medication increases the effects of the other. 28. A nurse is caring for a client is who has a deep vein thrombosis and is prescribed heparin continuous IV infusion at 1,200 Available is heparin units in 500 mL D5W. The nurse should set the IV pump to deliver how many (Round the answer to the nearest number. Use a leading zero if it applies. Do not use a trailing zero.) 24 Correct Rationale: STEP 1: What is the unit of measurement the nurse should calculate? STEP 2: What is the volume the nurse should infuse? 1200 STEP 3: What is the total infusion time? 2 hr STEP 4: Should the nurse convert the units of measurement? Yes (mL) X mL 50 X 50 STEP 5: Set up an equation and solve for X. Volume (hr) X 1200 X X 24 STEP 6: Round if necessary. STEP 7: Reassess to determine whether the amount to administer makes sense. If the provider prescribed 1200 units to infuse per hr, it makes sense to administer 24 Created Page 13 Detailed Answer Key RN 231 Quiz I The nurse should set the IV pump to deliver heparin 1200 at 24 29. A nurse is preparing to administer heparin subcutaneously to a client who has a deep vein thrombosis. Which of the following techniques should the nurse use? A. Cleanse the skin with an alcohol swab, insert the needle, aspirate, and inject the heparin. Rationale: This is the incorrect technique for the nurse to use to inject heparin. B. Cleanse the skin with an alcohol swab, insert the needle, aspirate, inject the heparin, and massage the site. Rationale: This is the incorrect technique for the nurse to use to inject heparin. C. Cleanse the skin with an alcohol swab, insert the needle, inject the heparin, and observe for bleeding. Rationale: This is the correct technique for the nurse to use to inject heparin. D. Cleanse the skin with an alcohol swab, insert the needle, inject the heparin, aspirate, and observe for bleeding. Rationale: This is the incorrect technique for the nurse to use to inject heparin. 30. A nurse is planning care for a client who has deep vein thrombosis of the lower leg. Which of the following interventions should the nurse include in the plan of care? A. Keep the affected leg elevated while in bed. Rationale: The nurse should keep the leg elevated when he is in bed to decrease edema. B. Have the client ambulate prior to applying antiembolic stockings. Rationale: The nurse should apply the antiembolic stockings before the client gets out of bed because the legs are less edematous when they have been in an elevated positon. C. Apply ice packs to affected leg. Rationale: The nurse should apply warm, moist soaks to the affected leg to promote the comfort and decrease edema. D. Massage the affected leg twice a day. Rationale: The nurse should avoid massaging the affected leg because this could cause the thrombus to dislodge and result in pulmonary embolism 31. A nurse is receiving a client who is immediately postoperative following hip arthroplasty. Which of the following medications should the nurse plan to administer for DVT prophylaxis? A. Aspirin PO Rationale: Created Page 14 Detailed Answer Key RN 231 Quiz I E. Immobility Rationale: BMI of 20 is incorrect. The nurse should identify obesity as a risk factor for a DVT. Oral contraceptive use is correct. Thromboembolic events are an adverse effect of oral contraceptives. Hypertension is incorrect. The nurse should identify trauma as a risk factor for clot formation. High calcium intake is incorrect. The nurse should identify trauma as a risk factor for clot formation. Immobility is correct. Immobility leads to stasis of blood, thus increasing the risk for clot formation. 34. A nurse is assessing a client who is postoperative following a vaginal hysterectomy. Which of the following findings is a manifestation of thrombosis (DVT)? A. Coolness of the leg or legs Rationale: Leg warmth is a manifestation of DVT. B. Decreased pedal pulses Rationale: DVT does not affect pedal pulses. C. Pain in the ankle and foot Rationale: Pain in a calf or the groin is a manifestation of DVT. D. Unilateral leg edema Rationale: Unilateral edema is a manifestation of DVT. 35. A nurse is planning care for a client who has thrombosis (DVT) and is receiving anticoagulation therapy. Which of the following interventions should the nurse include in the plan of care? A. Apply cold compresses to the affected extremity. Rationale: The nurse should apply warm, moist packs to the affected extremity to reduce discomfort. B. Massage the affected extremity gently. Rationale: DVT is a contraindication for massage because it increases the risk of clot dislodgement. C. Apply compression stockings at bedtime. Rationale: The nurse should remove compression stockings at night and reapply them in the morning before the client gets out of bed. D. Encourage the client to walk. Rationale: Created Page 16 Detailed Answer Key RN 231 Quiz I The client should avoid sitting or standing for long periods of time. After the client begins anticoagulant therapy, the nurse should encourage the client to walk. 36. A nurse is assessing a client who is at risk for thrombosis (DVT). Which of the following findings is a manifestation of DVT? A. Pallor in the affected extremity Rationale: Redness in the affected extremity is a manifestation of DVT. B. Cramping pain in one foot Rationale: Cramping pain in one foot is a manifestation of thromboangiitis obliterans. C. Auscultation of bruit over pedal pulse Rationale: A bruit is a manifestation of a narrowed artery. D. Groin tenderness Rationale: Calf pain, groin pain, and unilateral leg swelling are manifestations of DVT. 37. A nurse is caring for a client who has thrombophlebitis and is receiving heparin continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give? A. usually takes heparin at least 2 to 3 days to reach a therapeutic blood Rationale: The effects of heparin begin within minutes. This response does not accurately answer the question. B. pharmacist is the person to answer that Rationale: Contacting the pharmacist is not the appropriate answer for the nurse to give. C. does not dissolve clots. It stops new clots from Rationale: This statement accurately answers the question. D. oral medication you will take after this IV will dissolve the Rationale: This is not a correct response. Warfarin, a PO medication that is often started after the client has been on heparin, does not dissolve clots. 38. A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse effects? A. Vitamin K Rationale: Created Page 17 Detailed Answer Key RN 231 Quiz I B. Edema Rationale: An increase in venous hydrostatic pressure, which develops when fluid accumulates in the veins, causes fluid to leak out into the tissues resulting in edema. C. Hair loss Rationale: Hair loss is a manifestation of peripheral arterial disease. D. Thick, deformed toenails Rationale: Thick, deformed toenails are a manifestation of peripheral arterial disease. Created Page 19

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Test Bank RN 231 - Test Bank

Course: Advanced Medical /Surgical Nursing 2 €“ Theory (RN231)

4 Documents
Students shared 4 documents in this course

University: Carrington College

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Detailed Answer Key
RN 231 Quiz I
1. A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on
the client's EKG should the nurse interpret as a sign of hypokalemia?
A. Abnormally prominent U wave
Rationale: Although U waves are rare, their presence can be associated with hypokalemia, hypertension
and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip for
a flattened T wave, prolonged PR interval, prominent U wave, or ST depression.
B. Elevated ST segment
Rationale: The nurse should identify ST depression as an indication of hypokalemia.
C. Wide QRS
Rationale: The nurse should identify a widened QRS as an indication of hyperkalemia.
D. Inverted P wave
Rationale: Inverted P waves are associated with junctional rhythms.
2. Interpret the following ECG rhythm strip. Spell out your answer, abbreviations not acceptable.
Third degree heart block
3. Interpret the following ECG rhythm strip. See waveform below. Spell out your answer, abbreviations not acceptable.
Created on:10/29/2020 Page 1

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