Chapter 34

Question 1

A nurse assesses a client’s electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation?

Answer 1

Ventricular and atrial depolarizations are initiated from different sites.

Question 2

A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate?

Answer 2

“Avoid straining while having a bowel movement.”

Question 3

A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation?

Answer 3

A 50-year-old who is post coronary artery bypass graft surgery

Question 4

A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition?

Answer 4

Speech alterations

Question 5

A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this client’s medication administration record to prevent a common complication of this condition?

Answer 5

Warfarin (Coumadin)

Question 6

A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response?

Answer 6

Short period of asystole

Question 7

A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next?

Answer 7

Level of consciousness

Question 8

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client’s electrocardiogram. Which action should the nurse take next?

Answer 8

Assess vital signs and level of consciousness.

Question 9

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client?

Answer 9

Ensure that everyone is clear of contact with the client and the bed.

Question 10

After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the client’s understanding. Which statement by the client indicates a correct understanding of the teaching?

Answer 10

“I will avoid sources of strong electromagnetic fields.”

Question 11

A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this client’s concerns?

Answer 11

Schedule periods of exercise and rest during the day.

Question 12

A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion?

Answer 12

Turn off oxygen therapy.

Question 13

A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge?

Answer 13

Medication reconciliation

Question 14

A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?

Answer 14

Mid-sternal chest pain

Question 15

A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this client’s teaching?

Answer 15

“Minimize or abstain from caffeine.”

Question 16

The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, “Why do you want to know if I use cocaine?” How should the nurse respond?

Answer 16

“Clients who use cocaine are at risk for fatal dysrhythmias.”

Question 17

A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure?

Answer 17

“Clean the skin and clip hairs if needed.”

Question 18

A nurse assesses a client’s electrocardiogram (ECG) and observes the reading shown below:

How should the nurse document this client’s ECG strip?

Answer 18

Sinus rhythm with premature ventricular contractions (PVCs)

Question 19

A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below:

Which action should the nurse take first?

Answer 19

Assess airway, breathing, and level of consciousness.

Question 20

A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The client’s blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 liters per nasal cannula. The nurse assesses the client’s rhythm on the cardiac monitor and observes the reading shown below:

Which action should the nurse take first?

Answer 20

Ask the client what medications he or she takes.

Question 21

The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below:

After calling for assistance and a defibrillator, which action should the nurse take next?

Answer 21

Initiate cardiopulmonary resuscitation (CPR).

Question 22

A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.)

a. Decrease in cardiac output
b. Increase in cardiac output
c. Decrease in blood pressure
d. Increase in blood pressure
e. Decrease in urine output
f. Increase in urine output

Answer 22

A,D,E

Question 23

A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this client’s teaching? (Select all that apply.)

a. “Until your incision is healed, do not submerge your pacemaker. Only take showers.”
b. “Report any pulse rates lower than your pacemaker settings.”
c. “If you feel weak, apply pressure over your generator.”
d. “Have your pacemaker turned off before having magnetic resonance imaging (MRI).”
e. “Do not lift your left arm above the level of your shoulder for 8 weeks.

Answer 23

A,B,E

Question 24

A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this client’s teaching? (Select all that apply.)

a. Smoking cessation
b. Stress reduction and management
c. Avoiding vagal stimulation
d. Adverse effects of medications
e. Foods high in potassium

Answer 24

A,B,D