Exam 3

Question 1

The patient’s heart rate is 70 beats per minute, but the P waves come after the QRS complex. The nurse correctly determines that the patient’s heart rhythm is:

a. a normal junctional rhythm.
b. an accelerated junctional rhythm.
c. a junctional tachycardia.
d. atrial fibrillation.

Sole: Chapter 7- #18

Answer 1

b. an accelerated junctional rhythm.

Question 2

The patient is asymptomatic but is diagnosed with second-degree heart block Mobitz I. The patient is on digitalis medication at home. The nurse should expect that:

a. the patient has had an anterior wall
myocardial infarction.
b. the physician will order the digitalis to be
continued in the hospital.
c. a digitalis level would be ordered upon
admission.
d. the patient will require a transcutaneous
pacemaker.

Sole: Chapter 7- #24

Answer 2

c. a digitalis level would be ordered upon

admission.

Question 3

The patient is admitted with a suspected acute myocardial infarction (MI). In assessing the 12-lead electrocardiogram (ECG) changes, which findings would indicate to the nurse that the patient is in the process of an evolving Q wave myocardial infarction(MI)?

a. ST-segment elevation on ECG and elevated CPK-MB or troponin levels
b. Depressed ST-segment on ECG and elevated total CPK
c. Depressed ST-segment on ECG and normal cardiac enzymes
d. Q wave on ECG with normal enzymes and troponin levels

Sole: Chapter 12- #1

Answer 3

a. ST-segment elevation on ECG and elevated CPK-MB or troponin levels

Question 4

The nurse is assessing a patient with left-sided heart failure. Which symptom would the nurse expect to find?

a. Dependent edema
b. Distended neck veins
c. Dyspnea and crackles
d. Nausea and vomiting

Sole: Chapter 12- #2

Answer 4

c. Dyspnea and crackles

Question 5

A patient is admitted with the diagnosis of unstable angina. The nurse knows that the physiological mechanism present is most likely which of the following?

a. Complete occlusion of a coronary artery
b. Fatty streak within the intima of a coronary artery
c. Partial occlusion of a coronary artery with a thrombus
d. Vasospasm of a coronary artery

Sole: Chapter 12- #5

Answer 5

c. Partial occlusion of a coronary artery with a thrombus

In unstable angina, some blood continues to flow through the affected coronary artery; however, flow is diminished related to partial occlusion. The pain in unstable angina is more severe, may occur at rest, and requires more frequent nitrate therapy.

Question 6

A patient with coronary artery disease is having a cardiac evaluation to assess for possible valvular disease. Which study best identifies valvular function and measures the size of the cardiac chambers?

a. 12-lead electrocardiogram
b. Cardiac catheterization
c. Echocardiogram
d. Electrophysiology study

Sole: Chapter 12- #7

Answer 6

c. Echocardiogram

Question 7

While instructing a patient on what occurs with a myocardial infarction, the nurse plans to explain which process?

a. Coronary artery spasm.
b. Decreased blood flow (ischemia).
c. Death of cardiac muscle from lack of oxygen (tissue necrosis).
d. Sporadic decrease in oxygen to the heart (transient oxygen imbalance).

Sole: Chapter 12- #10

Answer 7

c. Death of cardiac muscle from lack of oxygen (tissue necrosis).

Question 8

A 72-year-old woman is brought to the ED by her family. The family states that she’s “just not herself.” Her respirations are slightly labored, and her heart monitor shows sinus tachycardia (rate 110 beats/min) with frequent premature ventricular contractions (PVCs). She denies any chest pain, jaw pain, back discomfort, or nausea. Her troponin levels are elevated, and her 12-lead electrocardiogram (ECG) shows elevated ST segments in leads II, III, and AVF. The nurse knows that these symptoms are most likely associated with which diagnosis?

a. Hypokalemia
b. Non–Q wave MI
c. Silent myocardial infarction
d. Unstable angina

Sole: Chapter 12- #11

Answer 8

c. Silent myocardial infarction

Question 9

A patient has been prescribed nitroglycerin in the ED for chest pain. In taking the health history, the nurse will be sure to verify whether the patient has taken medications prior to admission for:

a. Erectile dysfunction
b. Prostate enlargement
c. Asthma
d. Peripheral vascular disease

Sole: Chapter 12- #17

Answer 9

a. Erectile dysfunction

Question 10

A patient was admitted in terminal heart failure and is not eligible for transplant. The family wants everything possible done to maintain life. Which procedure might be offered to the patient for this condition to increase the patient’s quality of life?

a. Intraaortic balloon pump (IABP)
b. Left ventricular assist device (LVAD)
c. Nothing, because the patient is in terminal heart failure
d. Nothing additional; medical management is the only option

Sole: Chapter 12- #19

Answer 10

b. Left ventricular assist device (LVAD)

LVADs are capable of partial to complete circulatory support for short- to long-term use. At present, the LVAD is therapy for patients with terminal heart failure. It would provide better management than medical therapy alone. The IABP is for short-term management of acute heart failure.

Question 11

The patient has undergone open chest surgery for coronary artery bypass grafting. One of the nurse’s responsibilities is to monitor the patient for which common postoperative dysrhythmia?

a. Second degree heart block
b. Atrial fibrillation or flutter
c. Ventricular ectopy
d. Premature junctional contractions

Sole: Chapter 12- #25

Answer 11

b. Atrial fibrillation or flutter

Question 12

The nurse is providing care to a patient on fibrinolytic therapy. Which statement from the patient warrants further assessment and intervention by the critical care nurse?

a. “My back is killing me!”
b. “There is blood on my toothbrush!”
c. “Look at the bruises on my arms!”
d. “My arm is bleeding where my IV is!”

Sole: Chapter 12- #29

Answer 12

a. “My back is killing me!”

The nurse must continually monitor for clinical manifestations of bleeding. Mild gingival bleeding and oozing around venipuncture sites are common and not a cause for concern. Severe lower back pain and ecchymoses are suggestive of retroperitoneal bleeding. If serious bleeding occurs, all fibrinolytic heparin therapies must be discontinued, and volume expanders or coagulation factors, or both, are administered.

Question 13

Acute myocardial infarction (AMI) can be classified as which of the following? (Select all that apply.)

a. Angina
b. Nonischemic
c. Non–Q wave
d. Q wave

Sole: Chapter 12- #4 select all

Answer 13

c. Non–Q wave

d. Q wave

Question 14

Which clinical manifestations are indicative of right ventricular failure? (Select all that apply.)

a. Jugular venous distention
b. Peripheral edema
c. Crackles audible in the lungs
d. Weak peripheral pulses

Sole: Chapter 12- #7 select all

Answer 14

a. Jugular venous distention
b. Peripheral edema

Jugular venous distention, liver tenderness, hepatomegaly, and peripheral edema are signs of right ventricular failure.

Question 15

Which nursing interventions would be appropriate after angioplasty?
(Select all that apply.)

a. Elevate the head of the bed by 45 degrees for 6 hours
b. Assess pedal pulses on the involved limb every 15 minutes for 2 hours
c. Monitor the vascular hemostatic device for signs of bleeding
d. Instruct the patient bend his/her knee every 15 minutes while the sheath is in place

Sole: Chapter 12- #8 select all

Answer 15

b. Assess pedal pulses on the involved limb every 15 minutes for 2 hours
c. Monitor the vascular hemostatic device for signs of bleeding
d. Instruct the patient bend his/her knee every 15 minutes while the sheath is in place

Question 16

The nurse is writing a plan of care for a patient with a cardiac dysrhythmia. What would be the most appropriate goal for the patient?

A) Maintain a resting heart rate below 70 bpm.
B) Maintain adequate control of chest pain.
C) Maintain adequate cardiac output.
D) Maintain normal cardiac structure.

Brunner: Chapter 26- #5

Answer 16

C) Maintain adequate cardiac output.

Question 17

The nurse is caring for an adult patient who has gone into ventricular fibrillation. When assisting with defibrillating the patient, what must the nurse do?

A) Maintain firm contact between paddles and patient skin.
B) Apply a layer of water as a conducting agent.
C) Call “all clear” once before discharging the defibrillator.
D) Ensure the defibrillator is in the sync mode.

Brunner: Chapter 26- #8

Answer 17

A) Maintain firm contact between paddles and patient skin.

Question 18

A nurse is caring for a patient who is exhibiting ventricular tachycardia (VT). Because the patient is pulseless, the nurse should prepare for what intervention?

A) Defibrillation
B) ECG monitoring
C) Implantation of a cardioverter defibrillator
D) Angioplasty

Brunner: Chapter 26- #13

Answer 18

A) Defibrillation

Question 19

The nurse and the other members of the team are caring for a patient who converted to ventricular fibrillation (VF). The patient was defibrillated unsuccessfully and the patient remains in VF. According to national standards, the nurse should anticipate the administration of what medication?

A) Epinephrine 1 mg IV push
B) Lidocaine 100 mg IV push
C) Amiodarone 300 mg IV push
D) Sodium bicarbonate 1 amp IV push

Brunner: Chapter 26- #15

Answer 19

A) Epinephrine 1 mg IV push

Question 20

The ED nurse is caring for a patient who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform?

A) Place gel pads over the apex and posterior chest for better conduction.
B) Ensure no one is touching the patient at the time shock is delivered.
C) Continue to ventilate the patient via endotracheal tube during the procedure.
D) Allow at least 3 minutes between shocks.

Brunner: Chapter 26- #20

Answer 20

B) Ensure no one is touching the patient at the time shock is delivered.

Question 21

A group of nurses are participating in orientation to a telemetry unit. What should the staff educator tell this class about ST segments?

A) They are the part of an ECG that reflects systole.
B) They are the part of an ECG used to calculate ventricular rate and rhythm.
C) They are the part of an ECG that reflects the time from ventricular depolarization through repolarization.
D) They are the part of an ECG that represents early ventricular repolarization.

Brunner: Chapter 26- #21

Answer 21

D) They are the part of an ECG that represents early ventricular repolarization.

Question 22

New nurses on the telemetry unit have been paired with preceptors. One new nurse asks her preceptor to explain depolarization. What would be the best answer by the preceptor?

A) “Depolarization is the mechanical contraction of the heart muscles.”
B) “Depolarization is the electrical stimulation of the heart muscles.”
C) “Depolarization is the electrical relaxation of the heart muscles.”
D) “Depolarization is the mechanical relaxation of the heart muscles.”

Brunner: Chapter 26- #23

Answer 22

B) “Depolarization is the electrical stimulation of the heart muscles.”

Question 23

a dysrhythmic event. The nurse is aware of the need to assess for signs of diminished cardiac output (CO). What change in status may signal to the nurse a decrease in cardiac output?

A) Increased blood pressure
B) Bounding peripheral pulses
C) Changes in level of consciousness
D) Skin flushing

Brunner: Chapter 26- #31

Answer 23

C) Changes in level of consciousness

Question 24

The staff educator is teaching a CPR class. Which of the following aspects of defibrillation should the educator stress to the class?

A) Apply the paddles directly to the patient’s skin.
B) Use a conducting medium between the paddles and the skin.
C) Always use a petroleum-based gel between the paddles and the skin.
D) Any available liquid can be used between the paddles and the skin.

Brunner: Chapter 26- #37

Answer 24

B) Use a conducting medium between the paddles and the skin.

Question 25

During a CPR class, a participant asks about the difference between cardioversion and defibrillation. What would be the instructor’s best response?

A) “Cardioversion is done on a beating heart; defibrillation is not.”
B) “The difference is the timing of the delivery of the electric current.”
C) “Defibrillation is synchronized with the electrical activity of the heart, but cardioversion is not.”
D) “Cardioversion is always attempted before defibrillation because it has fewer risks.”

Brunner: Chapter 26- #38

Answer 25

B) “The difference is the timing of the delivery of the electric current.”

Question 26

Which of the following cardiac diagnostic tests would include monitoring the gag reflex before giving the patient anything to eat or drink?

a. Barium swallow
b. Transesophageal echocardiogram
c. MUGA scan
d. Stress test

Answer 26

ANS: B
 – In transesophageal echocardiography, an ultrasound probe is fitted on the end of a flexible gastroscope, which is inserted into the posterior pharynx and advanced into the esophagus. After the procedure, the patient is unable to eat until the gag reflex returns

Question 27

When hemodynamic monitoring is ordered for a patient, a catheter is inserted into the appropriate blood vessel or heart chamber. When assessing a patient who has such a device in place, the nurse should check which of the following components? Select all that apply.

A) A  transducer
B) A flush system
C) A leveler
D) A pressure bag
E) An Oscillator

Answer 27

A) A transducer
B) A flush system
D) A pressure bag

Question 28

The nurse is assessing a patient who is known to have right-sided HF. What assessment finding is most consistent with this patient’s diagnosis?

A) Pulmonary edema
B) Distended neck veins
C) Dry cough
D) Orthopnea

Answer 28

B) Distended neck veins

Question 29

The emergency nurse is admitting a patient experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation?

A) Increased urine output
B) Decreased heart rate
C) Hyperactive bowel sounds
D) Cool, clammy skin

Answer 29

D) Cool, clammy skin

Question 30

The triage nurse in the ED assesses a 66-year- old male patient who presents to the ED with complaints of midsternal chest pain that has lasted for the last 5 hours. If the patient’s symptoms are due to an MI, what will have happened to the myocardium?

A) It may have developed an increased area of infarction during the time without treatment.
B) It will probably not have more damage than if he came in immediately.
C) It may be responsive to restoration of the area of dead cells with proper treatment.
D) It has been irreparably damaged, so immediate treatment is no longer necessary.

Answer 30

A) It may have developed an increased area of infarction during the time without treatment.

Question 31

A patient who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the first postoperative day?

A) Assess pulse of affected extremity every 15 minutes at first.
B) Palpate the affected leg for pain during every assessment.
C) Assess the patient for signs and symptoms of compartment syndrome every 2 hours.
D) Perform Doppler evaluation once daily.

Answer 31

A) Assess pulse of affected extremity every 15 minutes at first.

Question 32

A nurse is describing the process by which blood is ejected into circulation as the chambers of the heart become smaller. The instructor categorizes this action of the heart as what?

A) Systole
B) Diastole
C) Repolarization
D) Ejection fraction

Answer 32

A) Systole

Question 33

Cardiopulmonary resuscitation has been initiated on a patient who was found unresponsive. When performing chest compressions, the nurse should do which of the following?

A) Perform at least 100 chest compressions per minute.
B) Pause to allow a colleague to provide a breath every 10 compressions.
C) Pause chest compressions to allow for vital signs monitoring every 4 to 5 minutes.
D) Perform high-quality chest compressions as rapidly as possible.

Answer 33

A) Perform at least 100 chest compressions per minute.

Question 34

The nurse is caring for a 68-year-old patient the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what assessment datum?

A) Skin turgor
B) Potassium level
C) White blood cell count
D) Peripheral pulses

Answer 34

B) Potassium level

Question 35

A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patient’s health problem?

A) Blood is shunted from vital organs to peripheral areas of the body.
B) Cells lack an adequate blood supply and are deprived of oxygen and nutrients.
C) Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient.
D) Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion.

Answer 35

B) Cells lack an adequate blood supply and are deprived of oxygen and nutrients.

Question 36

In an acute care setting, the nurse is assessing an unstable patient. When prioritizing the patient’s care, the nurse should recognize that the patient is at risk for hypovolemic shock in which of the following circumstances?

A) Fluid volume circulating in the blood vessels decreases.
B) There is an uncontrolled increase in cardiac output.
C) Blood pressure regulation becomes irregular.
D) The patient experiences tachycardia and a bounding pulse.

Answer 36

A) Fluid volume circulating in the blood vessels decreases.

Question 37

A nurse in the ICU receives report from the nurse in the ED about a new patient being admitted with a neck injury he received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that patient is probably experiencing?

A) Anaphylactic shock
B) Neurogenic shock
C) Septic shock
D) Hypovolemic shock

Answer 37

B) Neurogenic shock

Question 38

When circulatory shock occurs, there is massive vasodilation causing pooling of the blood in the periphery of the body. An ICU nurse caring for a patient in circulatory shock should know that the pooling of blood in the periphery leads to what pathophysiological effect?

A) Increased stroke volume
B) Increased cardiac output
C) Decreased heart rate
D) Decreased venous return

Answer 38

D) Decreased venous return

Question 39

A triage nurse in the ED is on shift when a grandfather carries his 4-year-old grandson into the ED. The child is not breathing, and the grandfather states the boy was stung by a bee in a nearby park while they were waiting for the boy’s mother to get off work. Which of the following would lead the nurse to suspect that the boy is experiencing anaphylactic shock?

A) Rapid onset of acute hypertension
B) Rapid onset of respiratory distress
C) Rapid onset of neurologic compensation
D) Rapid onset of cardiac arrest

Answer 39

B) Rapid onset of respiratory distress

Question 40

A critically ill patient is admitted to the ICU. The physician decides to use intra-arterial pressure monitoring. After this intervention is performed, what assessment should the nurse prioritize in the plan of care?

A) Fluctuations in core body temperature
B) Signs and symptoms of esophageal varices
C) Signs and symptoms of compartment syndrome
D) Perfusion distal to the insertion site

Answer 40

D) Perfusion distal to the insertion site

Question 41

The nurse is caring for a patient who has central venous pressure (CVP) monitoring in place. The nurse’s most recent assessment reveals that CVP is 7 mm Hg. What is the nurse’s most appropriate action?

A) Arrange for continuous cardiac monitoring and reposition the patient.
B) Remove the CVP catheter and apply an occlusive dressing.
C) Assess the patient for fluid overload and inform the physician.
D) Raise the head of the patient’s bed and have the patient perform deep breathing exercise, if possible.

Answer 41

C) Assess the patient for fluid overload and inform the physician.

The normal CVP is 2 to 6 mm Hg. Many problems can cause an elevated CVP, but the most common is due to hypervolemia. Assessing the patient and informing the physician are the most prudent actions. Repositioning the patient is ineffective and removing the device is inappropriate.

Question 42

The staff educator is teaching ED nurses about hypertensive crisis. The nurse educator should explain that hypertensive urgency differs from hypertensive emergency in what way?

A) The BP is always higher in a hypertensive emergency.
B) Vigilant hemodynamic monitoring is required during treatment of hypertensive emergencies.
C) Hypertensive urgency is treated with rest and benzodiazepines to lower BP.
D) Hypertensive emergencies are associated with evidence of target organ damage.

Answer 42

D) Hypertensive emergencies are associated with evidence of target organ damage.

Question 43

The critical care nurse is caring for a patient just admitted in a hypertensive emergency. The nurse should anticipate the administration of what medication?

A) Warfarin (Coumadin)
B) Furosemide (Lasix)
C) Sodium nitroprusside (Nitropress)
D) Ramipril (Altace)

Answer 43

C) Sodium nitroprusside (Nitropress)

Question 44

An older adult is newly diagnosed with primary hypertension and has just been started on a beta-blocker. The nurse’s health education should include which of the following?

A) Increasing fluids to avoid extracellular volume depletion from the diuretic effect of the beta-blocker
B) Maintaining a diet high in dairy to increase protein necessary to prevent organ damage
C) Use of strategies to prevent falls stemming from postural hypotension
D) Limiting exercise to avoid injury that can be caused by increased intracranial pressure

Answer 44

C) Use of strategies to prevent falls stemming from postural hypotension

Question 45

The physician has placed a central venous pressure (CVP) monitoring line in an acutely ill patient so right ventricular function and venous blood return can be closely monitored. The results show decreased CVP. What does this indicate?

A) Possible hypovolemia
B) Possible myocardial infarction (MI)
C) Left-sided heart failure
D) Aortic valve regurgitation

Answer 45

A) Possible hypovolemia

Question 46

The critical care nurse is caring for a patient with a central venous pressure (CVP) monitoring system. The nurse notes that the patient’s CVP is increasing. Of what may this indicate?

A) Psychosocial stress
B) Hypervolemia
C) Dislodgment of the catheter
D) Hypomagnesemia

Answer 46

B) Hypervolemia

Question 47

During an adult patient’s last two office visits, the nurse obtained BP readings of 122/84 mm Hg and 130/88 mm Hg, respectively. How would this patient’s BP be categorized?

A) Normal
B) Prehypertensive
C) Stage 1 hypertensive
D) Stage 2 hypertensive

Answer 47

B) Prehypertensive