Know how to interpret rhythm strips – Chapter 8 Test Bank for Questions with
Pictures of Strips
When assessing the 12-lead electrocardiogram (ECG) or
... [Show More] a rhythm strip, it is helpful to
understand that the electrical activity is viewed in relation to the positive electrode of that
particular lead. What is the effect on the inflection when an electrical signal is aimed
directlyat the positive electrode?
a. Negative
b. Upside down
c. Upright
d. Equally positive and negative
ANS: C
The nurse is examining the patient’s cardiac rhythm strip in lead II and notices that all of
the P waves are upright and look the same except one that has a different shape and is
inverted. The nurse realizes that the P wave with the abnormal shape is probably a result
of what?
a. Originating from the SA node since all P waves come from the SA node
b. .b. Originating from some area in the atria other than the SA node.
c. Ventricular depolarization.
d. Normal firing even though it is inverted in lead II.
ANS: B
The patient has a transcutaneous pacemaker in place. Pacemaker spikes followed by QRS
complexes are noted on the cardiac rhythm strip. To determine if the pacemaker is
working, the nurse must do which of the following?
a. Obtain a 12-lead electrocardiogram (ECG).
b. Call for a pacemaker interrogation.
c. Palpate the pulse.
d. Run a 2-minute monitor strip for analysis.
ANS: C
• Arterial lines assessment/rationale of why needed/care needed/interventions/process
for removing
The nursing is caring for a patient who has had an arterial line inserted. To reduce the risk
of complications, what is the priority nursing intervention?
a. Apply a pressure dressing to the insertion site.
b. Ensure all tubing connections are tightened.
c. Obtain a portable x-ray to confirm placement.
d. Restrain the affected extremity for 24 hours.
ANS: B
The primary health care provider writes an order to discontinue a patient’s left radial
arterial line. When discontinuing the patient’s invasive line, what is the priority nursing
action?
a. Apply an air occlusion dressing to insertion site.
b. Apply pressure to the insertion site for 5 minutes.
c. Elevate the affected limb on pillows for 24 hours.
d. Keep the patient’s wrist in a neutral position.
ANS: B
The nurse is caring for a mechanically ventilated patient being monitored with a left
radial arterial line. During the inspiratory phase of ventilation, the nurse assesses a 20
mm Hg decrease in arterial blood pressure. What is the best interpretation of this finding
by the nurse?
a. The mechanical ventilator is malfunctioning.
b. The patient may require fluid resuscitation.
c. The arterial line may need to be replaced.
d. The left limb may have reduced perfusion.
ANS: B
Upon entering the room of a patient with a right radial arterial line, the nurse assesses the
waveform to be slightly dampened and notices blood to be backed up into the pressure
tubing. What is the best action by the nurse?
a. Check the inflation volume of the flush system pressure bag.
b. Disconnect the flush system from the arterial line catheter.
c. Zero reference the transducer system at the phlebostatic axis.
d. Reduce the number of stopcocks in the flush system tubing.
ANS: A
The nurse is caring for a patient with a left radial arterial line, and a pulmonary artery
catheter inserted into the right subclavian vein. Which action by the nurse best ensures
the safety of the patient being monitored with invasive hemodynamic monitoring lines?
a. Document all waveform values.
b. Limit the pressure tubing length.
c. Zero reference the system daily.
d. Ensure alarm limits are turned on.
ANS: D
Which nursing actions are most important for a patient with a right radial arterial line?
(Select all that apply.)
a. Checking the circulation to the right hand every 2 hours
b. Maintaining a pressurized flush solution to the arterial line set [Show Less]