NURSING 223 Med Surg Test 2 Exam Questions & Answers
The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are
... [Show More] regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats/minute. Which would be a correct interpretation based on these characteristics?
1.
Sinus bradycardia
2.
Sick sinus syndrome
3.
Normal sinus rhythm
4.
First-degree heart block 3
Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively.
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiographic complexes on the screen. Which is the priority action of the nurse?
1.
Call a code.
2.
Call the health care provider.
3.
Check the client's status and lead placement.
4.
Press the recorder button on the electrocardiogram console. 3
Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. The remaining options are secondary to client assessment.
A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item?
1.
Sensation of palpitations 2.
Causative factors, such as caffeine
3.
Precipitating factors, such as infection
4.
Blood pressure and oxygen saturation 4
Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders, states of hypoxemia, or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by intake of caffeine, nicotine, or alcohol.
The nurse is evaluating a client's response to cardioversion. Which observation would be of highest priority to the nurse?
1.
Blood pressure
2.
Status of airway
3.
Oxygen flow rate
4.
Level of consciousness 2
Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection.
A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 second, the QRS complex measures 0.08 second, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm?
1.
Sinus dysrhythmia
2.
Sinus tachycardia
3.
Sinus bradycardia
4.
Normal sinus rhythm 2
Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats/minute.
The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status?
1.
The neurovascular status is normal because of increased blood flow through the leg.
2.
The neurovascular status is moderately impaired, and the surgeon should be called.
3.
The neurovascular status is slightly deteriorating and should be monitored for another hour.
4.
The neurovascular status is adequate from an arterial approach, but venous complications are arising. 1
An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. The remaining options are incorrect interpretations.
The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was unsuccessful?
1.
Rising blood pressure
2.
Clearly audible heart sounds
3.
Client expressions of relief
4.
Rising central venous pressure 4
Following pericardiocentesis, a rise in blood pressure and a fall in central venous pressure are expected. The client usually expresses immediate relief. Heart sounds are no longer muffled or distant.
A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often at rest in the absence of precipitating factors. How would the nurse best describe this type of anginal pain?
1.
Stable angina
2.
Variant angina
3.
Unstable angina
4.
Nonanginal pain 2
Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often at rest. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets.
Unstable angina occurs at lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction.
The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication?
1.
Flat neck veins
2.
A pulse rate of 60 beats/min
3.
Muffled or distant heart sounds
4.
Wheezing on auscultation of the lungs 3
Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention with clear lung sounds, and a falling blood pressure accompanied by pulsus paradoxus (a drop in inspiratory blood pressure greater than 10 mm Hg). Bradycardia is not a sign of cardiac tamponade.
The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction?
1.
"I need to be sure not to go barefoot around the house."
2.
"If I cut my toenails, I need to be sure that I cut them straight across."
3.
"It is all right to apply lanolin to my feet, but I shouldn't place it between my toes."
4.
"I need to be sure that I elevate my leg above my heart level for at least an hour every day." 4
Foot care instructions for the client with peripheral arterial disease are the same as those for a client with diabetes mellitus. The client with arterial disease, however, should avoid raising the legs above the level of the heart unless instructed to do so as part of an exercise program or if venous stasis is also present. The client statements in options 1, 2, and 3 are correct statements.
The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit. The nurse notes that a cardiac troponin T level assay was performed while the client was in the intensive care unit. The nurse determines that this test was performed to assist in diagnosing which condition?
1.
Heart failure
2.
Atrial fibrillation
3.
Myocardial infarction
4.
Ventricular tachycardia 3
Cardiac troponin T or cardiac troponin I has been found to be a protein marker in the detection of myocardial infarction, and assay for this protein is used in some institutions to aid in the diagnosis of a myocardial infarction. The test is not used to diagnose heart failure, ventricular tachycardia, or atrial fibrillation.
The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a ventricular rate of 150 beats/min. The nurse should next assess the client for which finding?
1.
Hypotension
2.
Flat neck veins
3.
Complaints of nausea
4.
Complaints of headache 1
The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/min is at risk for low cardiac output owing to loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.
The nurse is reviewing the electrocardiogram (ECG) rhythm strip obtained on a client with a diagnosis of myocardial infarction. The nurse notes that the PR interval is 0.20 second. The nurse should make which interpretation about this finding?
1.
A normal finding
2.
Indicative of atrial flutter
3.
Indicative of atrial fibrillation
4.
Indicative of impending reinfarction 1
The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The normal range for the PR interval is 0.12 to 0.20 second. Options 2, 3, and 4 are incorrect.
The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan, expecting that the health care provider will most likely prescribe which option?
1.
Maintain bed rest.
2.
Maintain the affected leg in a dependent position.
3.
Administer an opioid analgesic every 4 hours around the clock.
4.
Apply cool packs to the affected leg for 20 minutes every 4 hours. 1
Standard management for the client with DVT includes bed rest; limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed. Ambulation is contraindicated because such activity can cause the thrombus to dislodge and travel to the lungs. Opioid analgesics are not required to relieve pain, and pain normally is relieved with acetaminophen (Tylenol).
The nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions?
1.
"I'll need to become a strict vegetarian."
2.
"I should use polyunsaturated oils in my diet."
3.
"I need to substitute eggs and whole milk for meat."
4.
"I should eliminate all cholesterol and fat from my diet." 2
The client with coronary artery disease should avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is recommended to control hypercholesterolemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian.
A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places highest priority on telling the client to report which sensation during the procedure?
1.
Chest pain
2.
Urge to cough
3.
Warm, flushed feeling
4.
Pressure at the insertion site 1
The client is taught to report chest pain or any unusual sensations immediately. The client also is told that he or she may be asked to cough or breathe deeply from time to time during the procedure. The
client is informed that a warm, flushed feeling may accompany dye injection and is normal. Because a local anesthetic is used, the client is expected to feel pressure at the insertion site.
A client with a first-degree heart block has an electrocardiogram (ECG) taken during an episode of chest pain. The nurse knows that which ECG finding would be an indication of first-degree heart block?
1.
Presence of Q waves
2.
Tall, peaked T waves
3.
Prolonged PR interval
4.
Widened QRS complex 3
A prolonged PR interval indicates first-degree heart block. The development of Q waves indicates myocardial necrosis. Tall, peaked T waves may indicate hyperkalemia. A widened QRS complex indicates a delay in intraventricular conduction, such as bundle branch block. An ECG taken during a pain episode is intended to capture ischemic changes, which also include ST-segment elevation or depression.
A client with no history of heart disease has experienced acute myocardial infarction and has been given thrombolytic therapy with tissue plasminogen activator. What assessment finding should the nurse identify as the most likely indicator that the client is experiencing complications of this therapy?
1.
Tarry stools
2.
Nausea and vomiting
3.
Orange-colored urine
4.
Decreased urine output 1
Thrombolytic agents are used to dissolve existing thrombi, and the nurse should monitor the client for obvious or occult signs of bleeding. This includes assessment for obvious bleeding within the gastrointestinal (GI) tract, urinary system, and skin. It also includes Hematest testing of secretions for occult blood. The correct option is the only one that indicates the presence of blood.
A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily responsible for the symptoms?
1.
Left atrium
2.
Right atrium
3.
Left ventricle
4.
Right ventricle 3
Hypertension increases the workload of the left ventricle because the ventricle has to pump the stroke volume against increased resistance (afterload) in the major blood vessels. Over time this causes the left ventricle to fail, leading to signs and symptoms of heart failure. Options 1, 2, and 4 are not the chambers that are primarily responsible for this disease process although these chambers may become affected as the disease becomes more
A client has experienced a myocardial infarction. The nurse plans care for the client, knowing that the person's chest pain is caused by tissue hypoxia in which layer of the heart?
1.
Myocardium
2.
Endocardium
3.
Parietal pericardium
4.
Visceral pericardium 1
The myocardial layer of the heart is damaged when a client experiences a myocardial infarction. This is the middle layer that contains the striated muscle fibers responsible for the contractile force of the heart. The endocardium is the thin inner layer of cardiac tissue. The parietal pericardium and visceral pericardium are outer layers that protect the he [Show Less]