• Question 1
2.5 out of 2.5 points
The nurse is caring for a client who had a myocardial infarction (MI) 12 hours ago and is being monitored via remote telemetry. While reviewing the client's telemetry strip, the nurse notes the absence of P waves in the rhythm. The nurse should suspect ...
The nurse is caring for a client who had a myocardial infarction (MI) 12 hours ago and is
being monitored via remote telemetry. While reviewing the client's telemetry strip, the nurse
notes the absence of P waves in the rhythm. The nurse should suspect injury to which of the
following?
Response The SA node, also called the pacemaker, initiates the electrical conduction in
Feedback: the heart and is represented by the P wave on the telemetry rhythm analysis. An
absence of P waves on the telemetry reading could indicate injury to the SA
node. Injury to AV node would represent on the rhythm as a long P wave
interval. The QRS on the rhythm strip represents ventricular and septum
depolarization (contraction).Lewis 2017, p. 760
Question 2
0 out of 2.5 points
The nurse in the emergency room is caring for a client who reports having chest pain and
nausea. The cardiac monitor begins to show irregular waveforms of varying shapes and
amplitude on the cardiac monitor. Which of the following actions would be a priority for the
nurse to take?
Response The client is experience myocardial infarction and has characteristics consistent
Feedback: with V-fib. There should be no delay in starting chest compressions and
defibrillation when available. The actions in the distractors can be done
after.Lewis 2017, p. 770
Question 3
2.5 out of 2.5 points
The nurse in the emergency department (ED) is caring for client who reports having chest
pressure. The nurse performs a 12 lead electrocardiograph (ECG) and notes ST segment
elevation in leads I, avL, V5 and V6. Which of the following should the nurse suspect the
client may be experiencing?
Response The 12 lead ECG identifies ischemia or injury in the heart. The leads on the
Feedback: ECG reading represent different areas of the left ventricle and an elevation of
the ST segment can indicate injury or a myocardial infarction (MI). ST segment
elevation in leads I, avL, V5, and V6 looks at the lateral wall and could indicate
, an MI. Leads II, III, avF look at the inferior wall, leads V1 and V2 look at the
septum, and leads V3 and V4 look at the anterior wall. Lewis 2017, p. 758-759
Question 4
2.5 out of 2.5 points
The nurse has taught a client about anti-dysrhythmia medications. Which of the following
statements by the client would indicate a correct understanding of the teaching? Select all that
apply.
Response Calcium channel blockers decrease automaticity of SA node, delay AV node
Feedback: conduction and reduce myocardial contractility. Beta blockers decrease
automaticity of the SA node, slow impulse conduction in AV node and reduce
atrial and ventricular contractility causing bradycardia. Digoxin is sometimes
used as an antidysrhythmia medication. Class III medications help decrease
heart rate and quinidine is a class IA sodium channel blocker.Lewis 2017, p.
771
Question 5
0 out of 2.5 points
The licensed vocational nurse (LPN) is assigned to a client who is 2 days postoperative
femoral popliteal bypass graft to the right leg. The registered nurse (RN) should intervene if
the LPN does which of the following?
Response A client who is post op bypass graft to the lower extremity should avoid
Feedback: prolonged sitting with the leg dependent because it can cause pain and edema
and increase the risk of venous thrombosis. The actions in the distractors are all
appropriate for this client.Lewis 2017, pgs. 806-807
Question 6
2.5 out of 2.5 points
The nurse notes that a client who was admitted with heart failure has jugular venous distention
(JVD) when lying flat in bed. Which of the following actions should the nurse take next?
Response The nurse should first reassess the client’s jugular vein at a 45 degree angle to
Feedback: see if the vein is still distended. If it is then the client has true jugular vein
distention (JVD) which can be caused by right-sided heart failure. The options
in the distractors can be done after verifying if the client truly has JVD.Lewis
2017, pg. 666
Question 7
, 2.5 out of 2.5 points
The nurse is evaluating a client who received prescribed atropine IV for symptomatic type 1,
second-degree atrioventricular (AV) block. Which of the following findings would indicate
that the medication was effective?
Response Atropine is given to a client who is experiencing type 1, second-degree AV
Feedback: block and is symptomatic. If atropine is effective the client’s heart rate should
increase. The findings in the distractors do not indicate effective treatment from
the atropine.Lewis 2017, p. 768
Question 8
2.5 out of 2.5 points
The nurse has received change-of-shift report about the following clients. Which client should
the nurse see first?
Response The nurse should first see the client with the ICD that fired twice and has a dose
Feedback: of amiodarone due. The client should receive the medication asap because the
reason the ICD is firing is because it is detecting a lethal dysrhythmia. The
client with the temporary pacemaker is not a priority because the reason for the
failure to capture was identified already. The client with A-fib and the client
with second-degree atrioventricular (AV) block, type 1 are both stable.Lewis
2017, p. 773
Question 9
0 out of 2.5 points
The nurse is caring for a client with a cardiac monitor who suddenly experiences the rhythm
shown in the strip below. The client's blood pressure (BP) is 90/35 mm/Hg. Which of the
following actions should be a priority for the nurse to take?
Response This rhythm is ventricular tachycardia. The primary action is to assess the
Feedback: clients pulses as the treatment for this rhythm is dependent on the presence or
absence of pulses.Lewis 2017, p. 769-770
Question 10
0 out of 2.5 points
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