Nclex questions 4100 exam 3
.A chaotic small, irregular, disorganized cardiac pattern suddenly appears on a client's cardiac monitor. Which is the nurse's first action?
1.Check the blood pressure.
2.Call the health care provider (HCP).
3.Check the client and the chest leads.
4.Ini...
Rationale:This type of pattern on the cardiac monitor indicates either ventricular fibrillation or lead
displacement. The first action of the nurse is always to check the client and the chest leads. If the client is
nonresponsive and the leads are not the problem, CPR would be the next choice, along with designating
another person to contact the HCP.
.A chest x-ray report for a client indicates the presence of a left apical pneumothorax. The nurse would assess
the status of breath sounds in that area by placing the stethoscope in which location?
1.Just under the left clavicle
2.Midsternum, 1 inch to the left
3.Over the fifth intercostal space
4.Midsternum, 1 inch to the right - Answer-1
Rationale:The apex of the lung is the rounded, uppermost part of the lung. Therefore, the nurse would place
,the stethoscope just under the left clavicle. All of the other options are incorrect locations for assessing the left
apex.
.A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse caring
for the client uses which item as the best means to monitor respiratory status on an ongoing basis?
1.Apnea monitor
2.Oxygen flowmeter
3.Telemetry cardiac monitor
4.Oxygen saturation monitor - Answer-4
Rationale:Dyspnea in the cardiac client often is accompanied by hypoxemia. Hypoxemia can be detected by an
oxygen saturation monitor, especially if it is used continuously. An apnea monitor detects apnea episodes, such
as when the client has stopped breathing briefly. An oxygen flowmeter is part of the setup for delivering
oxygen therapy. Cardiac monitors detect dysrhythmias.
.A client being admitted to the coronary care unit from the emergency department has a stat prescription to
receive a dose of intravenous procainamide followed by a continuous infusion. Based on this prescription, the
nurse should assess for which condition?
1.Dyspnea
2.Bradycardia
3.Hypertension
4.Ventricular ectopy - Answer-4
Rationale:Procainamide is an antidysrhythmic medication used to treat ventricular dysrhythmias unresponsive
to lidocaine. The other options are not indications for giving this medication.
.A client develops atrial fibrillation with a ventricular rate of 140 beats/minute and signs of decreased cardiac
output. Which medication should the nurse anticipate administering first?
1.Warfarin
,2.Lidocaine
3.Metoprolol
4.Atropine sulfate - Answer-3
Rationale:Beta blockers such as metoprolol slow conduction of impulses through the atrioventricular node and
decrease the heart rate. In rapid atrial fibrillation, the goal first is to slow the ventricular rate and improve the
cardiac output and then attempt to restore normal sinus rhythm. Atropine sulfate will further increase the
heart rate and will further decrease the cardiac output. Although warfarin is administered to clients with atrial
fibrillation to prevent clots from forming in the atria, it will have no effect in decreasing the ventricular rate or
restoring normal sinus rhythm. Lidocaine is useful only in suppressing ventricular dysrhythmias.
.A client has been treated for pleural effusion with a thoracentesis. The nurse determines that this procedure
has been effective if the nurse notes which assessment finding?
1.Absence of dyspnea
2.Increased severity of cough
3.Dull percussion notes over lung tissue
4.Decreased tactile fremitus over lung tissue - Answer-1
Rationale:The client who has undergone thoracentesis should experience relief of the signs and symptoms
experienced before the procedure. Typical signs and symptoms of pleural effusion include dry, nonproductive
cough; dyspnea (usually on exertion); decreased or absent tactile fremitus; and dull or flat percussion notes on
respiratory assessment.
.A client has developed uncontrolled atrial fibrillation with a ventricular rate of 150 beats/min. What
manifestation should the nurse observe for when performing the client's focused assessment?
1.Flat neck veins
2.Nausea and vomiting
3.Hypotension and dizziness
4.Clubbed fingertips and headache - Answer-3
Rationale:The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/min is at
risk for low cardiac output due 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.
.A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most
commonly reported?
1. Hot, flushed feeling
2. Sudden chills and fever
3. Chest pain that occurs suddenly
4. Dyspnea when deep breaths are taken - Answer-3
The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most
commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical
symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.
.A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most
commonly reported?
1.Hot, flushed feeling
2.Sudden chills and fever
3.Chest pain that occurs suddenly
4.Dyspnea when deep breaths are taken - Answer-3
Rationale:The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The
next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate.
Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough,
and cyanosis.
.A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most
concerned about with this dysrhythmia?
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