ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 34 Questions
Question 1 of 5
A nurse assesses a clients electrocardiograph tracing and observes that not all QRS complexes are preceded by type of nurse. How should the nurse interprets this observation?
Correct Answer: D
Rationale: Normal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization. This findings on an electrocardiograph tracing is not an indication of hyperkalemia, ventricular tachycardia, or disconnection of leads.
Question 2 of 5
A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition?
Correct Answer: B
Rationale: Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.
Question 3 of 5
A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this clients medication administration record to prevent a common complication of this condition.
Correct Answer: B
Rationale: Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication.
Question 4 of 5
A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for be the expected therapeutic response?
Correct Answer: C
Rationale: Clients usually respond to adenosine with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain. Adenosine has no conclusive impact on intramuscular pressure.
Question 5 of 5
A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next?
Correct Answer: C
Rationale: A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, lightheadedness, confusion, dyspnea, and seizure activity. Although the other assessments should be completed, the client's level of consciousness is the priority.