ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 34 Questions
Question 1 of 5
A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: Which action should the nurse take first?
Correct Answer: A
Rationale: Ventricular dysrhythmias and ventricular fibrillation require immediate assessment of the client's airway, breathing, and level of consciousness to determine if the client is alert and breathing. If the client is pulseless, the nurse should call a Code Blue and begin CPR. Defibrillation is the treatment of choice for pulseless ventricular fibrillation. Amiodarone is the antiarrhythmic of choice, but it is not the first action.
Question 2 of 5
A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care service. What interventions should the nurse include to the home health nurse upon discharge?
Correct Answer: A
Rationale: The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a plan of care for the client.
Question 3 of 5
A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this clients concerns?
Correct Answer: C
Rationale: Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue when completing activities of daily living. The client should be encouraged to participate in self-care activities.
Question 4 of 5
A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure?
Correct Answer: A
Rationale:
To ensure the best signal transmission, the skin should be clean and hairs clipped. Electrodes should be placed on the anterior chest, and no additional gel is needed. Oxygen has no impact on electrocardiographic monitoring.
Question 5 of 5
A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 Beats/min. What should the nurse assess? (Select all that apply.)
Correct Answer: A,D,E
Rationale: Tachycardia may initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall.