NUR 221 (Critical Care - Test 1) PRACTICE QUESTIONS
WITH COMPLETE SOLUTIONS
A 75-year-old patient, who suffered a massive stroke 3 weeks
ago, has been unresponsive and has required ventilatory support
since the time of the stroke. The physician has approached the
spouse regarding placement of a permanent feeding tube. The
spouse states that the patient never wanted to be kept alive by
tubes and personally didn't want what was being done. After
holding a family conference with the spouse, the medical team
concurs, and the feeding tube is not placed. This situation is an
example of
A. euthanasia
B. palliative care
C. withdrawal of life support
D. withholding life support
**P-4** Correct Answers D
(withholding life support)
A client has frequent bursts of ventricular tachycardia on the
cardiac monitor. What should the nurse be MOST concerned
about with this dysrhythmia?
A. It can develop into ventricular fibrillation at any time
B. It is almost impossible to convert to a normal rhythm
C. It is uncomfortable for the client, giving a sense of impending
doom
,D. It produces a high cardiac output with cerebral and
myocardial ischemia
**Rationale: Review Book pg. 734** Correct Answers A
(It can develop into ventricular fibrillation at any time)
A client in sinus bradycardia, with a heart rate of 45 bpm and
blood pressure of 82/60, reports dizziness. Which intervention
should the nurse anticipate will be prescribed?
A. Administer digoxin
B. Defibrillate the client
C. Continue to monitor the client
D. Prepare for transcutaneous pacing
**Rationale: Review Book pg. 732** Correct Answers D
(Prepare for transcutaneous pacing)
A client in ventricular fibrillation is about to be defibrillated. To
convert this rhythm effectively, the monophasic defibrillator
machine should be set at which energy level (in joules, J) for the
first delivery?
A. 50 J
B. 120 J
C. 200 J
D. 360 J
**Rationale: Review Book pg. 734** Correct Answers D
,(360 J)
A client is being treated with procainamide for a cardiac
dysrhythmia. Following IV administration of the medication, the
client complains for dizziness. Which intervention should the
nurse take FIRST?
A. Obtain a 12-lead ECG
B. Check the client's fingerstick blood glucose level
C. Auscultate the client's apical pulse and blood pressure
D. Measure the QRS interval duration on the rhythm strip
**Rationale: Review Book pg. 752** Correct Answers C
(Auscultate the client's apical pulse and blood pressure)
A client is having frequent premature ventricular contractions.
The nurse should place priority on assessment of which item?
A. Causative factors, such as caffeine
B. Sensation of fluttering or palpitations
C. Blood pressure and oxygen saturation
D. Precipitating factors, such as infection
**Rationale: Review Book pg. 734** Correct Answers C
(Blood pressure and oxygen saturation)
, A client is wearing a continuous cardiac monitor, which begins
to sound its alarm. The nurse sees no ECG complexes on the
screen. Which is the PRIORITY nursing actions?
A. Call a code
B. Check the client's status
C. Call the HCP
D. Document the lack of complexes
**Rationale: Review Book pg. 733** Correct Answers B
(Check the client's status)
A client with a central venous access device receives parenteral
nutrition (PN). The nurse notes the PN is infusing at a very
sluggish rate. Which is the BEST action for the nurse to take?
A. Ask the client to turn on the left side and perform the
Valsalva maneuver
B. Stop the infusion and flush the intravenous catheter
C. Remove central venous catheter and insert a new central line
D. Lower the head of the bed and administer oxygen via mask
**K** Correct Answers B
(Stop the infusion and flush the intravenous catheter)
A client's ECG strip shows atrial and ventricular rates of 110
bpm. The PR interval is 0.14 secs, and the QRS complex
measures 0.08 secs, and the PP and RR intervals are regular.
How should the nurse interpret this rhythm?
WITH COMPLETE SOLUTIONS
A 75-year-old patient, who suffered a massive stroke 3 weeks
ago, has been unresponsive and has required ventilatory support
since the time of the stroke. The physician has approached the
spouse regarding placement of a permanent feeding tube. The
spouse states that the patient never wanted to be kept alive by
tubes and personally didn't want what was being done. After
holding a family conference with the spouse, the medical team
concurs, and the feeding tube is not placed. This situation is an
example of
A. euthanasia
B. palliative care
C. withdrawal of life support
D. withholding life support
**P-4** Correct Answers D
(withholding life support)
A client has frequent bursts of ventricular tachycardia on the
cardiac monitor. What should the nurse be MOST concerned
about with this dysrhythmia?
A. It can develop into ventricular fibrillation at any time
B. It is almost impossible to convert to a normal rhythm
C. It is uncomfortable for the client, giving a sense of impending
doom
,D. It produces a high cardiac output with cerebral and
myocardial ischemia
**Rationale: Review Book pg. 734** Correct Answers A
(It can develop into ventricular fibrillation at any time)
A client in sinus bradycardia, with a heart rate of 45 bpm and
blood pressure of 82/60, reports dizziness. Which intervention
should the nurse anticipate will be prescribed?
A. Administer digoxin
B. Defibrillate the client
C. Continue to monitor the client
D. Prepare for transcutaneous pacing
**Rationale: Review Book pg. 732** Correct Answers D
(Prepare for transcutaneous pacing)
A client in ventricular fibrillation is about to be defibrillated. To
convert this rhythm effectively, the monophasic defibrillator
machine should be set at which energy level (in joules, J) for the
first delivery?
A. 50 J
B. 120 J
C. 200 J
D. 360 J
**Rationale: Review Book pg. 734** Correct Answers D
,(360 J)
A client is being treated with procainamide for a cardiac
dysrhythmia. Following IV administration of the medication, the
client complains for dizziness. Which intervention should the
nurse take FIRST?
A. Obtain a 12-lead ECG
B. Check the client's fingerstick blood glucose level
C. Auscultate the client's apical pulse and blood pressure
D. Measure the QRS interval duration on the rhythm strip
**Rationale: Review Book pg. 752** Correct Answers C
(Auscultate the client's apical pulse and blood pressure)
A client is having frequent premature ventricular contractions.
The nurse should place priority on assessment of which item?
A. Causative factors, such as caffeine
B. Sensation of fluttering or palpitations
C. Blood pressure and oxygen saturation
D. Precipitating factors, such as infection
**Rationale: Review Book pg. 734** Correct Answers C
(Blood pressure and oxygen saturation)
, A client is wearing a continuous cardiac monitor, which begins
to sound its alarm. The nurse sees no ECG complexes on the
screen. Which is the PRIORITY nursing actions?
A. Call a code
B. Check the client's status
C. Call the HCP
D. Document the lack of complexes
**Rationale: Review Book pg. 733** Correct Answers B
(Check the client's status)
A client with a central venous access device receives parenteral
nutrition (PN). The nurse notes the PN is infusing at a very
sluggish rate. Which is the BEST action for the nurse to take?
A. Ask the client to turn on the left side and perform the
Valsalva maneuver
B. Stop the infusion and flush the intravenous catheter
C. Remove central venous catheter and insert a new central line
D. Lower the head of the bed and administer oxygen via mask
**K** Correct Answers B
(Stop the infusion and flush the intravenous catheter)
A client's ECG strip shows atrial and ventricular rates of 110
bpm. The PR interval is 0.14 secs, and the QRS complex
measures 0.08 secs, and the PP and RR intervals are regular.
How should the nurse interpret this rhythm?
