EXAM 3 NSG4100 2026 FINAL ASSESSMENT
TESTED CONTENT WITH ACCURATE
SOLUTIONS
◉ The ED is assessing a pt who has sustained a blunt injury to the
chest wall. Which finding indicated the presence of a pneumothorax
in this client?
a. a low respiratory rate
b. diminished breath sounds
c. the presence of a barrel chest
d. a sucking sound at the site of injury. Answer: B
◉ A client with a chest injury has suffered flail chest. The nurse
assesses the client for which most distinctive sign of flail chest?
a. cyanosis
b. hypotension
c. paradoxical chest movement
d. dyspnea, especially on exhalation. Answer: C
◉ 56 y/o male pt has been admitted to the cardiac unit w
exacerbations of HF sx. The nurse has given him a nursing dx of ↓CO
r/t HF as evidenced by poor ejection fraction, weakness, edema, &
,↓UO. Which of the following nursing interventions is most
appropriate in this situation?
a. administer stool softeners as ordered
b. administer IV fluid boluses to increase urine output
c. maintain pt in Trendelenburg position while in bed
d. increase activity by encouraging ambulation. Answer: C
◉ An adult pt w/ 3rd-degree AV block is admitted to the cardiac care
unit and placed on continuous cardiac monitoring. What rhythm
characteristic will the ECG most likely show?
a. PP interval and RR interval are irregular
b. PP interval is equal to RR interval
c. fewer QRS complexes than P waves
d. PR interval is constant. Answer: C
◉ The Nurs is waiting a plan of care for a pt w/ a cardiac
dysrhythmia what would be the most appropriate goal for the pt?
a. maintain a resting HR below 70 bpm
b. maintainability adequate control of CP
c. maintain adequate cardiac output
d. maintain normal cardiac structure. Answer: C
,◉ A pt has returned to the cardiac care unit after having a
permanent pacemaker implantation. For which potential
complications should the nurse most closely assess this pt?
a. chest pain
b. bleeding at implantation site
c. malignant hyperthermia
d. bradycardia. Answer: B
◉ The nurse is caring for an adult pt who has gone into ventricular
fibrillation. When assessing with defibrillating the pt, what must the
nurse do?
a. maintain firm contact between paddles and pt skin
b. apply a layer of water as a conducting agent
c. call all clear before discharging the defibrillator
d. ensure the defibrillator is in sync mode. Answer: A
◉ A pt who is a candidate for an implantable cardioverter
defibrillator (ICD) asks the nurse about the purpose of this device.
What would be the nurses best response?
a. to detect and treat dysrhythmias such as ventricular fibrillation
and ventricular tachycardia
b. to detect and treat bradycardia, which is an excessively slowHR
c. to detect and treat atrial fibrillation, in which your heart beats too
quickly and inefficiently
, d. to shock your heart if you have a heart attack at home. Answer: A
◉ The nurse is caring for a pt who has just had an implantable
cardioverter defibrillator (ICD) placed. What is the priority area for
the nurses assessment?
a. assessing the pt's activity level
b. facilitating trans thoracic echocardiography
c. vigilant monitoring of the pt's ECG
d. close monitoring of the pt's peripheral perfusion. Answer: C
◉ During a pt's care conference, the team is discussing whether the
pt is a candidate for cardiac conduction surgery. What would be the
most important criterion for a pt to have this surgery?
a. angina pectoris not responsive to other treatments
b. decreased activity tolerance r/t decreased cardiac output
c. atrial and ventricular tachycardias not responsible to other tx
d. ventricular fibrillation not responsive to other tx. Answer: C
◉ A nurse is caring for a pt who Is exhibiting ventricular tachycardia
(VT). Because the pt is pulseless, the nurse should prepare for what
intervention?
a. defibrillation
b. ECG monitoring
TESTED CONTENT WITH ACCURATE
SOLUTIONS
◉ The ED is assessing a pt who has sustained a blunt injury to the
chest wall. Which finding indicated the presence of a pneumothorax
in this client?
a. a low respiratory rate
b. diminished breath sounds
c. the presence of a barrel chest
d. a sucking sound at the site of injury. Answer: B
◉ A client with a chest injury has suffered flail chest. The nurse
assesses the client for which most distinctive sign of flail chest?
a. cyanosis
b. hypotension
c. paradoxical chest movement
d. dyspnea, especially on exhalation. Answer: C
◉ 56 y/o male pt has been admitted to the cardiac unit w
exacerbations of HF sx. The nurse has given him a nursing dx of ↓CO
r/t HF as evidenced by poor ejection fraction, weakness, edema, &
,↓UO. Which of the following nursing interventions is most
appropriate in this situation?
a. administer stool softeners as ordered
b. administer IV fluid boluses to increase urine output
c. maintain pt in Trendelenburg position while in bed
d. increase activity by encouraging ambulation. Answer: C
◉ An adult pt w/ 3rd-degree AV block is admitted to the cardiac care
unit and placed on continuous cardiac monitoring. What rhythm
characteristic will the ECG most likely show?
a. PP interval and RR interval are irregular
b. PP interval is equal to RR interval
c. fewer QRS complexes than P waves
d. PR interval is constant. Answer: C
◉ The Nurs is waiting a plan of care for a pt w/ a cardiac
dysrhythmia what would be the most appropriate goal for the pt?
a. maintain a resting HR below 70 bpm
b. maintainability adequate control of CP
c. maintain adequate cardiac output
d. maintain normal cardiac structure. Answer: C
,◉ A pt has returned to the cardiac care unit after having a
permanent pacemaker implantation. For which potential
complications should the nurse most closely assess this pt?
a. chest pain
b. bleeding at implantation site
c. malignant hyperthermia
d. bradycardia. Answer: B
◉ The nurse is caring for an adult pt who has gone into ventricular
fibrillation. When assessing with defibrillating the pt, what must the
nurse do?
a. maintain firm contact between paddles and pt skin
b. apply a layer of water as a conducting agent
c. call all clear before discharging the defibrillator
d. ensure the defibrillator is in sync mode. Answer: A
◉ A pt who is a candidate for an implantable cardioverter
defibrillator (ICD) asks the nurse about the purpose of this device.
What would be the nurses best response?
a. to detect and treat dysrhythmias such as ventricular fibrillation
and ventricular tachycardia
b. to detect and treat bradycardia, which is an excessively slowHR
c. to detect and treat atrial fibrillation, in which your heart beats too
quickly and inefficiently
, d. to shock your heart if you have a heart attack at home. Answer: A
◉ The nurse is caring for a pt who has just had an implantable
cardioverter defibrillator (ICD) placed. What is the priority area for
the nurses assessment?
a. assessing the pt's activity level
b. facilitating trans thoracic echocardiography
c. vigilant monitoring of the pt's ECG
d. close monitoring of the pt's peripheral perfusion. Answer: C
◉ During a pt's care conference, the team is discussing whether the
pt is a candidate for cardiac conduction surgery. What would be the
most important criterion for a pt to have this surgery?
a. angina pectoris not responsive to other treatments
b. decreased activity tolerance r/t decreased cardiac output
c. atrial and ventricular tachycardias not responsible to other tx
d. ventricular fibrillation not responsive to other tx. Answer: C
◉ A nurse is caring for a pt who Is exhibiting ventricular tachycardia
(VT). Because the pt is pulseless, the nurse should prepare for what
intervention?
a. defibrillation
b. ECG monitoring
