NURSING N223 MEDSURGE TEST 2 QUESTIONS AND ANSWERS.

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats/minute. Which would be a correct interpretation based on these characteristics? 1. Sinus bradycardia 2. Sick sinus syndrome 3. Normal sinus rhythm 4. First-degree heart block 3 Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiographic complexes on the screen. Which is the priority action of the nurse? 1. Call a code. 2. Call the health care provider. 3. Check the client's status and lead placement. 4. Press the recorder button on the electrocardiogram console. 3 Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. The remaining options are secondary to client assessment. A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item? 1. Sensation of palpitations 2. Causative factors, such as caffeine 3. Precipitating factors, such as infection 4. Blood pressure and oxygen saturation 4 Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders, states of hypoxemia, or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by intake of caffeine, nicotine, or alcohol. The nurse is evaluating a client's response to cardioversion. Which observation would be of highest priority to the nurse? 1. Blood pressure 2. Status of airway 3. Oxygen flow rate 4. Level of consciousness 2 Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 second, the QRS complex measures 0.08 second, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm? 1. Sinus dysrhythmia 2. Sinus tachycardia 3. Sinus bradycardia 4. Normal sinus rhythm 2 Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats/minute. The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status? 1. The neurovascular status is normal because of increased blood flow through the leg. 2. The neurovascular status is moderately impaired, and the surgeon should be called. 3. The neurovascular status is slightly deteriorating and should be monitored for another hour. 4. The neurovascular status is adequate from an arterial approach, but venous complications are arising. 1 An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. The remaining options are incorrect interpretations. The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was unsuccessful? 1. Rising blood pressure 2. Clearly audible heart sounds 3. Client expressions of relief 4. Rising central venous pressure 4 Following pericardiocentesis, a rise in blood pressure and a fall in central venous pressure are expected. The client usually expresses immediate relief. Heart sounds are no longer muffled or distant.