Question 1

The nurse is providing care to a client who has signs of pacemaker failure.Which will the nurse document for pacemaker failure? Select all that apply.
A)Bradycardia
B)Bradypnea
C)Decreased urine output
D)Increased blood pressure
E)Increase in temperature

Accepted Answer

Pacemaker failure can lead to inadequate heart rate control, resulting in bradycardia (A), as the heart may not be stimulated sufficiently to maintain an appropriate rate. Decreased urine output (C) can occur due to reduced cardiac output associated with pacemaker failure, leading to decreased perfusion of the kidneys.

Question 2

The RN is precepting a new graduate RN who is preparing to transfuse blood.For which action by the new graduate nurse will the nurse intervene immediately?
A)Starts blood transfusion immediately upon return to unit
B)Primes infusion set with normal saline solution
C)Educates the client about possible side effects
D)Reviews client chart for history of allergies

Accepted Answer

Starting a blood transfusion immediately upon return to the unit without verifying the correct blood product and patient identity, among other safety checks, can lead to serious transfusion errors. It is essential to follow proper protocols to ensure patient safety.

Question 3

How should the nurse calculate the heart rate from a rhythm strip?
A)Count the number of R waves in 30 large blocks and multiply by 10.
B)Count the number of small squares in a 3-second period and multiply by 0.20.
C)Count the number of large squares and multiply by 3.
D)Count the number of P waves in a 0.04 second and multiply by 5.

Accepted Answer

The correct method to calculate the heart rate from a rhythm strip is to count the number of R waves (QRS complexes) in 30 large blocks (6 seconds on a standard ECG where each large block represents 0.20 seconds) and then multiply by 10 to estimate the heart rate per minute. This method provides a quick and easy estimation of heart rate.

Question 4

How will the nurse know that the electrodes have been placed properly?
A)Lights on the box come on when electrodes are placed properly.
B)Follow the picture on the box for proper placement of electrodes.
C)Call the base station to run an ECG strip to check the signal of transmission.
D)Electrodes are placed correctly unless notified by the monitoring station.

Accepted Answer

Running an ECG strip to check the signal of transmission ensures that the electrodes are placed correctly and are functioning properly.

Question 5

A nurse is providing care to a client with a temporary pacemaker.The nurse observes a spike on the ECG.What should the nurse do first?
A)Notify the healthcare provider that the client is having an arrhythmia.
B)Document the client's rhythm,pacing spikes,and post strip in the client's chart.
C)Complete the pain assessment because this is an irregular finding and causes pain.
D)Delegate this client to the UAP until the temporary pacemaker is not needed.

Accepted Answer

The observation of a spike on the ECG in a client with a temporary pacemaker indicates that the pacemaker is delivering an electrical impulse. This is an expected finding, not an arrhythmia or an indication of pain. The first action the nurse should take is to document the client's rhythm, pacing spikes, and post a strip in the client's chart. This documentation is crucial for ongoing assessment and management of the client's condition. Notifying the healthcare provider, assessing for pain, or delegating care to an unlicensed assistive personnel (UAP) are not appropriate first steps in response to this expected finding.

Question 6

The nurse is providing care to a client with an arrhythmia.For which arrhythmia will the nurse administer prescribed digoxin?
A)Atrial fibrillation
B)Atrial flutter
C)Premature ventricular contractions
D)Sinus bradycardia

Accepted Answer

Digoxin is commonly used to treat atrial fibrillation as it helps to control the heart rate by increasing vagal tone and decreasing conduction through the AV node.

Question 7

The nurse observes an irregular chaotic rhythm.Which arrhythmia should the nurse document?
A)Ventricular tachycardia
B)Ventricular fibrillation
C)Atrial flutter
D)Atrial fibrillation

Accepted Answer

Ventricular fibrillation is characterized by an irregular, chaotic rhythm with no discernible P waves, QRS complexes, or T waves, leading to ineffective heart contractions.

Question 8

The nurse is reading a 12-lead recording.Which lead will the nurse review as the best for monitoring atrial functioning?
A)Lead I
B)Lead II
C)Lead aVL
D)Lead aVF

Accepted Answer

Lead II is considered the best for monitoring atrial functioning because it provides a clear view of the P waves, which represent atrial depolarization. This lead's orientation is most aligned with the electrical activity of the atria, making it ideal for observing atrial rhythms.

Question 9

A new nurse asks the RN why blood needs to be hung within 30 minutes after leaving the blood bank.Which is the most appropriate answer by the nurse?
A)"Coagulation occurs faster the warmer the blood gets."
B)"Rejection occurs when the blood is not administered cold."
C)"Risk for bacterial growth occurs as it gets warmer."
D)"An allergy will occur if administered when cold."

Accepted Answer

The primary concern with delaying the administration of blood after it has left the controlled environment of the blood bank is the risk of bacterial growth as the blood warms up. Blood products are stored at specific temperatures to minimize this risk, and once they are out of this environment, the risk increases the longer the blood is kept at room temperature.

Question 10

A client receiving a blood transfusion begins to have difficulty breathing and complains of itchiness.What action should the nurse instruct a new graduate RN to take first?
A)Stop the infusion.
B)Call a code blue.
C)Reassess the client.
D)Administer albuterol.

Accepted Answer

Stopping the infusion is the first action to take when a client shows signs of a transfusion reaction, such as difficulty breathing and itchiness, to prevent further exposure to the potentially harmful blood product.

Question 11

A nurse is providing care to a client on complete bed rest.Which is the best explanation by the nurse as to the function of sequential compression devices?
A)"Inflatable compartments compress legs in a graduated sequential fashion."
B)"An air compressor fills an inflatable sleeve,then allows the air to drain out of the sleeve."
C)"Proper measurement will provide adequate pressure on the legs to facilitate venous return."
D)"The function is to promote circulation in the upper legs."

Accepted Answer

Sequential compression devices (SCDs) work by inflating compartments in a graduated sequential fashion to promote venous return and prevent blood clots in the legs.

Question 12

The nurse receives a prescription to administer blood stat to a client receiving total parenteral nutrition (TPN).Which is the first action the nurse should implement?
A)Administer the blood.
B)Take vital signs.
C)Start a new IV line.
D)Premedicate the client.

Accepted Answer

Before administering blood, especially to a client receiving total parenteral nutrition (TPN), it's crucial to start a new IV line. This is because TPN requires a dedicated line due to its high glucose content and osmolarity, which can lead to complications if mixed with other infusions. Blood administration requires its own line to prevent interactions and ensure accurate monitoring and infusion rates.

Question 13

The nurse is providing care to a client with a history of a diagnosis of heart disease who has been placed on a telemetry monitor.The nurse observes an irregular rhythm on the monitor.Which is the first action the nurse should implement?
A)Immediately initiate cardioversion.
B)Place oxygen on the client.
C)Administer calcium channel blockers.
D)Complete a cardiac assessment.

Accepted Answer

The first action the nurse should take upon observing an irregular rhythm on a telemetry monitor is to complete a cardiac assessment. This allows the nurse to gather more information about the client's condition before deciding on further interventions. Immediate interventions like cardioversion or administering medications may not be appropriate without a thorough assessment.

Question 14

The nurse is administering a blood transfusion to a client.Which should the nurse implement first when a client is complaining of chills and back pain within the first 15 minutes of this transfusion?
A)Infuse normal saline.
B)Give the client a blanket.
C)Stop the infusion.
D)Notify the charge nurse.

Accepted Answer

Stopping the infusion is the first and most critical step when a client exhibits signs of a transfusion reaction, such as chills and back pain, to prevent further exposure to the potentially harmful blood product.

Question 15

A client asked the nurse "Why do I need to have this transcutaneous pacemaker?" Which is the most appropriate response by the nurse?
A)"It provides close monitoring by your healthcare provider."
B)"It delivers impulses and transmissions to the myocardium."
C)"It is for an emergency when you have an irregular rhythm."
D)"It is for symptomatic bradycardia that is unresponsive to atropine."

Accepted Answer

Transcutaneous pacing is used as a temporary measure for symptomatic bradycardia that does not respond to atropine, providing electrical stimulation to maintain adequate heart rate and perfusion.

Question 16

Which dysrhythmia is considered life threatening?
A)P wave normal;atrial rate > 100;QRS complex width 0.06-0.08 second
B)P wave normal;atrial rate< 60;QRS complex width 0.08 second
C)P wave none identifiable;atrial rate disorganized activity greater 350 beats/min;QRS complex width irregular
D)P wave none;atrial rate cannot differentiate;ventricular rate 130-250 beats/min

Accepted Answer

Ventricular tachycardia (choice D) is considered life-threatening because it can lead to ventricular fibrillation, which is a cause of sudden cardiac arrest.

Question 17

Before removing a unit of blood from the blood bank,what should the nurse ask first?
A)Verify the client's name,date of birth,and blood type.
B)Review the signed consent form in the client's EMR.
C)Ask if any family members had a reaction to a blood transfusion.
D)Administer prescribed premedications before starting the blood transfusion.

Accepted Answer

The answer of Before removing a unit of blood from...

Question 18

The nurse is placing electrodes on a client.Which is the correct placement of a 3-lead telemetry?
A)RA (white)-below right clavicle;LA (black)-below left clavicle;LL (red)-left lowest rib cage area
B)RA (white)-right wrist;LA (black)-left wrist;LL (red)-left leg
C)RA (green)-right lowest rib cage;LA (brown)-midaxillary line;LL (red)left lowest rib cage
D)RA (green)-below right clavicle;LA (black)-below left clavicle;LL (red)-left leg

Accepted Answer

The correct placement for a 3-lead telemetry involves positioning the RA (white) electrode below the right clavicle, the LA (black) electrode below the left clavicle, and the LL (red) electrode in the left lowest rib cage area. This configuration allows for accurate monitoring of the heart's electrical activity from different angles.

Question 19

The client diagnosed with anemia has the following lab results: hemoglobin 7.8 g/dL,platelets 150,000,white blood cells 4.7,and hematocrit 23.4%.Which lab result indicates the transfusion worked after receiving 2 units of packed red blood cells?
A)Hemoglobin 11 g/dL
B)Platelets 130,000
C)White blood cells 5.3
D)Hematocrit 15%

Accepted Answer

The increase in hemoglobin from 7.8 g/dL to 11 g/dL indicates the transfusion of packed red blood cells was effective, as it directly increases the hemoglobin level, which is a primary indicator of anemia treatment success.

Question 20

The nurse is providing care to a client with a history of a diagnosis of organic heart disease.The nurse received a phone call from the telemetry base station and reported a reading of ventricular rate <40 beats/min from the Purkinje fibers.After the nurse checks the client,what should the nurse do next?
A)Prepare the client for pacemaker insertion.
B)Start CPR at 100 chest compressions/minute.
C)Administer oxygen to maintain tissue perfusion.
D)Assign the UAP to monitor the client.

Accepted Answer

The client has a dangerously low heart rate, indicating a need for a pacemaker to regulate the heart rhythm.

Quiz 12: Perfusion

The nurse is providing care to a client who has signs of pacemaker failure.Which will the nurse document for pacemaker failure? Select all that apply.

The RN is precepting a new graduate RN who is preparing to transfuse blood.For which action by the new graduate nurse will the nurse intervene immediately?

How should the nurse calculate the heart rate from a rhythm strip?

How will the nurse know that the electrodes have been placed properly?

A nurse is providing care to a client with a temporary pacemaker.The nurse observes a spike on the ECG.What should the nurse do first?

The nurse is providing care to a client with an arrhythmia.For which arrhythmia will the nurse administer prescribed digoxin?

The nurse observes an irregular chaotic rhythm.Which arrhythmia should the nurse document?

The nurse is reading a 12-lead recording.Which lead will the nurse review as the best for monitoring atrial functioning?

A new nurse asks the RN why blood needs to be hung within 30 minutes after leaving the blood bank.Which is the most appropriate answer by the nurse?

A client receiving a blood transfusion begins to have difficulty breathing and complains of itchiness.What action should the nurse instruct a new graduate RN to take first?

A nurse is providing care to a client on complete bed rest.Which is the best explanation by the nurse as to the function of sequential compression devices?

The nurse receives a prescription to administer blood stat to a client receiving total parenteral nutrition (TPN) .Which is the first action the nurse should implement?

The nurse is providing care to a client with a history of a diagnosis of heart disease who has been placed on a telemetry monitor.The nurse observes an irregular rhythm on the monitor.Which is the first action the nurse should implement?

The nurse is administering a blood transfusion to a client.Which should the nurse implement first when a client is complaining of chills and back pain within the first 15 minutes of this transfusion?

A client asked the nurse "Why do I need to have this transcutaneous pacemaker?" Which is the most appropriate response by the nurse?

Which dysrhythmia is considered life threatening?

Before removing a unit of blood from the blood bank,what should the nurse ask first?

The nurse is placing electrodes on a client.Which is the correct placement of a 3-lead telemetry?

The client diagnosed with anemia has the following lab results: hemoglobin 7.8 g/dL,platelets 150,000,white blood cells 4.7,and hematocrit 23.4%.Which lab result indicates the transfusion worked after receiving 2 units of packed red blood cells?