AH2 Quiz Answers Cardiovascular quiz answers

11 July 2024

Cardiovascular Quiz Answers

Adult Health II (Roseman University of Health Sciences)

Detailed Answer Key AH2 Cardiovascular

  1. A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client’s EKG should the nurse interpret as a sign of hypokalemia?
    • A. Abnormally prominent U wave (Correct answer)
      • Rationale: Although U waves are rare, their presence can be associated with hypokalemia, hypertension, and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip for a flattened T wave, prolonged PR interval, prominent U wave, or ST depression.
    • B. Elevated ST segment
      • Rationale: The nurse should identify ST depression as an indication of hypokalemia.
    • C. Wide QRS
      • Rationale: The nurse should identify a widened QRS as an indication of hyperkalemia.
    • D. Inverted P wave
      • Rationale: Inverted P waves are associated with junctional rhythms.
  2. A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client’s restored rhythm is symptomatic bradycardia?
    • A. Epinephrine
      • Rationale: The team administers epinephrine during cardiopulmonary resuscitation (CPR) to clients who have asystole or pulseless electrical activity.
    • B. Magnesium
      • Rationale: The team administers magnesium during CPR for clients who have torsade de pointes, which is a specific type of ventricular tachycardia.
    • C. Atropine (Correct answer)
      • Rationale: The team administers atropine during CPR if the client has symptomatic bradycardia or is hemodynamically unstable.
    • D. Sodium bicarbonate
      • Rationale: The team administers sodium bicarbonate to correct metabolic acidosis that does not improve with CPR.
  3. A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client?
    • A. Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues.
      • Rationale: Creatine kinase is an enzyme that indicates damage to brain, heart, and skeletal muscle tissue.
    • B. Troponin is a lipid whose levels reflect the risk for coronary artery disease.
      • Rationale: Cholesterol is a lipid whose levels reflect the risk for coronary artery disease.
    • C. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. (Correct answer)
      • Rationale: Troponin is a myocardial muscle protein that releases into the bloodstream when there is injury to the myocardial muscle. Troponin levels are specific point-of-care testing for clients who are having a myocardial infarction.
    • D. Troponin is a protein that helps transport oxygen throughout the body.
      • Rationale: Myoglobin is a heme protein, not to be confused with hemoglobin, found in the blood after damage to both skeletal and cardiac muscle, thus it is not specific to cardiac muscle.
  4. A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client’s plan of care? (Select all that apply.)
    • A. Check peripheral pulses in the affected extremity. (Correct answer)
      • Rationale: The nurse should check pulse points plus skin temperature and color in the affected extremity as prescribed by the facility, which is commonly every 15 min for 1 hr, every 30 min for 1 hr, and hourly for 4 hr.
    • B. Place the client in high-Fowler’s position.
      • Rationale: The client should remain flat or with the head of the bed elevated no more than 30° for 2 to 6 hr after the procedure.
    • C. Measure the client’s vital signs every 4 hr.
      • Rationale: The nurse should measure the client’s vital signs frequently, with each check of the affected extremity.
    • D. Keep the client’s hip and leg extended. (Correct answer)
      • Rationale: The nurse should keep the client from flexing the knee or hip and can use a knee brace to prevent bending the affected leg.
    • E. Have the client remain in bed up to 6 hr. (Correct answer)
      • Rationale: Clients who had manual or mechanical pressure after catheter removal require 6 hr of bed rest. Those who had a closure device or patch only need 2 hr of bed rest.
  5. A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?
    • A. Check the client’s blood pressure.
      • Rationale: The nurse should check the client’s vital signs when chest pain is present. However, these findings will not determine if the client is experiencing a myocardial infarction.
    • B. Auscultate heart tones.
      • Rationale: The nurse should auscultate heart tones as part of a complete assessment when a client complains of chest pain. However, these findings will not determine if the client is experiencing a myocardial infarction.
    • C. Perform a 12-lead ECG (Correct answer)
      • Rationale: The nurse should perform a 12-lead ECG when a client complains of chest pain to determine if the client is experiencing a myocardial infarction.
    • D. Determine if pain radiates to the left arm.
      • Rationale: The nurse should identify the location of pain as part of a complete assessment. However, radiation to the left arm can be present in other conditions and therefore does not indicate that the client is experiencing a myocardial infarction.
  6. A nurse enters a client’s room and finds him unresponsive. After notifying the rapid response team, which of the following actions should the nurse take first?
    • A. Attach defibrillator pads to the client.
      • Rationale: Summoning the code team is an appropriate intervention for a client who is in respiratory or cardiac arrest. However, this is not the first action the nurse should take.
    • B. Check for a carotid pulse. (Correct answer)
      • Rationale: The first action the nurse should take when using the nursing process is to assess the client. The nurse should check the client’s circulatory status by palpating the carotid pulse for 5 to 10 seconds first before initiating further interventions.
    • C. Begin chest compressions.
      • Rationale: Delivering chest compressions is an appropriate intervention for a client who is in cardiac arrest. However, this is not the first action the nurse should take.
    • D. Deliver two breaths.
      • Rationale: Delivering breaths is an appropriate intervention for a client who is in respiratory or cardiac arrest. However, this is not the first action the nurse should take.
  7. A nurse enters an adult client’s room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, which of the following actions should the nurse take first?
    • A. Summon the code team. (Correct answer)
      • Rationale: After determining that the client is in respiratory or cardiac arrest the nurse should first summon the code team before initiating CPR.
    • B. Begin chest compressions.
      • Rationale: Delivering chest compressions is an appropriate intervention when administering CPR for a client who is in cardiac arrest. However, this is not the first action the nurse should take.
    • C. Administer rescue breathing.
      • Rationale: Delivering rescue breaths is an appropriate intervention when administering CPR for a client who is in respiratory or cardiac arrest. However, this is not the first action the nurse should take.
    • D. Open the client’s airway.
      • Rationale: Opening the client’s airway is an appropriate intervention when administering CPR for a client who is in respiratory or cardiac arrest. However, this is not the first action the nurse should take.
  8. A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective?
    • A. Increased heart rate
      • Rationale: Tachycardia is an adverse effect of dobutamine.
    • B. Increased urine output (Correct answer)
      • Rationale: Dobutamine is administered to clients who have heart failure to improve their hemodynamic status. The nurse should identify an increase in client’s urine output as an indication that the medication is effective.
    • C. Decreased blood pressure
      • Rationale: Dobutamine is administered to improve hemodynamic status. Therefore, the nurse should identify an increase in blood pressure, not a decrease, as an indication that the medication is effective.
    • D. Decreased blood glucose level
      • Rationale: Dobutamine is administered to clients who have heart failure to improve their hemodynamic status. It does not affect blood glucose levels.
  9. A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse’s priority?
    • A. The client’s ECG tracing shows irregular heart rate without P waves.
      • Rationale: A client who has atrial fibrillation will have an irregularly irregular heart rate, absent P waves, and a variable ventricular rate; therefore, this is not the nurse’s priority finding.
    • B. The client has an aPTT of 80 seconds.
      • Rationale: A client who has atrial fibrillation may receive heparin to extend the clotting time and prevent the formation of clots. An aPTT result of 80 seconds is double the control value and indicates the effectiveness of the heparin therapy; therefore, this is not the nurse’s priority finding.
    • C. The client experiences sudden weakness of one arm and leg. (Correct answer)
      • Rationale: Sudden weakness or numbness of the face and one arm or leg can indicate that the client is at greatest risk for stroke; therefore, this is the nurse’s priority finding. In addition to these findings, the client may appear confused, have slurred speech, loss of balance, dizziness, or sudden severe headache.
    • D. The client’s urine output is cloudy and odorous.
      • Rationale: Cloudy, odorous urine output can indicate the client has a urinary tract infection; however, there is another finding that is the nurse’s priority.
  10. A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse’s priority?
  • A. Defibrillation (Correct answer)
    • Rationale: The greatest risk to the client is death from a lack of cardiac output. Ventricular fibrillation is a lethal rhythm in which the ventricles are in a quivering pattern and there is no atrial activity. Defibrillation is essential to resolve ventricular fibrillation promptly and convert the rhythm to restore cardiac output. The nurse should follow defibrillation with cardiopulmonary resuscitation and repeated defibrillation, if necessary, to convert the ventricular fibrillation into a sustainable rhythm.
  • B. Airway management
    • Rationale: The nurse should ensure the client has an effective airway to provide needed oxygen. However, a ventricular fibrillation rhythm means the client has no cardiac output. Therefore, there is another action that the nurse should take first.
  • C. Epinephrine administration
    • Rationale: The nurse should administer epinephrine, a first-line medication, to the client as this medication is a cardiac stimulant. However, there is another action that the nurse should take first.
  • D. Amiodarone administration
    • Rationale: In conjunction with defibrillation, CPR, and airway management, the client should receive medication therapy. Amiodarone is a second-line medication (after epinephrine) to treat refractory ventricular fibrillation. Although this medication is important, there is another action that the nurse should take first.
  1. A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?
  • A. Defibrillation
    • Rationale: Defibrillation is performed to correct life-threatening cardiac arrhythmias including VT. In cardiac emergencies, defibrillation should be performed immediately after identifying the client is experiencing an arrhythmia. The client in the question is awake and reporting sudden heart palpitations. There is no indication the client is unstable.
  • B. Elective cardioversion (Correct answer)
    • Rationale: Elective cardioversion is the priority intervention when the client is awake and responsive. Ventricular tachycardia might not be an immediate threat to the client, but it does require intervention to prevent long-term cardiac impairment.
  • C. CPR
    • Rationale: The nurse should assess the client’s airway, breathing, circulation, level of consciousness, and oxygenation level prior to beginning CPR. Because this client is awake and in a stable VT rhythm, the nurse should not initiate CPR.
  • D. Radiofrequency catheter ablation
    • Rationale: Radiofrequency catheter ablation is a procedure used to destroy the area of the heart (irritable focus) that causes the VT. It is used to treat clients who have repeated episodes of stable VT, but it is not used in initial treatment.