1. A client’s cardiac status is being observed by telemetry
monitoring. The nurse observes a P wave that changes shape in lead II. What
conclusion does the nurse make about the P wave?
a. It
originates from an ectopic focus.
b. The P
wave was replaced by U waves.
c. It is
from the sinoatrial (SA) node.
d. Multiple
P waves are present.
ANS: A
If the P wave is firing consistently from the SA node, the P
wave will have a consistent shape in a given lead. If the impulse is from an
ectopic focus, then the P wave will vary in shape in that lead.
DIF: Cognitive Level: Comprehension/Understanding REF: p.
715
TOP: Client Needs Category: Physiological Integrity
(Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
2. The nurse is assessing the client’s electrocardiography
(ECG). What does the P wave on the ECG tracing represent?
a. Contraction
of the atria
b. Contraction
of the ventricles
c. Depolarization
of the atria
d. Depolarization
of the ventricles
ANS: C
The ECG tracing of a P wave represents electrical changes
caused by atrial depolarization.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 715
TOP: Client Needs Category: Physiological Integrity
(Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
3. A nurse notes that the PR interval on a client’s
electrocardiograph (ECG) tracing is 0.14 second. What action does the nurse
take?
a. Assess
serum cardiac enzymes.
b. Administer
1 mg epinephrine IV.
c. Administer
oxygen via nasal cannula.
d. Document
the finding in the client’s chart.
ANS: D
The PR interval normally ranges from 0.12 to 0.20 second.
This is a normal finding, so the nurse simply documents this. No further action
is required.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Physiological Integrity Physiological
Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process:
Nursing Process (Analysis)
4. When analyzing a client’s electrocardiograph (ECG)
tracing, the nurse observes that not all QRS complexes are preceded by a P
wave. What is the nurse’s interpretation of this observation?
a. The
client has hyperkalemia causing irregular QRS complexes.
b. Ventricular
tachycardia is overriding the normal atrial rhythm.
c. The
client’s chest leads are not making sufficient contact with the skin.
d. Ventricular
and atrial depolarizations are initiated from different sites.
ANS: D
Normal rhythm shows one P wave preceding each QRS,
indicating that all depolarization is initiated at the sinoatrial node. QRS
complexes without a P wave indicate a different source of initiation of
depolarization.
DIF: Cognitive Level: Comprehension/Understanding REF: p.
718
TOP: Client Needs Category: Physiological Integrity
(Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
5. The nurse observes a prominent U wave on the client’s
electrocardiograph (ECG) tracing. What is the most appropriate action for the
nurse to take?
a. Document
the finding as a normal variant.
b. Review
the client’s daily electrolyte results.
c. Move the
crash cart closer to the client’s room.
d. Call for
an immediate electrocardiogram.
ANS: B
Prominent U waves may be the result of hypokalemia. The
nurse should review the client’s daily electrolyte results. Although
documentation is important, this is not a normal variant. Moving the crash cart
closer to the room may or may not be warranted. The client does not need an
immediate ECG.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Physiological Integrity
(Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process
(Analysis)
Category | ATI |
Release date | 2021-09-14 |
Pages | 19 |
Language | English |
Comments | 0 |
Sales | 0 |
{{ userMessage }}