Chapter 08 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 08 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Question 1

Type: MCSA

A patient has been diagnosed with premature ventricular contractions. The nurse realizes that this dysrhythmia can result from a weaker than normal stimulus during which action potential period?

1. Absolute refractory period
2. Relative refractory period
3. Supranormal period
4. Subnormal period

Correct Answer: 3

Rationale 1: During the absolute refractory period the cell cannot deal with any new electrical impulses and is completely “resistant” to stimuli.

Rationale 2: In the relative refractory period a stronger than normal electrical stimuli is needed to trigger depolarization. This stimulus could result in premature ventricular contraction.

Rationale 3: During the supranormal period a weaker than normal stimulus can produce depolarization and can result in premature ventricular contractions.

Rationale 4: “Subnormal” is not used to describe a phase or period of the action potential.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8-1

 

Question 2

Type: MCSA

A patient’s electrocardiogram ST segment tracing is deflected from baseline. The nurse would conduct assessment for which condition?

1. Ventricular muscle injury
2. Atrial muscle injury
3. Respiratory acidosis
4. Hypocalcemia

Correct Answer: 1

Rationale 1: The ST segment represents the completion of ventricular depolarization and the beginning of ventricular repolarization. The segment should be isoelectric, or consistent with the baseline. There should be no deflections present because positive and negative charges are balanced. Deflections in the ST segment usually indicate ventricular muscle injury.

Rationale 2: The ST segment is not associated with atrial depolarization or repolarization.

Rationale 3: The ST segment is not associated with respiratory acidosis.

Rationale 4: Deflection of the ST segment is not associated with calcium levels.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8-2

 

Question 3

Type: MCSA

A patient’s heart rate averages 86 beats per minute. If this patient is to have continuous electrocardiogram monitoring the nurse will set the rate alarms at which level?

1. Low 76, high 96
2. Low 66, high 106
3. Low 60, high 100
4. Low 80, high 100

Correct Answer: 2

Rationale 1: Setting the alarms at these levels does not reflect the usual protocol.

Rationale 2: Alarms on the monitor are set typically at 20 bpm higher and lower than the patient’s baseline rates. The alarms are left on and audible to the nurse. If the patient’s normal heart rate is 86 beats per minute, the alarms should be set to low 66 and high 106.

Rationale 3: Setting the alarms at these levels does not reflect the usual protocol.

Rationale 4: Setting the alarms at these levels does not reflect the usual protocol.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8-2

 

Question 4

Type: MCSA

The nurse has determined that the patient has a bundle branch block. In order for this determination which condition must exist?

1. The PR interval must be longer than 0.20 seconds.
2. The ST segment must be elevated.
3. QRS segment should not be longer than 0.128 seconds.
4. The PR interval lengthens with each beat.

Correct Answer: 3

Rationale 1: The length of the PR interval is not associated with bundle branch block.

Rationale 2: Presence of a bundle branch block is not determined by the position of the ST segment.

Rationale 3: The QRS complex should be 0.12 seconds or less in length unless there is a delay in the impulse reaching the ventricles. A widened QRS complex means delayed conduction through the bundle branches or a bundle branch block, abnormal conduction within the ventricles, or early activation of the ventricles through a bypass route.

Rationale 4: Lengthening PR interval is related to heart block, not bundle branch block.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8-3