Chapter 30 Medical Surgical Nursing Preparation For Practice 2nd Edition By Osborn

Chapter 30 Medical Surgical Nursing Preparation For Practice 2nd Edition By Osborn

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Question 1

Type: MCMA

A patient is in the critical care area with ventricular tachycardia. The nurse realizes that the patient will require which action?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Immediate assessment and probable emergency intervention
2. Cardioversion, if the ventricular tachycardia is sustained and symptomatic
3. Probable drug intervention
4. Close observation for 1 hour prior to calling the physician
5. Defibrillation to convert the rhythm in the awake patient

Correct Answer: 1,2,3

Rationale 1: The nurse should immediately assess the patient to see how the potentially life-threatening rhythm is being tolerated.

Rationale 2: The nurse should be prepared to cardiovert the patient in ventricular tachycardia with a pulse according to standing prescriptions. The nurse in critical care needs to be aware of standing prescriptions for each patient prior to an emergent event and to have the necessary emergency equipment and medications ready.

Rationale 3: If the patient is hemodynamically stable, drug intervention may correct this arrhythmia.

Rationale 4: Observation prior to calling a physician is not an appropriate action when a potentially life-threatening rhythm is identified.

Rationale 5: Defibrillation is only performed in ventricular tachycardia when the patient is pulseless; otherwise, time is taken to synchronize for cardioversion.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 30-4

 

Question 2

Type: MCSA

Which is the priority nursing intervention for a patient with a junctional escape rhythm?

1. Assess the patient for symptoms associated with this rhythm.
2. Contact the physician immediately for emergency orders.
3. Eliminate caffeine from the diet.
4. Prepare for a pacemaker insertion.

Correct Answer: 1

Rationale 1: Junctional escape rhythms may be monitored if the patient is not symptomatic. It is most important to assess the patient to see how he or she is affected by the rhythm.

Rationale 2: After another intervention is performed, calling the physician to report the rhythm may be appropriate.

Rationale 3: Eliminating caffeine is not an appropriate action for this patient. There is no indication of symptoms relating to the rhythm.

Rationale 4: Preparing for a pacemaker insertion is not an appropriate action for this patient. There is no indication of symptoms relating to the rhythm.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 30-4

 

Question 3

Type: SEQ

The nurse is caring for a patient who develops atrial fibrillation with a heart rate above 100 beats per minute. Place the nursing actions in sequence from the highest priority to the lowest priority.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Assess the patient for comfort level and vital signs.

Choice 2. Check the patency of an intermittent IV.

Choice 3. Check the patient’s chart for lab results from today’s tests.

Choice 4. Call the physician to report the dysrhythmia.

Correct Answer: 1,2,3,4

Rationale 1: Assess the patient first.

Rationale 2: Check the patency of the IV in case it is needed to administer medication.

Rationale 3: Check for lab results to report to the physician.

Rationale 4: Call the physician to report the dysrhythmia and the lab results and receive the physician’s orders.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 30-4

 

Question 4

Type: MCSA

Identify the ECG rhythm.

1. Ventricular fibrillation
2. Atrial flutter
3. Sinus tachycardia
4. Ventricular tachycardia

Correct Answer: 1

Rationale 1: Ventricular fibrillation is too rapid to count and is grossly irregular; P:QRS shows no identifiable P waves; the PR interval is absent; and the QRS interval is bizarre and varies in shape and direction. It is important to identify this rhythm because it is a medical emergency; it is known as cardiac arrest because the heart is not pumping. Death will follow if this condition is not resolved within 4 minutes.

Rationale 2: This rhythm is not atrial flutter.

Rationale 3: This rhythm is not sinus tachycardia.

Rationale 4: This rhythm is not ventricular tachycardia.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-3