Question

The nurse is monitoring a 53-year-old client who is undergoing a cardiac exercise stress test after experiencing an episode of angina. Which client finding will require the test to be discontinued?

Answer 1

Correct Answers:

Three premature ventricular contractions in a row

Rationale :

🔷 PVCs in a triplet (three in a row) signal ventricular tachycardia, which is a potentially life-threatening arrhythmia.

🔷 This warrants immediate discontinuation of the stress test and rapid cardiac evaluation.

🔷 Exercise-induced arrhythmias are an indication of poor coronary perfusion and may precede sudden cardiac arrest.

🔷 The goal of the test is early detection of myocardial ischemia, not provoking dangerous rhythms.

🔷 Early recognition of abnormal rhythms allows for prompt interventions, such as defibrillation if necessary.

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Answer 2

Correct Answers:

Fasciotomy

Rationale :

🔶 A fasciotomy is the treatment of choice to relieve compartment pressure and prevent tissue necrosis.

🔶 Compartment syndrome causes compression of vessels and nerves, risking limb loss if untreated.

🔶 Clinical signs such as pain unrelieved by opioids, pallor, pulselessness, and paresthesia indicate worsening pressure.

🔶 Without timely surgical intervention, permanent neuromuscular damage can occur within hours.

🔶 This is a surgical emergency, not a vascular access or diagnostic priority.

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Answer 3

Correct Answers:

Avoid positioning the client with neck and hip flexion.

Rationale :

✳️ Flexion of the neck or hips increases intracranial pressure (ICP) by impeding venous return.

✳️ Maintaining a neutral head and neck position allows optimal cerebral drainage.

✳️ The goal is to prevent increased pressure on brain tissue to reduce risk of herniation.

✳️ Nursing interventions aim to optimize cerebral perfusion pressure (CPP) and reduce brain swelling.

✳️ Frequent repositioning with head elevation (usually 30°) and straight alignment is standard care.

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Answer 4

Correct Answers:

Complete a neurovascular check of the affected extremity.

Rationale :

🟢 A neurovascular assessment is essential post-femoral catheterization to detect bleeding, occlusion, or arterial injury.

🟢 It includes checking for pulses, sensation, motor function, color, and temperature.

🟢 Complications like retroperitoneal hemorrhage or arterial dissection may be subtle initially.

🟢 Distal pulses and capillary refill provide clues about circulation compromise.

🟢 Early detection of limb ischemia can prevent permanent damage and limb loss.

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Answer 5

Correct Answers:

Cardioversion

Rationale :

💠 Cardioversion is used when atrial flutter is unresponsive to medications and the patient is hemodynamically stable.

💠 It delivers a synchronized shock on the R wave to reset cardiac rhythm safely.

💠 This procedure allows restoration of sinus rhythm, improving cardiac output and reducing thromboembolic risk.

💠 The client is typically sedated prior to the procedure for comfort.

💠 Anticoagulation may be needed before cardioversion to prevent stroke from dislodged clots.

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Answer 6

Correct Answers:

It discharges during ventricular depolarization of the heart.

Rationale :

🟣 In synchronized cardioversion, the shock is timed to ventricular depolarization (QRS complex).

🟣 This avoids shocking during the T wave, which could trigger ventricular fibrillation.

🟣 The defibrillator uses sensing technology to deliver a shock precisely during the safe period.

🟣 This method is used in atrial fibrillation, atrial flutter, and stable VT with a pulse.

🟣 The synchronization feature differentiates cardioversion from defibrillation.

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Answer 7

Correct Answers:

It indicates a normal depolarization of the atria.

Rationale :

🔴 A PR interval of 0.16 seconds is within the normal range (0.12–0.20 sec) and reflects atria to AV node conduction.

🔴 The PR interval shows the time for electrical impulses to travel from the SA node to the ventricles.

🔴 No abnormality is present with this interval; thus, no intervention is needed.

🔴 It confirms the integrity of the atrioventricular conduction system.

🔴 This value does not indicate a block or delay.

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Answer 8

Correct Answers:

A client with left-sided heart failure on oxygen via nasal cannula

Rationale :

✅ Left-sided heart failure can cause pulmonary edema, a life-threatening condition needing priority assessment.

✅ The presence of oxygen therapy suggests compromised respiratory status, requiring immediate evaluation.

✅ Initial rounds should prioritize clients with potential airway or perfusion compromise.

✅ The nurse must evaluate breath sounds, respiratory rate, and oxygen saturation urgently.

✅ Early intervention can prevent acute decompensation or the need for intubation.

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Answer 9

Correct Answers:

Document the finding and continue to monitor the client.

Rationale :

🟤 A PR interval of 0.24 seconds indicates a first-degree AV block, but if the patient is asymptomatic and vital signs are stable, no immediate treatment is needed.

🟤 The rhythm is generally benign and monitored for progression to more severe blocks.

🟤 The nurse should continue telemetry, assess for changes, and document accurately.

🟤 This condition is often caused by medications like beta-blockers or aging conduction tissue.

🟤 No pharmacological intervention is warranted unless the patient becomes symptomatic.

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Answer 10

Correct Answers:

Sinus tachycardia

Rationale :

🔶 Sinus tachycardia presents with a regular rhythm, rate usually between 100–160 bpm, with P waves present.

🔶 It is a normal physiologic response to exercise, stress, pain, or fever.

🔶 In this scenario, post-exercise increased heart rate is expected, confirming normal sinus conduction.

🔶 No abnormal atrial or ventricular rhythm patterns are identified.

🔶 Sinus tachycardia is managed by treating the underlying cause, not rhythm suppression.

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QLexNursing

1 :
The nurse is monitoring a 53-year-old client who is undergoing a cardiac exercise stress test after experiencing an episode of angina. Which client finding will require the test to be discontinued?

2 :
The nurse is caring for a client who sustained a crushed injury to the lower extremity and has developed compartment syndrome. What intervention should the nurse plan for next?

3 :
A nurse is caring for client with increased intracranial pressure What is an appropriate nursing intervention for the client?

4 :
A client has undergone a right femoral cardiac catheterization. What nursing action is the priority following the procedure?

5 :
A client with new-onset atrial flutter is unresponsive to drug therapy and is scheduled to receive further treatment. Which intervention should the nurse prepare the client to receive?

6 :
The charge nurse is teaching a group of telemetry nurses about cardioversion. Which statement by the telemetry nurse would indicate that they understand the instruction about the electrical discharge?

7 :
The nurse is caring for a client who is on cardiac telemetry monitoring and notes that the PR interval is 0.16 seconds. Which interpretation is correct for the nurse to make?

8 :
The nurse is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?

9 :
The nurse is evaluating a cardiac monitor strip for their client that displays a sinus rhythm with a heart rate of 72 bpm. The PR interval is 0.24 seconds. The vital signs are stable and the client reports no symptoms. What is the most appropriate nursing intervention?

10 :
After exercising, a client is hooked up to a cardiac monitor. The rhythm below is noted. How should the nurse document this rhythm?

QLexNursing

1 : The nurse is monitoring a 53-year-old client who is undergoing a cardiac exercise stress test after experiencing an episode of angina. Which client finding will require the test to be discontinued?

2 : The nurse is caring for a client who sustained a crushed injury to the lower extremity and has developed compartment syndrome. What intervention should the nurse plan for next?

3 : A nurse is caring for client with increased intracranial pressure What is an appropriate nursing intervention for the client?

4 : A client has undergone a right femoral cardiac catheterization. What nursing action is the priority following the procedure?

5 : A client with new-onset atrial flutter is unresponsive to drug therapy and is scheduled to receive further treatment. Which intervention should the nurse prepare the client to receive?

6 : The charge nurse is teaching a group of telemetry nurses about cardioversion. Which statement by the telemetry nurse would indicate that they understand the instruction about the electrical discharge?

7 : The nurse is caring for a client who is on cardiac telemetry monitoring and notes that the PR interval is 0.16 seconds. Which interpretation is correct for the nurse to make?

8 : The nurse is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?

9 : The nurse is evaluating a cardiac monitor strip for their client that displays a sinus rhythm with a heart rate of 72 bpm. The PR interval is 0.24 seconds. The vital signs are stable and the client reports no symptoms. What is the most appropriate nursing intervention?

10 : After exercising, a client is hooked up to a cardiac monitor. The rhythm below is noted. How should the nurse document this rhythm?

1 :
The nurse is monitoring a 53-year-old client who is undergoing a cardiac exercise stress test after experiencing an episode of angina. Which client finding will require the test to be discontinued?

2 :
The nurse is caring for a client who sustained a crushed injury to the lower extremity and has developed compartment syndrome. What intervention should the nurse plan for next?

3 :
A nurse is caring for client with increased intracranial pressure What is an appropriate nursing intervention for the client?

4 :
A client has undergone a right femoral cardiac catheterization. What nursing action is the priority following the procedure?

5 :
A client with new-onset atrial flutter is unresponsive to drug therapy and is scheduled to receive further treatment. Which intervention should the nurse prepare the client to receive?

6 :
The charge nurse is teaching a group of telemetry nurses about cardioversion. Which statement by the telemetry nurse would indicate that they understand the instruction about the electrical discharge?

7 :
The nurse is caring for a client who is on cardiac telemetry monitoring and notes that the PR interval is 0.16 seconds. Which interpretation is correct for the nurse to make?

8 :
The nurse is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?

9 :
The nurse is evaluating a cardiac monitor strip for their client that displays a sinus rhythm with a heart rate of 72 bpm. The PR interval is 0.24 seconds. The vital signs are stable and the client reports no symptoms. What is the most appropriate nursing intervention?

10 :
After exercising, a client is hooked up to a cardiac monitor. The rhythm below is noted. How should the nurse document this rhythm?