ECG and ACLS Evaluation Exam

An unlicensed assistive personnel (UAP) reports to the nurse that a postoperative surgical client, who had an abdominal mass removed 12 hours ago, has a blood pressure of 88/62 mm Hg. The client’s prescriptions from the healthcare provider (HCP) indicate to report any systolic blood pressure < 100 mm Hg. Which is the nurse’s priority action based on the current data? Select all that apply.

• Call for a stat 12-lead electrocardiogram (ECG).
• Check level of consciousness.
• Contact the HCP immediately.
• Palpate the client's abdomen.
• Percuss anterior lung fields.

The nurse provides care for a client who is diagnosed with type 2 diabetes mellitus and hypertension. Which prescribed medication is likely the cause of the client’s bradycardia that is noted on the echocardiogram (EKG)?

• Atorvastatin 80 mg PO once a day.
• Labetalol 100 mg PO twice a day.
• Metformin 500 mg once daily.
• Albuterol 120 mcg prn.

Which is the priority nursing intervention for a client who is about to leave the hospital against medical advice (AMA)?

• Advise the client of the diagnosis and the danger of leaving.
• Discontinue the client's peripheral intravenous (IV) lines and the electrocardiogram (EKG) leads.
• Ensure a witness is present to verify the client's wish to leave AMA.
• Tell the client they must sign the AMA form.

The nurse provides care for a client who is receiving chemotherapy with the following laboratory data: ALT 50 U/L; AST 45 U/L; absolute neutrophil count (ANC) 500/mm3 (0.5 x 109/L); hemoglobin 9 g/dL (90 g/L); platelet count 160,000/mm3 (160 x 109/L); serum potassium 3.3 mEq/L (3.3 mmol/L); serum sodium 142 mEq/L (142 mmol/L); and a white blood cell (WBC) count 1,300/mm3 (1.3 x 109/L). Based on this data, which is the priority action by the nurse?

• Assess the client for any signs of bleeding.
• Call the healthcare provider (HCP) to prescribe oprelvekin, by subcutaneous injection.
• Evaluate the client's EKG strip for QT interval prolongation.
• Instruct the client to wear a mask over the mouth and nose.

A client who is prescribed hemodialysis has the following assessment data: serum potassium level is 8 mEq/L (8 mmol/L) and the latest electrocardiogram (ECG) indicates tall, peaked T waves. Which is the priority prescription for the nurse to implement to protect the client from experiencing dysrhythmias related to hyperkalemia?

• Calcium gluconate by intravenous piggyback (IVPB).
• Intravenous (IV) regular insulin with dextrose.
• Sodium polystyrene sulfonate by mouth.
• Furosemide 40 mg by intravenous push (IVP) now.

An adolescent client who is diagnosed with type 1 diabetes mellitus (DM) experiences blurred vision, fatigue, increased thirst, and decreased urine output. Labs have been drawn and the client’s fasting blood glucose is 375 mg/dL (20.8 mmol/L) and arterial blood gas (ABG) shows a pH of 7.25. The client’s electrocardiogram (ECG) indicates a normal sinus rhythm at a rate of 108 beats/minute with peaked T waves. Which is the priority action by the nurse?

• Begin regular insulin, per infusion pump as prescribed.
• Administer 0.9% sodium chloride as prescribed.
• Collect a clean catch urine specimen for urinalysis.
• Give prescribed potassium 40 mEq/L over 4 hours.

The nurse provides care for a client who presents to the emergency department (ED) reporting a pounding heart beat after consuming several energy drinks throughout the day. Current vital signs are as follows: blood pressure 164/100 mm Hg, heart rate 126 beats/minute, respiratory rate 24 breaths/minute, and oxygen saturation is 92% on room air (RA). An electrocardiogram (ECG) is obtained. Which does the nurse anticipate when reviewing the ECG based on the current data?

• Normal sinus rhythm with premature atrial contractions.
• Sinus tachycardia with premature ventricular contractions.
• Third degree atrioventricular heart block.
• Ventricular tachycardia with a pulse.

The nurse provides care for a client who is scheduled for a minor procedure. Prior to the procedure, an electrocardiogram (ECG) is performed indicating new-onset ST segment elevation of 2 mm in two contiguous leads. Which is the priority nursing action based on this data?

• Fax a copy of the ECG to the clinic of the client's primary care health care provider (HCP).
• Give the client sublingual nitroglycerin and PO aspirin 325 mg stat.
• Place the results on the front of the client's medical record for the surgical team.
• Report findings to the health care provider (HCP) immediately.

An electrocardiogram (ECG) unlicensed technician prints a cardiac rhythm strip and gives it to the nurse. The rate is regular and 84 beats/minute, a P wave is present before each QRS, the PR interval is 0.12 seconds, and the QRS is 0.08 seconds. Which rhythm does the nurse identify based on the current data?

• Atrial flutter.
• Bundle branch block.
• First-degree atrioventricular (AV) block.
• Sinus rhythm.

A client presents to the emergency department with reports of chest pain and ECG changes are noted upon initial assessment. Thirty minutes after receiving a 161 mg dose of aspirin, the client reports shortness of breath and chest tightness. Upon auscultation, the nurse notes audible wheezes. Which action should the nurse implement?

• Administer epinephrine 1:10000 IM.
• Raise the client’s head of bed.
• Begin 0.9% sodium chloride at 500 mL/hr.
• Insert a nasogastric tube for gastric decompression.