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RANKING AND SATA TEST 1 SPRING Questions and Answers 100% Solved 2024/2025
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RANKING AND SATA TEST 1 SPRING1 3 4 2 (Because atrial fibrillation causes a decrease in cardiac output, the HR increases in
response to this drop. As a result of an increased HR the O2 demands of the heart increase. It
is important O2 is administered first to compensate for the increased workload and o2 demand.
Placing the client on a cardiac monitor will help confirm a diagnosis of atrial fibrillation.
Performing VS will determine the client response to the abnormal rhythm and responses to
treatment. If the rhythm is determined to be atrial fibrillation it will be necessary for an IV to be
inserted so medication can be administered) - ANSA client has atrial fibrillation and a HR of 165
bpm. In which order from first to last should the nurse implement these prescriptions? Use all
options, no commas
1. admin o2 via nasal cannula
2.. gather supplies for IV insertion
3. place the client on ECG monitor
4. obtain VS including BP, HR, RR, T and O2 sat
1,2,4
(Explanation:
If the client is experiencing hypovolemic shock related to blood loss in surgery, the hemoglobin
(oxygen carrying capacity) will be lowered. The central venous pressure will drop with
hypovolemic shock. Pulmonary artery wedge pressure indicates left ventricular function.
NORMS: Pulmonary Artery Pressure (PA) Systolic 20-30 mmHg (PAS) Diastolic 8-12 mmHg
(PAD) Mean 25 mmHg (PAM). The hematocrit is the number of red blood cells per cubic
millimeter. The troponin is elevated, but indicates cardiac muscle damage, not hypovolemia.) -
ANSThe client is admitted to the intensive care unit following a coronary artery bypass graft.
The nurse checks the vital signs and notes a heart rate of 120 beats per minute, blood pressure
of 70/40, and respiration of 32 breaths per minute. The nurse hypovolemic shock. Which
assessment tools would
contribute to a diagnosis of hypovolemic shock?
Select all that apply.
1 Hemoglobin of 5g
2 Central venous pressure of 2mm of mercury
3 Pulmonary artery wedge pressure of 16mm of mercury
4 Hematocrit of 22%
5 Troponin (T 1) level of 4mcg/L
a,b
(The consistency of the RR interval indicates regular rhythm. A normal P wave before each
complex indicates the impulse originated in the SA node. The number of complexes in a 6
second strip is multiplied by 10 to approximate the heart rate; normal sinus rhythm is 60 to 100.
Elevation of the ST segment is a sign of cardiac ischemia and is unrelated to the rhythm. The
,QRS duration should be less than 0.12 second; the PR interval should be 0.12 to 0.20 second.)
- ANSWhat criteria should the nurse use to determine normal sinus rhythm for a client on a
cardiac monitor? Check all that apply.
A The RR intervals are relatively consistent
B One P wave precedes each QRS complex
C Four to eight complexes occur in a 6 second strip
D The ST segment is higher than the PR interval
E The QRS complex ranges from 0.12 to 0.20 second
1,3,4 (The client has atrial fibrillation and will have an irregularly irregular pulse and will
commonly be tachycardic, with rapid ventricular responses (HR) typically in the 110 to 140
range, but rarely over 150-170. The goal of treatment is the restoration of sinus rhythm. With a
heart rate >150 and symptoms of sob, dizziness and syncope, and chest pain, synchronized
cardioversion will most likely be the treatment of choice. With more controlled HR and more
minor S/S, chemical conversion with drugs such as diltiazem and digoxin prior to other
interventions such as synchronized cardioversion with appropriate anticoagulation may be
attempted. Because of the decreased cardiac output, monitoring is essential. Obtaining consent
for cardioversion requires a prescription from the HCP, but with the current HR having
cardioversion is a very strong possibility for this client. Defib is used for ventricular fibrillation,
not - ANSAn 85 year old client is admitted to the ER at 2000 hrs with syncope, shortness of
breath, and reported palpitations. (see notes below) At 2015 the nurse places the client on the
ECG monitor and identifies the following rhythm (Afib) What should the nurse do? SATA
Admitted: 2000 hours
HR 150
BP 90/62
O2 sat 92% room air
RR 22
client is sob states "heart is jumping out of my chest and hurts some, I am having trouble
catching my breath, I dont want to faint again"
1. apply oxygen
2.. prepare to defibrillate
3. monitor VS
4. have the client sign the consent for cardioversion as prescribed
5. teach the client about warfarin treatment and the need for frequent blood testing
6. draw a CBC count and thyroid function study
2 1 3 4 (To decrease myocardial workload and promote timely intervention, the client should be
assisted to the bed. Assessing the VS provides the data needed to determine client tolerance.
Early initiation of an IV access will enable timely medication administration if it is emergently
needed. While a 12 lead ECG is needed it can be obtained after the IV is initiated) -
ANSCardiac telemetry shows that a client who is up to the bathroom has converted from normal
sinus rhythm with a rate of 72 to atrial fibrillation with a ventricular response rate of 100 bpm. In
, what order from first to last should the nurse perform these interventions? Use all and no
commas
1. assess the VS
2 assist the client to bed
3. initiate IV access
4. obtain a 12 lead electrocardiogram stat
1,2,4,5
(ORthostatic hypotension is a drop in BP that occurs with position changes, usually to a more
upright position. Often occurs in elderly clients, and it is a common cause of falls. Nurses must
assess clients for and assist all clients with standing to aid in prevention of decreased
orthostatic systolic BP and reduce symptoms in elderly clients with progressive OT. Nurses must
teach clients to gradually change position, and conduct a fall risk assessment. SCD's may be
helpful in clients at high risk and should be considered when developing a care plan.
Antihypertensives may precipitate dangerous drops in BP. Clients should be encouraged to be
ambulatory) - ANSThe nurse is planning care for a group of elderly clients who are affected by
orthostatic hypotension. What should the nurse do? SATA
1. Assist the clients to stand to help prevent falls
2. Teach clients how to gradually change their position
3 request a prescription for an antihypertensive med for clients at high risk
4. conduct fall risk assessments
5. consider use of SCDs for high risk clients
6. Place the clients on bed rest
4,5 - ANSThe nurse is caring for a group of clients on a medical surgical nursing unit. Which
task(s) can be delegated to UAP? SATA
1. Assess pedal pulses on a client just returned from a cardiac angiogram
2. admin O2 via nasal cannula to a client with O2 sat of 89%
3. Admin Tylenol to a client with a pain level of "5" out of "10"
4.. Perform VS and O2 sat on client returning from a cath lab
5. obtain I&O on a client experiencing heart failure
2 4 3 1 (Even though the chest pain experienced by Client 2 is resolved, it was recent and
requires reassessment. Client 4 is scheduled to leave for major surgery very soon. The nurse
should check this client and the clients chart and make certain that everything is ready so as not
to delay the surgery. Client 3 has scheduled medications for BP control. While not experiencing
any acute problems, this medication should be administered as scheduled. Client 1 is stable at
this time and can be seen last.) - ANSA nurse working the day shift on a cardiac unit receives
the following shift report: At the conclusion of the report it is 0730. Put the clients in order from
first to last in which the nurse should plan to assess them. All options must be used
1 client 1. Admitted yesterday morning with hypokalemia Awaiting repeat electrolyte lab results
drawn at 0600
2. Client 2: Experiencing chest pain at 0630. Pain resolved after 2 sublingual nitro tablets
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