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HESI Exit Exam Test Bank QUESTIONS AND ANSWERS

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A client’s cardiac status is being observed by telemetry monitoring. The nurse observes a P wave that changes shape in lead II. What conclusion does the nurse make about the P wave? It originates from an ectopic focus. If the P wave is firing consistently from the SA node, the P wave will have a consistent shape in a given lead. If the impulse is from an ectopic focus, then the P wave will vary in shape in that lead. The nurse is assessing the client’s electrocardiography (ECG). What does the P wave on the ECG tracing represent? Depolarization of the atria The ECG tracing of a P wave represents electrical changes caused by atrial depolarization. A nurse notes that the PR interval on a client’s electrocardiograph (ECG) tracing is 0.14 second. What action does the nurse take? Document the finding in the client’s chart. The PR interval normally ranges from 0.12 to 0.20 second. This is a normal finding, so the nurse simply documents this. No further action is required . When analyzing a client’s electrocardiograph (ECG) tracing, the nurse observes that not all QRS complexes are preceded by a P wave. What is the nurse’s interpretation of this observation? Ventricular and atrial depolarizations are initiated from different sites. Normal rhythm shows one P wave preceding each QRS, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization. The nurse observes a prominent U wave on the client’s electrocardiograph (ECG) tracing. What is the most appropriate action for the nurse to take? Review the client’s daily electrolyte results. Prominent U waves may be the result of hypokalemia. The nurse should review the client’s daily electrolyte results. Although documentation is important, this is not a normal variant. Moving the crash cart closer to the room may or may not be warranted. The client does not need an immediate ECG. The client’s heart rate increases slightly during inspiration and decreases slightly during expiration. What action does the nurse take? Document the finding in the chart. Sinus dysrhythmia is noted when the heart rate increases slightly during inspiration and decreases slightly during expiration. Sinus dysrhythmia is a variant of normal sinus rhythm that is frequently observed in healthy children and adults. No other actions are needed. A client with tachycardia is experiencing clinical manifestations. Which manifestation requires immediate intervention by the nurse? Mid-sternal chest pain Chest pain, possibly angina, indicates that tachycardia may be increasing the client’s myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. A client is experiencing sinus bradycardia with hypotension and dizziness. What medication does the nurse administer? Atropine (Atropine) Atropine is a cholinergic antagonist that inhibits parasympathetically-induced hyperpolarization of the sinoatrial node. This inhibition results in an increased heart rate. The other medications are not appropriate.

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