Saunders NCLEX Exam Questions And
Answers 100% Pass.
The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are
regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall
heart rate is 64 beats/minute. Which would be a correct interpretation based on these
characteristics?
1.
Sinus bradycardia
2.
Sick sinus syndrome
3.
Normal sinus rhythm
4.
First-degree heart block - answer✔3
Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100
beats/minute. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and
0.04 to 0.10 second, respectively.
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees
no electrocardiographic complexes on the screen. Which is the priority action of the nurse?
1.
Call a code.
2.
Call the health care provider.
3.
Check the client's status and lead placement.
4.
Press the recorder button on the electrocardiogram console. - answer✔3
Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly
electrode displacement. Accurate assessment of the client and equipment is necessary to
determine the cause and identify the appropriate intervention. The remaining options are
secondary to client assessment.
A client is having frequent premature ventricular contractions. The nurse should place priority on
assessment of which item?
Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority
is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can
lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations.
Premature ventricular contractions can be caused by cardiac disorders, states of hypoxemia, or
by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by
intake of caffeine, nicotine, or alcohol.
The nurse is evaluating a client's response to cardioversion. Which observation would be of
highest priority to the nurse?
Nursing responsibilities after cardioversion include maintenance first of a patent airway, and
then oxygen administration, assessment of vital signs and level of consciousness, and
dysrhythmia detection.
A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR
interval is 0.14 second, the QRS complex measures 0.08 second, and the PP and RR intervals are
regular. How should the nurse correctly interpret this rhythm?
1.
Sinus dysrhythmia
2.
Sinus tachycardia
3.
Sinus bradycardia
4.
Normal sinus rhythm - answer✔2
Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval
and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus
tachycardia, the atrial and ventricular rates are greater than 100 beats/minute.
The nurse is assessing the neurovascular status of a client who returned to the surgical nursing
unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse
notes redness and edema. The pedal pulse is palpable and unchanged from admission. How
should the nurse correctly interpret the client's neurovascular status?
1.
The neurovascular status is normal because of increased blood flow through the leg.
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