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Saunders Nclex – Cardiac (Q’s And A’s)
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Saunders Nclex – Cardiac (Q’s And A’s)
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Saunders Nclex – Cardiac (Q’s And A’s)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?
Correct Ans - Normal sinus rhythm
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 having frequent premature ventricular contractions. The nurse
should place priority on assessment of which item? Correct Ans -
Blood pressure and oxygen saturation
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? Correct Ans -
Status of airway
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? Correct Ans - Sinus tachycardia
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 caring for a client with cardiac disease who has been placed
on a cardiac monitor. The nurse notes that the client has developed atrial
fibrillation and has a ventricular rate of 150 beats/min. The nurse should
next assess the client for which finding? Correct Ans - hypotension
The client with uncontrolled atrial fibrillation with a ventricular rate
greater than 100 beats/min is at risk for low cardiac output owing to loss
of atrial kick. The nurse assesses the client for palpitations, chest pain or
discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness,
syncope, shortness of breath, and distended neck veins.
The nurse is performing an assessment on a client with a diagnosis of left-
sided heart failure. Which assessment component would elicit specific
information regarding the client's left-sided heart function? Correct
Ans - Listening to lung sounds
The client with heart failure may present with different symptoms,
depending on whether the right or the left side of the heart is failing.
Peripheral and sacral edema, jugular vein distention, and organomegaly all
are manifestations of problems with right-sided heart function. Lung
sounds constitute an accurate indicator of left-sided heart function.
The nurse is reviewing the electrocardiogram (ECG) rhythm strip obtained
on a client with a diagnosis of myocardial infarction. The nurse notes that
the PR interval is 0.20 second. The nurse should make which interpretation
about this finding? Correct Ans - A normal finding
The PR interval represents the time it takes for the cardiac impulse to
spread from the atria to the ventricles. The normal range for the PR
interval is 0.12 to 0.20 second. Options 2, 3, and 4 are incorrect.
The home care nurse has taught a client with a problem of inadequate
cardiac output about helpful lifestyle adaptations to promote health. Which
statement by the client best demonstrates an understanding of the
information provided? Correct Ans - "I will eat enough daily fiber
to prevent straining at stool."
Standard home care instructions for a client with this problem include,
among others, lifestyle changes such as decreased alcohol intake, avoiding
activities that increase the demands on the heart, instituting a bowel
regimen to prevent straining and constipation, and maintaining fluid and
electrolyte balance. Consuming 3000 to 3500 mL of fluid and exercising
vigorously will increase the cardiac workload.
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