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Saunders Nclex Questions Latest Update 2024/2025
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Saunders Nclex Questions Latest Update 2024/2025
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Saunders Nclex Questions Latest Update2024/2025
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 - ANS;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.
QUESTION;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. - ANS;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.
QUESTION;A client is having frequent premature ventricular contractions. The nurse
should place priority on assessment of which item?
1.
Sensation of palpitations
2.
Causative factors, such as caffeine
3.
,Precipitating factors, such as infection
4.
Blood pressure and oxygen saturation - ANS;4
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.
QUESTION;The nurse is evaluating a client's response to cardioversion. Which observation
would be of highest priority to the nurse?
1.
Blood pressure
2.
Status of airway
3.
Oxygen flow rate
4.
Level of consciousness - ANS;2
, 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.
QUESTION;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 - ANS;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.
QUESTION;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?
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