Saunders NCLEX Questions & Answers
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?
1.
The neurovascular status is normal because of increased blood flow through the leg.
2.
The neurovascular status is moderately impaired, and the surgeon should be called.
3.
The neurovascular status is slightly deteriorating and should be monitored for another hour.
4.
The neurovascular status is adequate from an arterial approach, but venous complications are arising. -
ANS;1
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?
1.
The neurovascular status is normal because of increased blood flow through the leg.
2.
The neurovascular status is moderately impaired, and the surgeon should be called.
3.
The neurovascular status is slightly deteriorating and should be monitored for another hour.
4.
The neurovascular status is adequate from an arterial approach, but venous complications are arising. -
ANS;1
