Saunders NCLEX-RN Test Bank
Saunders NCLEX-RN Test Bank VERIFIED
Questions And Answers(100% CORRECT
ANSWERS) WITH RATIONALES/
GUARANTEED PASS GRADED A+
The nurse notes that a client's cardiac rhythm shows absent P waves, no PR interval, and an irregular
rhythm. How should the nurse interpret this rhythm?
1.
Bradycardia
2.
Tachycardia
3.
A+ TEST BANK 1
, Saunders NCLEX-RN Test Bank
Atrial fibrillation
4.
Normal sinus rhythm (NSR) –
Correct Answer :Atrial fibrillation
In atrial fibrillation, the P waves are absent and replaced by fibrillatory waves. There is no PR interval,
and the QRS duration usually is normal and constant and the rhythm is irregular. Bradycardia is a
slowed heart rate, and tachycardia is a fast heart rate. In NSR, a P wave precedes each QRS complex,
the rhythm is essentially regular, the PR interval is 0.12 to 0.20 second, and the QRS interval is 0.06 to
0.10 second.
The nurse is assigned the care of a client with a diagnosis of heart failure who is receiving intravenous
doses of furosemide. The client is attached to cardiac telemetry, and the nurse is monitoring the
client's cardiac status. The nurse notes that the client's cardiac rhythm has changed to this pattern.
The nurse determines that the most likely cause of this cardiac rhythm in the client is which problem?
Refer to Figure.
.
1.
Pacemaker dysfunction
2.
The presence of hypokalemia
3.
The effectiveness of the furosemide
4.
An impending myocardial infarction (MI) –
A+ TEST BANK 2
, Saunders NCLEX-RN Test Bank
Correct Answer :The presence of hypokalemia
This cardiac rhythm is normal sinus rhythm with unifocal premature ventricular complexes (PVCs).
PVCs may be insignificant, or they may occur with myocardial ischemia or MI; heart failure;
hypokalemia; hypomagnesemia; medications; stress; nicotine, caffeine, or alcohol intake; infection;
trauma; or surgery. This client is receiving furosemide, a diuretic that causes the excretion of
potassium. The most likely cause of the PVCs in this client is hypokalemia. Option 3 is an incorrect
interpretation. The question presents no data indicating that this client has a pacemaker or has signs
or symptoms of an impending MI.
A client is attached to a cardiac monitor, and the nurse notes the presence of this cardiac rhythm on
the monitor. The nurse quickly assesses the client, knowing that this rhythm is indicative of which
rhythm? Refer to Figure.
1.
Atrial fibrillation
2.
Ventricular fibrillation (VF)
3.
Ventricular tachycardia (VT)
4.
Premature ventricular complexes –
Correct Answer :Ventricular tachycardia (VT
In VT, it usually is not possible to determine the atrial rhythm. The ventricular rhythm usually is regular
or nearly regular. The P waves usually are not visible and are obscured in the QRS complexes. VT
occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180
beats/min or more.
A+ TEST BANK 3
, Saunders NCLEX-RN Test Bank
The nurse is assessing a client's legs for the presence of edema. The nurse notes that the client has
mild pitting with slight indentation and no perceptible swelling of the leg. How should the nurse define
and document this finding?
1.
1+ edema
2.
2+ edema
3.
3+ edema
4.
4+ edema –
Correct Answer :1+ edema
Edema is accumulation of fluid in the intercellular spaces and is not normally present. To check for
edema, the nurse would imprint his or her thumbs firmly against the ankle malleolus or the tibia.
Normally, the skin surface stays smooth. If the pressure leaves a dent in the skin, pitting edema is
present. Its presence is graded on the following 4-point scale: 1+, mild pitting, slight indentation, no
perceptible swelling of the leg; 2+, moderate pitting, indentation subsides rapidly; 3+, deep pitting,
indentation remains for a short time, leg looks swollen; 4+, very deep pitting, indentation lasts a long
time, leg is very swollen.
The post-myocardial infarction client is scheduled for a technetium-99m ventriculography (multigated
acquisition [MUGA] scan). The nurse ensures that which item is in place before the procedure?
1.
A urinary catheter
2.
Signed informed consent
A+ TEST BANK 4
Saunders NCLEX-RN Test Bank VERIFIED
Questions And Answers(100% CORRECT
ANSWERS) WITH RATIONALES/
GUARANTEED PASS GRADED A+
The nurse notes that a client's cardiac rhythm shows absent P waves, no PR interval, and an irregular
rhythm. How should the nurse interpret this rhythm?
1.
Bradycardia
2.
Tachycardia
3.
A+ TEST BANK 1
, Saunders NCLEX-RN Test Bank
Atrial fibrillation
4.
Normal sinus rhythm (NSR) –
Correct Answer :Atrial fibrillation
In atrial fibrillation, the P waves are absent and replaced by fibrillatory waves. There is no PR interval,
and the QRS duration usually is normal and constant and the rhythm is irregular. Bradycardia is a
slowed heart rate, and tachycardia is a fast heart rate. In NSR, a P wave precedes each QRS complex,
the rhythm is essentially regular, the PR interval is 0.12 to 0.20 second, and the QRS interval is 0.06 to
0.10 second.
The nurse is assigned the care of a client with a diagnosis of heart failure who is receiving intravenous
doses of furosemide. The client is attached to cardiac telemetry, and the nurse is monitoring the
client's cardiac status. The nurse notes that the client's cardiac rhythm has changed to this pattern.
The nurse determines that the most likely cause of this cardiac rhythm in the client is which problem?
Refer to Figure.
.
1.
Pacemaker dysfunction
2.
The presence of hypokalemia
3.
The effectiveness of the furosemide
4.
An impending myocardial infarction (MI) –
A+ TEST BANK 2
, Saunders NCLEX-RN Test Bank
Correct Answer :The presence of hypokalemia
This cardiac rhythm is normal sinus rhythm with unifocal premature ventricular complexes (PVCs).
PVCs may be insignificant, or they may occur with myocardial ischemia or MI; heart failure;
hypokalemia; hypomagnesemia; medications; stress; nicotine, caffeine, or alcohol intake; infection;
trauma; or surgery. This client is receiving furosemide, a diuretic that causes the excretion of
potassium. The most likely cause of the PVCs in this client is hypokalemia. Option 3 is an incorrect
interpretation. The question presents no data indicating that this client has a pacemaker or has signs
or symptoms of an impending MI.
A client is attached to a cardiac monitor, and the nurse notes the presence of this cardiac rhythm on
the monitor. The nurse quickly assesses the client, knowing that this rhythm is indicative of which
rhythm? Refer to Figure.
1.
Atrial fibrillation
2.
Ventricular fibrillation (VF)
3.
Ventricular tachycardia (VT)
4.
Premature ventricular complexes –
Correct Answer :Ventricular tachycardia (VT
In VT, it usually is not possible to determine the atrial rhythm. The ventricular rhythm usually is regular
or nearly regular. The P waves usually are not visible and are obscured in the QRS complexes. VT
occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180
beats/min or more.
A+ TEST BANK 3
, Saunders NCLEX-RN Test Bank
The nurse is assessing a client's legs for the presence of edema. The nurse notes that the client has
mild pitting with slight indentation and no perceptible swelling of the leg. How should the nurse define
and document this finding?
1.
1+ edema
2.
2+ edema
3.
3+ edema
4.
4+ edema –
Correct Answer :1+ edema
Edema is accumulation of fluid in the intercellular spaces and is not normally present. To check for
edema, the nurse would imprint his or her thumbs firmly against the ankle malleolus or the tibia.
Normally, the skin surface stays smooth. If the pressure leaves a dent in the skin, pitting edema is
present. Its presence is graded on the following 4-point scale: 1+, mild pitting, slight indentation, no
perceptible swelling of the leg; 2+, moderate pitting, indentation subsides rapidly; 3+, deep pitting,
indentation remains for a short time, leg looks swollen; 4+, very deep pitting, indentation lasts a long
time, leg is very swollen.
The post-myocardial infarction client is scheduled for a technetium-99m ventriculography (multigated
acquisition [MUGA] scan). The nurse ensures that which item is in place before the procedure?
1.
A urinary catheter
2.
Signed informed consent
A+ TEST BANK 4
