Page 60 - Saunders Comprehensive Review For NCLEX-RN

3. Places a nitroglycerin tablet under the client’s tongue
4. Continues to monitor the client and then contacts the cardiologist

Answer: 2
This question requires you to identify the cardiac rhythm, and then determine the
priority nursing action. Note the strategic word, immediately. This cardiac rhythm
identifies a coarse ventricular fibrillation (VF). The goals of treatment are to
terminate VF promptly and to convert it to an organized rhythm. The primary
health care provider, cardiologist, or an Advanced Cardiac Life Support (ACLS)–
qualified nurse must immediately defibrillate the client. If a defibrillator is not
readily available, CPR is initiated until the defibrillator arrives. Options 1, 3, and 4
are incorrect actions and delay lifesaving treatment.

Chart/Exhibit Questions

In this type of question, you will be presented with a problem and a chart or exhibit.
You will be provided with tabs or buttons that you need to click to obtain the
information needed to answer the question. A prompt or message will appear that
will indicate the need to click on a tab or button. See Box 1-10 for an example.

Box 1-10

Chart/Exhibit Question

The nurse reviews the history and physical examination documented in the medical
record of a client requesting a prescription for oral contraceptives. The nurse
determines that oral contraceptives are contraindicated because of which
documented items? Refer to chart. Select all that apply.

Answer: Items 2, 3, 4, 11
This chart/exhibit question provides you with data from the client’s medical record.
Focus on the subject, the item(s) that are a contraindication to the use of oral
contraceptives. Oral contraceptives are contraindicated in women with a history of
any of the following: thrombophlebitis and thromboembolic disorders,
cardiovascular or cerebrovascular diseases (including stroke), any estrogen-
dependent cancer or breast cancer, benign or malignant liver tumors, impaired liver
function, hypertension, and diabetes mellitus with vascular involvement. Adverse

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