Page 1757 - Saunders Comprehensive Review For NCLEX-RN

Test-Taking Strategy: Focus on the subject, cardiogenic shock, and note the words
myocardial ischemia. Recall that ischemia makes the myocardium irritable, producing
dysrhythmias. Also, knowledge of the classic signs of shock helps eliminate the
incorrect options.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Complex Care: Emergency Situations/Management
Health Problem: Adult Health: Cardiovascular: Shock
Priority Concepts: Clinical Judgment; Perfusion
Reference: Ignatavicius, Workman (2016), p. 759.

606. Answer: 2

Rationale: The client who undergoes cardiac surgery is at risk for renal injury
from poor perfusion, hemolysis, low cardiac output, or vasopressor medication
therapy. Renal injury is signaled by decreased urine output and increased blood
urea nitrogen (BUN) and creatinine levels. Normal reference levels are BUN, 10 to
20 mg/dL (3.6 to 7.1 mmol/L), and creatinine 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) for
males and 0.5 to 1.1 mg/dL (44 to 97 mcmol/L) for females. The client may need
medications to increase renal perfusion and possibly could need peritoneal dialysis
or hemodialysis. No data in the question indicate the presence of hypovolemia,
glomerulonephritis, or urinary tract infection.
Test-Taking Strategy: Eliminate glomerulonephritis and urinary tract infection
first because they are comparable or alike in that there are no data indicating
infection or inflammation. Noting that the creatinine level is elevated and the
minimal urinary response to the fluid bolus will assist you in eliminating
hypovolemia.
Level of Cognitive Ability: Synthesizing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Analysis
Content Area: Adult Health: Renal and Urinary
Health Problem: Adult Health: Cardiovascular: Coronary Artery Disease
Priority Concepts: Clinical Judgment; Perfusion
References: Ignatavicius, Workman (2016), p. 777; Lewis et al. (2014), p. 1102.

607. Answer: 3

Rationale: Normal sinus rhythm is defined as a regular rhythm, with an overall
rate of 60 to 100 beats per minute. The PR and QRS measurements are normal,
measuring between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds, respectively.
There are no irregularities in this rhythm currently, so there is no immediate need to
check vital signs or laboratory results, or to notify the primary health care provider.
Therefore, the nurse would continue to monitor the client for any rhythm change.
Test-Taking Strategy: Focus on the subject, electrocardiogram rhythm strip
measurements. A baseline knowledge of normal electrocardiographic measurements
is needed to answer this question. Focusing on the data in the question and recalling

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