Page 1758 - Saunders Comprehensive Review For NCLEX-RN

the characteristics of normal sinus rhythm will help you prioritize your actions.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Implementation
Content Area: Adult Health: Cardiovascular
Health Problem: Adult Health: Cardiovascular: Dysrhythmias
Priority Concepts: Clinical Judgment; Perfusion
Reference: Ignatavicius, Workman (2016), p. 656.

608. Answer: 2

Rationale: Sudden loss of electrocardiographic complexes indicates ventricular
asystole or possibly electrode displacement. Accurate assessment of the client is
necessary to determine the cause and identify the appropriate intervention. The
remaining options are secondary to client assessment.
Test-Taking Strategy: Note the strategic word, priority. Use the steps of the
nursing process. Always assess the client directly before taking any action related to
equipment. The correct option is the only one that addresses assessment.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Complex Care: Emergency Situations/Management
Health Problem: Adult Health: Cardiovascular: Dysrhythmias
Priority Concepts: Clinical Judgment; Perfusion
Reference: Lewis et al. (2014), p. 790.

609. Answer: 3

Rationale: Ventricular tachycardia is characterized by the absence of P waves,
wide QRS complexes (longer than 0.12 seconds), and typically a rate between 140
and 180 impulses per minute. The rhythm is regular.
Test-Taking Strategy: Focus on the subject, the characteristics of an
electrocardiogram pattern, and note the data in the question. Eliminate sinus
tachycardia first, because there are no P waves. Premature ventricular contractions
are isolated ectopic beats superimposed on an underlying rhythm, so that option is
eliminated next. Recalling that there are no true QRS complexes with ventricular
fibrillation will direct you to the correct option from those remaining.
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: Dysrhythmias
Priority Concepts: Clinical Judgment; Perfusion
Reference: Lewis et al. (2014), pp. 794, 799-800.

610. Answer: 1

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