Page 1759 - Saunders Comprehensive Review For NCLEX-RN

Rationale: Ventricular tachycardia is a life-threatening dysrhythmia that results
from an irritable ectopic focus that takes over as the pacemaker for the heart.
Ventricular tachycardia can deteriorate into ventricular fibrillation at any time.
Clients frequently experience a feeling of impending doom. The low cardiac output
that results can lead quickly to cerebral and myocardial ischemia. Ventricular
tachycardia is treated with antidysrhythmic medications, cardioversion (if the client
is awake), or defibrillation (loss of consciousness).
Test-Taking Strategy: Note the strategic word, most. The option indicating that it
is impossible to convert is incorrect and is eliminated first. From the remaining
options, focusing on the strategic word will direct you to the correct option because
this option identifies the life-threatening condition.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Analysis
Content Area: Complex Care: Emergency Situations/Management
Health Problem: Adult Health: Cardiovascular: Dysrhythmias
Priority Concepts: Clinical Judgment; Perfusion
Reference: Ignatavicius, Workman (2016), p. 670.

611. Answer: 3

Rationale: 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; any
number of physiological stressors, such as infection, illness, surgery, or trauma; and
intake of caffeine, nicotine, or alcohol.
Test-Taking Strategy: Note the strategic word, priority. Use the ABCs—airway,
breathing, and circulation—to direct you to the correct option.
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), p. 799.

612. Answer: 1, 2, 3

Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate
more than 100 beats per minute is at risk for low cardiac output because of loss of
atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort,
hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of
breath, and distended neck veins. Hypertension and flat neck veins are not
associated with the loss of cardiac output.
Test-Taking Strategy: Focus on the subject, signs and/or symptoms associated

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