Page 1760 - Saunders Comprehensive Review For NCLEX-RN

with atrial fibrillation. Flat neck veins are normal or indicate hypovolemia, so this
option can be eliminated. From the remaining options, think of the consequences of a
falling cardiac output 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. 707.

613. Answer: 1

Rationale: Atrial fibrillation is characterized by a loss of P waves and fibrillatory
waves before each QRS complex. The atria quiver, which can lead to thrombus
formation.
Test-Taking Strategy: Focus on the subject, interpreting a heart rhythm. Note the
data in the question. Noting the words There are no P waves should direct you to the
correct option. Loss of P waves is characteristic of this dysrhythmia.
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: Ignatavicius, Workman (2016), pp. 666-667.

614. Answer: 4

Rationale: Until the defibrillator is attached and charged, the client is resuscitated
by using cardiopulmonary resuscitation. Once the defibrillator has been attached,
the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation
or pulseless ventricular tachycardia. Leads also are checked for any loose
connections. A nitroglycerin patch, if present, is removed. The client does not have
to be intubated to be defibrillated. The machine is not set to the synchronous mode
because there is no underlying rhythm with which to synchronize.
Test-Taking Strategy: Note the strategic word, priority. Focus on the subject,
ventricular fibrillation. Note that the correct option directly addresses this subject
and also addresses assessment of the client.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Complex Care: Basic Life Support/Cardiopulmonary
Resuscitation/Cardiac Arrest
Health Problem: Adult Health: Cardiovascular: Dysrhythmias
Priority Concepts: Perfusion; Safety
Reference: Lewis et al. (2014), pp. 801-802.

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