Page 1761 - Saunders Comprehensive Review For NCLEX-RN

615. Answer: 4

Rationale: The energy level used for all defibrillation attempts with a monophasic
defibrillator is 360 joules.
Test-Taking Strategy: Focus on the subject, monophasic defibrillation. As a
general rule, though, remember that lower levels of energy are used for
cardioversion and biphasic defibrillation. Higher levels are used in monophasic
defibrillation.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
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), p. 802.

616. Answer: 1

Rationale: After defibrillation, the client requires continuous monitoring of
electrocardiographic rhythm, hemodynamic status, and neurological status.
Respiratory and metabolic acidosis develop during ventricular fibrillation because of
lack of respiration and cardiac output. These can cause cerebral and
cardiopulmonary complications. Arousable status, adequate BP, and a sinus rhythm
indicate successful response to defibrillation.
Test-Taking Strategy: Note the strategic word, most. Eliminate the options that
contain the word nonarousable. From the remaining options, select the correct option,
because a sinus rhythm is a more successful response compared with marked
bradycardia.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Evaluation
Content Area: Complex Care: Basic Life Support/Cardiopulmonary
Resuscitation/Cardiac Arrest
Health Problem: Adult Health: Cardiovascular: Dysrhythmias
Priority Concepts: Evidence; Perfusion
Reference: Ignatavicius, Workman (2016), p. 672.

617. Answer: 2

Rationale: Nursing responsibilities after cardioversion include maintenance first
of a patent airway, and then oxygen administration, assessment of vital signs and
level of consciousness, and dysrhythmia detection.
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

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