Page 1762 - Saunders Comprehensive Review For NCLEX-RN

Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Cardiovascular
Health Problem: Adult Health: Cardiovascular: Dysrhythmias
Priority Concepts: Clinical Judgment; Perfusion
Reference: Ignatavicius, Workman (2016), p. 668.

618. Answer: 2

Rationale: The nurse who is caring for the client after insertion of an automatic
internal cardioverter-defibrillator needs to assess device settings, similar to after
insertion of a permanent pacemaker. Specifically, the nurse needs to know whether
the device is activated, the heart rate cutoff above which it will fire, and the number
of shocks it is programmed to deliver. The remaining options are also nursing
interventions but are not the priority.
Test-Taking Strategy: Note the strategic word, priority. Use Maslow’s Hierarchy
of Needs theory. The correct option is the one that identifies the physiological need.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Cardiovascular
Health Problem: Adult Health: Cardiovascular: Dysrhythmias
Priority Concepts: Perfusion; Safety
Reference: Lewis et al. (2014), p. 803.

619. Answer: 1

Rationale: Sinus tachycardia has the characteristics of normal sinus rhythm,
including a regular PP interval and normal-width PR and QRS intervals; however,
the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular
rates are greater than 100 beats per minute.
Test-Taking Strategy: Focus on the subject, interpreting a cardiac rhythm.
Eliminate sinus bradycardia and normal sinus rhythm first, because the ventricular
rate is 110 beats per minute. Next eliminate sinus dysrhythmia, because this is an
irregular rhythm, with changing PP and RR intervals.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Cardiovascular
Health Problem: Adult Health: Cardiovascular: Dysrhythmias
Priority Concepts: Clinical Judgment; Perfusion
Reference: Ignatavicius, Workman (2016), pp. 662-663.

620. Answer: 1

Rationale: An expected outcome of aortoiliac bypass graft surgery is warmth,
redness, and edema in the surgical extremity because of increased blood flow. The
remaining options are incorrect interpretations.

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