Question: A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 100 beats/min. The nurse determines that the client is experiencing which of the following dysrhythmias?
1. Sinus tachycardia
2. Ventricular fibrillation
3. Ventricular tachycardia
4. Premature ventricular contractions
Rationale:Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 second), and typically a rate between 140 and 180 impulses/min. The rhythm is regular.
Test-taking Strategy:Focus on the data in the question. Eliminate option 1 first because there are no P waves. Premature ventricular contractions are isolated ectopic beats superimposed on an underlying rhythm, so option 4 is eliminated next. Recalling that there are no true QRS complexes with ventricular fibrillation will direct you to option 3 from the remaining options. Review the characteristics of ventricular tachycardia if you are unfamiliar with it.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process--Assessment
Content Area: Critical Care
Reference: Ingatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 748). St. Louis: Saunders.
This week’s NCLEX exam practice question came from:
Silvestri: Saunders Comprehensive Review for the NCLEX-RN Examination, 5th Edition, Chapter 60, page 824, Question 701
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