Chapter 36: Care of Patients with Dysrhythmias

A client experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. What instruction does the nurse include in the client's teaching plan? a. "Minimize or abstain from caffeine." b. "Lie on your side until the attack subsides." c. "Use your oxygen when you experience PACs." d. "Take quinidine (Cardioquin) daily to prevent PACs."

a. "Minimize or abstain from caffeine." ANS: A PACs usually have no hemodynamic consequences. For a client experiencing infrequent bouts of PACs, the nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the client first should try lifestyle changes to control them.

A client's electrocardiograph (ECG) tracing shows a run of sustained ventricular tachycardia. What is the nurse's first action? a. Assess airway, breathing, and level of consciousness. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR).

a. Assess airway, breathing, and level of consciousness. ANS: A The first action that the nurse should take when ventricular tachycardia is observed is to assess the client's airway, breathing, and level of consciousness. If the client is unconscious or has experienced respiratory arrest, defibrillation and CPR are begun.

A client is experiencing sinus bradycardia with hypotension and dizziness. What medication does the nurse administer? a. Atropine (Atropine) b. Digoxin (Lanoxin) c. Lidocaine (Xylocaine) d. Metoprolol (Lopressor)

a. Atropine (Atropine) ANS: A Atropine is a cholinergic antagonist that inhibits parasympathetically-induced hyperpolarization of the sinoatrial node. This inhibition results in an increased heart rate. The other medications are not appropriate.

A client has a consistently regular heart rate of 128 beats/min. Which related physiologic alterations does the nurse assess for? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Increase in blood pressure d. Decrease in blood pressure e. Increase in urine output

a. Decrease in cardiac output d. Decrease in blood pressure

21. A client with ischemic heart disease has an electrocardiograph (ECG) tracing that shows a PR interval of 0.24 second. What is the nurse's best action? a. Document the finding in the chart. b. Measure blood pressure. c. Notify the health care provider. d. Administer oxygen.

a. Document the finding in the chart. ANS: A This prolonged PR interval indicates a first-degree heart block. First-degree heart block in a stable client requires no intervention.

A client has an epicardial pacemaker. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiograph (ECG) tracing. How does the nurse interpret this event? a. Loss of capture b. Ventricular fibrillation c. Failure to sense d. A normal tracing

a. Loss of capture ANS: A In epicardial pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture.

A client with tachycardia is experiencing clinical manifestations. Which manifestation requires immediate intervention by the nurse? a. Mid-sternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave

a. Mid-sternal chest pain ANS: A Chest pain, possibly angina, indicates that tachycardia may be increasing the client's myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain.

The nurse notes the following rhythm on a client's telemetry monitor. How does the nurse interpret these findings? a. Ventricular tachycardia b. Second-degree heart block c. Supraventricular tachycardia d. Premature ventricular contractions

a. Ventricular tachycardia

A client has a heart rate averaging 56 beats/min with no adverse symptoms. What activity modifications does the nurse suggest to avoid further slowing of the heart rate? a. "Make certain that your bath water is warm (100° F)." b. "Avoid bearing down or straining while having a bowel movement." c. "Avoid strenuous exercise, such as running, during the late afternoon." d. "Limit your intake of caffeinated drinks to no more than 2 cups per day."

b. "Avoid bearing down or straining while having a bowel movement." ANS: B Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition

The nurse is providing discharge instructions for a client with an implantable cardioverter-defibrillator (ICD). What statement by the client indicates a good understanding of the instructions? a. "I should wear a snug-fitting shirt over the ICD." b. "I will avoid sources of strong electromagnetic fields." c. "I can't perform activities that increase my heart rate." d. "Now I can discontinue my antidysrhythmic medication."

b. "I will avoid sources of strong electromagnetic fields." ANS: B The client being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields. Clients should avoid tight clothing, which could cause irritation over the ICD generator. The client should not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. The client should continue all prescribed medications.

A client was admitted for a permanent pacemaker insertion. What priority instruction does the nurse include in the client's discharge teaching? a. "Do not submerge your pacemaker, take only showers." b. "Report pulse rates lower than your pacemaker setting." c. "If you feel weak, apply pressure over your generator." d. "Have your pacemaker turned off before having an MRI."

b. "Report pulse rates lower than your pacemaker setting." ANS: B The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min.

A client with myocardial ischemia is having frequent early, wide ventricular complexes seen on the cardiac monitor. Which medication does the nurse administer? a. Lanoxin (Digoxin) b. Amiodarone (Cordarone) c. Dobutamine (Dobutamine) d. Atropine sulfate (Atropisol)

b. Amiodarone (Cordarone) ANS: B Early, wide ventricular complexes are premature ventricular contractions (PVCs). Amiodarone, an antidysrhythmic, is the treatment of choice for frequent PVCs. The other medications are not appropriate for this condition.

The nurse is assessing clients at a community clinic. Which client does the nurse assess most carefully for atrial fibrillation? a. Middle-aged client who takes an aspirin daily b. Client who is dismissed after coronary artery bypass surgery c. Older adult client after a carotid endarterectomy d. Client with chronic obstructive pulmonary disease

b. Client who is dismissed after coronary artery bypass surgery ANS: B Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft (CABG) surgery. The other conditions do not place a client at higher risk for atrial fibrillation.

A client with ventricular tachycardia (VT) is unresponsive and has no pulse. The nurse calls for assistance and a defibrillator. What is the nurse's priority intervention while waiting for the defibrillator to arrive? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation. c. Start an 18-gauge IV in the antecubital. d. Ask the client's family about code status.

b. Initiate cardiopulmonary resuscitation. ANS: B A client with pulseless VT should be defibrillated immediately. If the defibrillator is not available, the nurse should initiate cardiopulmonary resuscitation (CPR) and then should defibrillate as soon as possible. Basic life support (BLS) is the basis of emergency cardiac care; if the client does not have an IV already, this can wait until others have arrived to help. Providing good quality CPR is vital. The client should have already been assessed for code status

A client with unstable ventricular tachycardia is receiving amiodarone by intravenous infusion. The nurse notes that the client's heart rate has decreased from 68 to 50 beats/min. The client is asymptomatic. What is the nurse's priority intervention? a. Stop the infusion and flush the IV. b. Slow the amiodarone infusion rate. c. Administer a precordial thump. d. Place the client in a side-lying position.

b. Slow the amiodarone infusion rate ANS: B IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly ceasing the medication could allow fatal dysrhythmias to occur. A precordial thump is not required at this time because the client still has a heart rate. A side-lying position will not increase the client's heart rate.

The nurse is caring for a client with atrial fibrillation. What manifestation most alerts the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity

b. Speech alterations ANS: B Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.

The nurse is caring for a client with chronic atrial fibrillation. Which drug does the nurse expect to administer to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Atropine) d. Lidocaine (Xylocaine)

b. Warfarin (Coumadin) ANS: B Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. The other drugs are not appropriate for this complication.

The nurse has administered adenosine (Adenocard). What is the expected therapeutic response? a. Increased intraocular pressure b. A brief tonic-clonic seizure c. A short period of asystole d. Hypertensive crisis

c. A short period of asystole ANS: C Clients usually respond to this medication with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain.

The nurse is caring for a client with a complete heart block (third-degree atrioventricular [AV] block). What is the nurse's priority intervention? a. Perform a cardioversion. b. Assist with carotid massage. c. Begin external pacing. d. Administer adenosine (Adenocard) IV.

c. Begin external pacing. ANS: C The nurse would expect the client with complete heart block or third-degree AV block to be paced externally until the client can be scheduled for a permanent pacemaker.

The nurse is assessing the client's electrocardiography (ECG). What does the P wave on the ECG tracing represent? a. Contraction of the atria b. Contraction of the ventricles c. Depolarization of the atria d. Depolarization of the ventricles

c. Depolarization of the atria ANS: C The ECG tracing of a P wave represents electrical changes caused by atrial depolarization.

The client's heart rate increases slightly during inspiration and decreases slightly during expiration. What action does the nurse take? a. Evaluate for a respirator disorder. b. Assess the client for chest pain. c. Document the finding in the chart. d. Administer antidysrhythmic drugs.

c. Document the finding in the chart. ANS: C Sinus dysrhythmia is noted when the heart rate increases slightly during inspiration and decreases slightly during expiration. Sinus dysrhythmia is a variant of normal sinus rhythm that is frequently observed in healthy children and adults. No other actions are needed.

The nurse is caring for a client with a temporary pacemaker. The client's bedside monitor shows a spike followed by a QRS complex. What is the nurse's best action? a. Remove the pacemaker; it is not needed. b. Decrease the threshold of the pacemaker. c. Document the finding in the client's chart. d. Set the pacemaker to the synchronous mode.

c. Document the finding in the client's chart. ANS: C A spike followed by a QRS complex indicates "capture," meaning that the pacemaker has successfully depolarized or captured the ventricle. No action other than documentation of this finding is necessary.

A client with third-degree heart block is admitted to the telemetry unit. The nurse observes wide QRS complexes on the monitor with a heart rate of 35 beats/min. What priority assessment does the nurse perform? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability

c. Level of consciousness ANS: C A heart rate of 40 beats/min or less, with widened QRS complexes, could have hemodynamic consequences, and the client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, lightheadedness, confusion, syncope, and seizure activity.

The physician is about to perform carotid sinus massage on a client with supraventricular tachycardia. What equipment is most important for the nurse to have ready? a. Emesis basin b. Magnesium sulfate c. Resuscitation cart d. Padded tongue blade

c. Resuscitation cart ANS: C Complications of this procedure include bradydysrhythmias, asystole, ventricular fibrillation, and cerebral damage. The resuscitation cart, complete with defibrillator, should be available whenever this procedure is initiated. The other equipment is not needed.

The nurse is caring for a client admitted for myocardial infarction. The client's monitor shows frequent premature ventricular contractions (PVCs). What dysrhythmia does the nurse remain alert for? a. Sinus tachycardia b. Rapid atrial flutter c. Ventricular tachycardia d. Atrioventricular junctional rhythm

c. Ventricular tachycardia ANS: C With an acute myocardial infarction (MI), the onset of PVCs may be considered as a warning that could herald the onset of ventricular tachycardia or ventricular fibrillation.

The nurse identifies a client's rhythm to be a sustained supraventricular tachycardia. What medication does the nurse administer? a. Atropine (Atropine) b. Epinephrine (Adrenalin) c. Lidocaine (Xylocaine) d. Diltiazem (Cardizem)

d. Diltiazem (Cardizem) ANS: D Diltiazem, a calcium channel blocker, slows depolarization through the conduction system and is commonly used as an agent to terminate a sustained episode of supraventricular tachycardia.

A nurse notes that the PR interval on a client's electrocardiograph (ECG) tracing is 0.14 second. What action does the nurse take? a. Assess serum cardiac enzymes. b. Administer 1 mg epinephrine IV. c. Administer oxygen via nasal cannula. d. Document the finding in the client's chart.

d. Document the finding in the client's chart. ANS: D The PR interval normally ranges from 0.12 to 0.20 second. This is a normal finding, so the nurse simply documents this. No further action is required.

The nurse is assisting with resuscitation of a client. What priority intervention does the nurse perform before defibrillating a client? a. Make sure the defibrillator is set to the synchronous mode. b. Deliver a precordial thump to the upper portion of the sternum. c. Test the equipment by delivering a smaller shock at 100 J. d. Ensure that all personnel are clear of contact with the client and the bed.

d. Ensure that all personnel are clear of contact with the client and the bed. ANS: D To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thumb can be delivered when no defibrillator is available. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Defibrillation is done in asynchronous mode.

The nurse is recovering a client after insertion of an implantable cardioverter-defibrillator (ICD). What complication must the nurse intervene for immediately? a. 2/4 bilateral peripheral edema b. Heart rate of 56 beats/min c. Temperature of 96° F (35.5° C) d. Muffled heart sounds

d. Muffled heart sounds ANS: D In the postimplantation period, the nurse should be alert for complications of cardiac tamponade, bleeding, and dysrhythmias. Muffled heart sounds are a manifestation of cardiac tamponade. Edema and a lower temperature would not be indicative of a complication of this procedure. Bradycardia might need intervention, but this client's heart rate is not critically low.