Exam 1: Dysrhythmias (NCLEX)

A client's electrocardiogram strip shows atrial and ventricular rates of 80 complexes per minute. The PR interval is 0.14 second, and the QRS complex measures 0.08 second. The nurse interprets this rhythm is: A) Normal sinus rhythm B) Sinus bradycardia C) Sinus tachycardia D) Sinus dysrhythmia

A

A patient in asystole is likely to receive which of the following drug treatments? a. Atropine and epinephrine b. Lidocaine and amiodarone c. Digoxin and procainamide d. β-Adrenergic blockers and dopamine

A

The nurse is caring for a client who has developed a bradycardia. Which possible causes should the nurse investigate? Select all that apply a. Bearing down for a bowel movement b. Possible inferior wall myocardial infarction (MI) c. Client stating that he just had a cup of coffee d. Client becoming emotional when visitors arrived e. Diltiazem (Cardizem) administered an hour ago

ABE The Valsalva maneuver stimulates the vagus nerve, causing bradycardia. Inferior wall MI is a cause of bradycardia and heart blocks. Calcium channel blockers such as diltiazem may cause bradycardia.

The nurse is caring for a client with unstable angina whose cardiac monitor shows ventricular tachycardia. Which action is appropriate to implement first? a. Defibrillate using 200 J. b. Check the client for a pulse. c. Cardiovert the client at 50 J. d. Administer IV ibutilide (Corvert).

B

The nurse is watching the cardiac monitor, and a patient's rhythm suddenly changes. There are no P waves. Instead there are fine, wavy lines between the QRS complexes. The QRS complexes measure 0.08 sec (narrow), but they occur irregularly with a rate of 120 beats/min. The nurse correctly interprets that this rhythm is which of the following? a. Sinus tachycardia b. Atrial fibrillation c. Ventricular fibrillation d. Ventricular tachycardia

B

The nurse obtains a 6-second rhythm strip and charts the following analysis: atrial rate 70, regular; ventricular rate 40, regular; QRS 0.04 sec; no relationship between P waves and QRS complexes; atria and ventricles beating independently of each other. Which of the following would be a correct interpretation of this rhythm strip? a. Sinus dysrhythmias b. Third-degree heart block c. Wenckebach phenomenon d. Premature ventricular contractions

B

The nurse receives in report that the client with a pacemaker has experienced loss of capture. Which situation is consistent with this? a. The pacemaker spike falls on the T wave. b. Pacemaker spikes are noted, but no P wave or QRS complex follows. c. The heart rate is 42, and no pacemaker spikes are seen on the rhythm strip. d. The client demonstrates hiccups.

B

A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily b. A 50-year-old who is post coronary artery bypass graft surgery c. A 78-year-old who had a carotid endarterectomy d. An 80-year-old with chronic obstructive pulmonary disease

B Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these clients at higher risk for atrial fibrillation.

A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Sal-Tropine) d. Lidocaine (Xylocaine)

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. Sotalol, atropine, and lidocaine are not appropriate for this complication.

After receiving a permanent pacemaker, the client asks the nurse if there are any activities to avoid during a vacation scheduled for 4 months after discharge. Which of the following is the most appropriate response by the nurse? a. "Swimming in the ocean should be avoided." b. "You should avoid working over a running engine." c. "There are no restrictions on your activity." d. "Avoid standing in front of microwave ovens."

B Early microwave ovens required avoidance by persons with pacemakers, but not current models. Swimming would be contraindicated for the first few weeks due to abduction of the arm while the leads were still adhering to the muscle of the heart. However, 4 months postoperatively, the client should be able to abduct arms for swimming. Working over a running engine, as well as being near high frequency power waves, is contraindicated for anyone with a permanent pacemaker.

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. Which action should the nurse take next? a. Administer intravenous diltiazem (Cardizem). b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.

B In temporary 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. If there is no capture, then there is no ventricular depolarization and contraction. The nurse should assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture.

Which teaching is essential for a client who has had a permanent pacemaker inserted? a. Avoid talking on a cell phone. b. Avoid contact sports and blows to the chest. c. Avoid sexual activity. d. Do not take tub baths.

B No pressure should be applied over the generator site.

The nurse is caring for a client with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol (Lopressor). Which monitoring is essential when administering the medication? a. ST segment b. Heart rate c. Troponin d. Myoglobin

B The effects of metoprolol are to decrease heart rate, blood pressure, and myocardial oxygen demand. ST segment elevation is consistent with MI; it does not address monitoring of metoprolol. Elevation in troponin is consistent with a diagnosis of MI but does not address needed monitoring for metoprolol. Elevation in myoglobin is consistent with myocardial injury in ACS but does not address needed monitoring related to metoprolol.

The nurse is caring for a client with unstable angina whose cardiac monitor shows ventricular tachycardia. Which action is appropriate to implement first? a. Defibrillate the client at 200 J. b. Check the client for a pulse. c. Cardiovert the client at 50 J. d. Give the client IV lidocaine.

B The nurse needs to assess the client to determine stability before proceeding with further interventions. If the client has a pulse and is relatively stable, elective cardioversion or antidysrhythmic medications may be prescribed.

One hour after administering IV furosemide (Lasix) to a client with heart failure, a short burst of ventricular tachycardia appears on the cardiac monitor. Which of the following electrolyte imbalances should the nurse suspect? 1.Hypocalcemia 2.Hypermagnesemia 3.Hypokalemia 4.Hypernatremia

3

After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective? a.Increase in the patient's heart rate b.Increase in strength of peripheral pulses c.Decrease in premature atrial contractions d.Decrease in premature ventricular contractions

A Atropine will increase the heart rate and conduction through the AV node. Because the medication increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have premature atrial or ventricular contractions.

The nurse is caring for a client with atrial fibrillation. In addition to an antidysrhythmic, what medication does the nurse plan to administer? a. Heparin b. Atropine c. Dobutamine d. Magnesium sulfate

A Clients with atrial fibrillation are prone to blood pooling in the atrium, clotting, then embolizing. Heparin is used to prevent thrombus development in the atrium and the consequence of embolization (i.e., stroke).

A client admitted after using crack cocaine develops ventricular fibrillation. After determining unresponsiveness, which action should the nurse take next? a. Defibrillate at 200 J. b. Establish IV access. c. Place an oral airway and ventilate. d. Start cardiopulmonary resuscitation (CPR).

A Defibrillating is of priority before any other resuscitative measures according to Advanced Cardiac Life Support protocols.

The nurse is caring for a client with advanced heart failure who develops asystole. The nurse corrects the new graduate when the graduate offers to perform which intervention? a. Defibrillation b. Cardiopulmonary resuscitation (CPR) c. Administration of atropine d. Administration of oxygen

A Defibrillation interrupts the heart rhythm and allows normal pacemaker cells to take over: in asystole, there is no rhythm to interrupt; therefore this intervention is not used.

For which of the following dysrhythmias is defibrillation primarily indicated? a. Ventricular fibrillation b. Third-degree AV block c. Uncontrolled atrial fibrillation d. Ventricular tachycardia with a pulse

A Defibrillation is always indicated in the treatment of ventricular fibrillation. Drug treatments are normally used in the treatment of uncontrolled atrial fibrillation and for ventricular tachycardia with a pulse (if the patient is stable). Otherwise, synchronized cardioversion is used (as long as the patient has a pulse). Pacemakers are the treatment of choice for third-degree heart block.

A 20-year-old has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. Blood pressure (BP) is 114/54, and the student denies any health problems. What action by the nurse is most appropriate? a.Allow the student to participate on the soccer team. b.Refer the student to a cardiologist for further diagnostic testing. c.Tell the student to stop playing immediately if any dyspnea occurs. d.Obtain more detailed information about the student's family health history.

A In an aerobically trained individual, sinus bradycardia is normal. The student's normal BP and negative health history indicate that there is no need for a cardiology referral or for more detailed information about the family's health history. Dyspnea during an aerobic activity such as soccer is normal.

To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the duration of the patient's a.P wave. b.Q wave. c.P-R interval. d.QRS complex.

A The P wave represents the depolarization of the atria. The P-R interval represents depolarization of the atria, atrioventricular (AV) node, bundle of His, bundle branches, and the Purkinje fibers. The QRS represents ventricular depolarization. The Q wave is the first negative deflection following the P wave and should be narrow and short.

Which intervention by a new nurse who is caring for a patient who has just had an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more education about care of patients with ICDs? a.The nurse assists the patient to do active range of motion exercises for all extremities. b.The nurse assists the patient to fill out the application for obtaining a Medic Alert ID. c.The nurse gives amiodarone (Cordarone) to the patient without first consulting with the health care provider. d.The nurse teaches the patient that sexual activity usually can be resumed once the surgical incision is healed.

A The patient should avoid moving the arm on the ICD insertion site until healing has occurred in order to prevent displacement of the ICD leads. The other actions by the new nurse are appropriate for this patient.

You are the charge nurse on the telemetry unit and are responsible for making client assignments. Which client would be appropriate to assign to the float RN from the medical-surgical unit? a. The 64-year-old admitted for weakness who has a first-degree heart block with a heart rate of 58 beats/min b. The 71-year-old admitted for heart failure who is short of breath and has a heart rate of 120 to 130 beats/min c. The 88-year-old admitted with an elevated troponin level who is hypotensive with a heart rate of 96 beats/min d. The 92-year-old admitted with chest pain who has premature ventricular complexes and a heart rate of 102 beats/min

A This client has a stable, asymptomatic dysrhythmia, which usually requires no treatment; this client can be managed by a nurse with less cardiac dysrhythmia training.

A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic and has no palpable pulses. What is the first action that the nurse should take? a.Perform synchronized cardioversion. b.Start cardiopulmonary resuscitation (CPR). c.Administer atropine per agency dysrhythmia protocol. d.Provide supplemental oxygen via non-rebreather mask.

B The patient's clinical manifestations indicate pulseless electrical activity and the nurse should immediately start CPR. The other actions would not be of benefit to this patient.

The nurse teaches a client with new-onset atrial fibrillation that risk factors for this dysrhythmia may include which? Select all that apply. a. Use of beta-adrenergic blockers b. Excessive alcohol use c. Advancing age d. High blood pressure e. Palpitations

BCD

The nurse administers amiodarone (Cordarone) to a client with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? Select all that apply. a. Respiratory rate b. QT interval c. Heart rate and rhythm d. Magnesium level e. Urine output

BCD Amiodarone causes prolongation of the QT interval, which can precipitate dysrhythmia. Antidysrhythmic medications cause changes in cardiac rhythm and rate; therefore monitoring of heart rate and rhythm is needed.Electrolyte depletion, specifically potassium and magnesium, may predispose to further dysrhythmia. Although it is always important to monitor vital signs and urine output, these assessments are not specific to amiodarone.

A client with atrial fibrillation with rapid ventricular response has received medication to slow the ventricular rate. The pulse is now 88. For which additional therapy does the nurse plan? a. Synchronized cardioversion b. Electrophysiology studies (EPS) c. Anticoagulation d. Radiofrequency ablation therapy

C

The client's rhythm strip shows a heart rate of 76 beats/min, one P wave occurring before each QRS complex, a PR interval measuring 0.24 second, and a QRS complex measuring 0.08 second. How does the nurse interpret this rhythm strip? a. Normal sinus rhythm b. Sinus bradycardia c. Sinus rhythm with first-degree atrioventricular (AV) block d. Sinus rhythm with premature ventricular contractions

C

What teaching does the nurse include for a client with atrial fibrillation who has a new prescription for warfarin? a. It is important to consume a diet high in green leafy vegetables. b. You should take aspirin or ibuprofen for headache. c. Report nosebleeds to your provider immediately. d. Avoid caffeinated beverages.

C

The nurse is determining whether the client's rhythm strip demonstrates proper firing of the sinoatrial (SA) node. Which waveform indicates proper function of the SA node? a. The QRS complex is present. b. The PR interval is 0.24 second. c. A P wave precedes every QRS complex. d. The ST segment is elevated.

C A P wave is generated by the SA node and represents atrial depolarization.

The nurse is caring for a patient who is 24 hours postpacemaker insertion. Which of the following nursing interventions is most appropriate at this time? a. Reinforcing the pressure dressing as needed b. Encouraging range-of-motion exercises of the involved arm c. Assessing the incision for any redness, swelling, or discharge d. Applying wet-to-dry dressings every 4 hours to the insertion site

C After pacemaker insertion, it is important for the patient to limit activity of the involved arm to minimize pacemaker lead displacement. The nonpressure dressing is kept dry until removed, usually 24 hours postoperative. It is important for the nurse to observe signs of infection by assessing for any redness, swelling, or discharge from the incision site.

A patient who is on the progressive care unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first? a.Obtain a 12-lead electrocardiogram (ECG). b.Notify the health care provider of the change in rhythm. c.Give supplemental O2 at 2 to 3 L/min via nasal cannula. d.Assess the patient's vital signs including oxygen saturation.

C Because this patient has dyspnea and chest pain in association with the new rhythm, the nurse's initial actions should be to address the patient's airway, breathing, and circulation (ABC) by starting with oxygen administration. The other actions also are important and should be implemented rapidly.

The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, "Why do you want to know if I use cocaine?" How should the nurse respond? a. "Substance abuse puts clients at risk for many health issues." b. "The hospital requires that I ask you about cocaine use." c. "Clients who use cocaine are at risk for fatal dysrhythmias." d. "We can provide services for cessation of substance abuse."

C Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias. The other responses do not adequately address the client's question.

Which of the following ECG characteristics is consistent with a diagnosis of ventricular tachycardia (VT)? a. Unmeasurable rate and rhythm b. Rate 150 beats/min; inverted P wave c. Rate 200 beats/min; P wave not visible d. Rate 125 beats/min; normal QRS complex

C VT is associated with a rate of 150 to 250 beats/min; the P wave is not normally visible. P wave inversion and a normal QRS complex are not associated with VT. Rate and rhythm are not measurable in ventricular fibrillation.

The nurse is teaching the client with a new permanent pacemaker. Which statement by the client indicates the need for further discharge education? a. "I will be able to shower again soon." b. "I need to take my pulse every day." c. "I might trigger airport security metal detectors." d. "I no longer need my heart pills."'

D

The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use? a.Count the number of large squares in the R-R interval and divide by 300. b.Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes. c.Calculate the number of small squares between one QRS complex and the next and divide into 1500. d.Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.

D

When analyzing the rhythm of a patient's electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n) a.isoelectric ST segment. b.P-R interval of 0.18 second. c.Q-T interval of 0.38 second. d.QRS interval of 0.14 second.

D Because the normal QRS interval is 0.04 to 0.10 seconds, the patient's QRS interval of 0.14 seconds indicates that the conduction through the ventricular conduction system is prolonged. The P-R interval and Q-T interval are within normal range, and ST segment should be isoelectric (flat).

In teaching clients at risk for bradydysrhythmias, what information does the nurse include? a. "Avoid potassium-containing foods." b. "Stop smoking and avoid caffeine." c. "Take nitroglycerin for a slow heartbeat." d. "Use a stool softener."

D Clients at risk for bradydysrhythmias should avoid bearing down or straining during a bowel movement; the Valsalva maneuver can cause bradycardia. Taking a stool softener helps to prevent this.

A client with atrial fibrillation is receiving digoxin (Lanoxin). It is MOST important for the nurse to? a. Record an EKG strip after administration b. Monitor blood pressure every 4 hours c. Maintain accurate intake and output records d. Measure apical pulse prior to administration

D Digitoxin decreases conduction velocity through the AV node and prolongs the refractory period. If the apical heart rate is less than 60 beats/minute, withhold the drug. The apical pulse should be taken with a stethoscope so that there will be no mistake about what the heart rate actually is.

A patient has a normal cardiac rhythm and a heart rate of 72 beats/minute. The nurse determines that the P-R interval is 0.24 seconds. The most appropriate intervention by the nurse would be to a.notify the health care provider immediately. b.give atropine per agency dysrhythmia protocol. c.prepare the patient for temporary pacemaker insertion. d.document the finding and continue to monitor the patient.

D First-degree atrioventricular (AV) block is asymptomatic and requires ongoing monitoring because it may progress to more serious forms of heart block. The rate is normal, so there is no indication that atropine is needed. Immediate notification of the health care provider about an asymptomatic rhythm is not necessary.

A nurse assesses a client's electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The client's chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.

D Normal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization. This finding on an electrocardiograph tracing is not an indication of hyperkalemia, ventricular tachycardia, or disconnection of leads.

How does the nurse recognize that atropine has produced a positive outcome for the client with bradycardia? a. Client states he is dizzy and weak. b. The nurse notes dyspnea. c. The client has a heart rate of 42. d. The monitor shows sinus rhythm.

D Sinus rhythm presents with heart rates from 60 to 100 beats/min; by definition, the bradydysrhythmia has resolved.

The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, P-R interval not measurable, ventricular rate 162, R-R interval regular, and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as a.atrial flutter. b.sinus tachycardia. c.ventricular fibrillation. d.ventricular tachycardia.

D The absence of P waves, wide QRS, rate >150 beats/minute, and the regularity of the rhythm indicate ventricular tachycardia. Atrial flutter is usually regular, has a narrow QRS configuration, and has flutter waves present representing atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration.

A patient who was admitted with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute. Which of the following actions should the nurse take next? a.Immediately notify the health care provider. b.Document the rhythm and continue to monitor the patient. c.Perform synchronized cardioversion per agency dysrhythmia protocol. d.Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol.

D The burst of sustained ventricular tachycardia indicates that the patient has significant ventricular irritability, and antidysrhythmic medication administration is needed to prevent further episodes. The nurse should notify the health care provider after the medication is started. Defibrillation is not indicated given that the patient is currently in a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation.

The nurse is caring for a client on a telemetry unit with a regular heart rhythm and rate of 60; a P wave precedes each QRS complex, and the PR interval is 0.24 second. Additional vital signs are as follows: blood pressure 118/68, respiratory rate 16, and temperature 98.8° F. The following medications are available on the medication record. What action should the nurse take? a. Administer atropine. b. Administer digoxin. c. Administer clonidine. d. Continue to monitor.

D The client is displaying sinus rhythm with first-degree atrioventicular heart block; this is usually asymptomatic and does not require treatment. Atropine is used in emergency treatment of symptomatic bradycardia. This client has normal vital signs. Digoxin is used in the treatment of atrial fibrillation, which is, by definition, an irregular rhythm. Clonidine is used in the treatment of hypertension; a side effect is bradycardia.

After providing a patient with discharge instructions on the management of a new permanent pacemaker, the nurse knows that teaching has been effective when the patient states a."I will avoid cooking with a microwave oven or being near one in use." b."It will be 1 month before I can take a bath or return to my usual activities." c."I will notify the airlines when I make a reservation that I have a pacemaker." d."I won't lift the arm on the pacemaker side up very high until I see the doctor."

D The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The patient should notify airport security about the presence of a pacemaker before going through the metal detector, but there is no need to notify the airlines when making a reservation. Microwave oven use does not affect the pacemaker. The insertion procedure involves minor surgery that will have a short recovery period.

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a. Make sure the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 joules. d. Ensure that everyone is clear of contact with the client and the bed.

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 thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation.

A client has frequent bursts of ventricular tachycardia on the cardiac monitor. A nurse is most concerned with this dysrhythmia because: A) It is uncomfortable for the client, giving a sense of impending doom. B) It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia. C) It is almost impossible to convert to a normal sinus rhythm. D) It can develop into ventricular fibrillation at any time.

D Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Client's frequently experience a feeling of impending death. Ventricular tachycardia is treated with antidysrhythmic medications or magnesium sulfate, cardioversion (client awake), or defibrillation (loss of consciousness), Ventricular tachycardia can deteriorate into ventricular defibrillation at any time.