Lewis Dysrhythmias Questions

The components of the autonomic nervous system that affect the heart are

the vagus nerve fibers of the parasympathetic nervous system and nerve fibers of the sympathetic nervous system.

The nurse performs discharge teaching for a patient with an implantable cardioverter-defibrillator (ICD). Which statement by the patient indicates to the nurse that further teaching is needed? "The device may set off the metal detectors in an airport." "My family needs to keep up to date on how to perform CPR." "I should not stand next to antitheft devices at the exit of stores." "I can expect redness and swelling of the incision site for a few days."

"I can expect redness and swelling of the incision site for a few days." Patients should be taught to report any signs of infection at incision site (e.g., redness, swelling, drainage) or fever to their primary care providers immediately. Teach patients to inform TSA airport security of presence of ICD because it may set off metal detectors. If a handheld screening wand is used, it should not be placed directly over the ICD. Teach patients to avoid standing near antitheft devices in doorways of stores and public buildings and to walk through them at a normal pace. Caregivers should learn cardiopulmonary resuscitation.

A patient develops third-degree heart block and reports feeling chest pressure and shortness of breath. Which instructions should the nurse provide to the patient before initiating emergency transcutaneous pacing? "The device will convert your heart rate and rhythm back to normal." "The device uses overdrive pacing to slow the heart to a normal rate." "The device is inserted through a large vein and threaded into your heart." "The device delivers a current through your skin that can be uncomfortable."

"The device delivers a current through your skin that can be uncomfortable." Before initiating transcutaneous pacing therapy, it is important to tell the patient what to expect. The nurse should explain that the muscle contractions created by the pacemaker when the current passes through the chest wall are uncomfortable. Pacing for complete heart block will not convert the heart rhythm to normal. Overdrive pacing is used for very fast heart rates. Transcutaneous pacing is delivered through pacing pads adhered to the skin.

A patient with a newly inserted pacemaker receives discharge instructions. Which patient statement indicates that further teaching is required? 1. "I should avoid using microwave ovens." 2. "I should avoid standing near antitheft devices." 3. "I should avoid direct blows to the pacemaker site." 4. "I should avoid close proximity to high-output electric generators."

1. "I should avoid using microwave ovens." Microwaves do not interfere with a pacemaker's function and can be used safely. Electric signals from antitheft devices can affect pacemaker functioning. The patient should avoid direct blows to the pacemaker site to reduce pressure at the site. Electric signals from high-output electric generators can move the pacemaker from its position and affect its functioning.

After synchronized cardioversion, a patient's electrocardiogram (ECG) tracing reveals the following. Which statement by a nurse is accurate? 1. "The cardioversion was successful." 2. "Cardioversion will need to be repeated." 3. "The patient is now in accelerated junctional rhythm." 4. "The ECG tracing indicates hyperkalemia."

1. "The cardioversion was successful." The patient has converted to a normal sinus rhythm (NSR). The cardioversion was successful. Accelerated junctional rhythm is characterized by an absent P wave and inverted P wave before or following the QRS complex. Hyperkalemia is characterized by a peaked T wave. The T wave in this tracing is normal.

A patient who is on a cardiac monitor is shivering. What should the nurse expect to see on this patient's tracing? 1. Artifact 2. Asystole 3. Atrial flutter 4. Junctional dysrhythmia

1. Artifact An artifact is a distortion of the baseline and waveforms seen on the electrocardiogram (ECG). If the patient is shivering or shows any muscle activity, accurate interpretation of the heart rhythm is difficult and artifacts can occur on the monitor. Asystole is the absence of all cardiac electrical activity. Atrial flutter occurs in chronic lung disease or hypertension. Junctional dysrhythmias are associated with an electrolyte imbalance or rheumatic heart disease.

The nurse responds to a cardiac monitor alarm and notes that the atrial flutter has developed. The patient is responsive, awake, and sitting up in bed. Which action should the nurse take first? 1. Assessing the patient for dyspnea 2. Initiating cardiopulmonary resuscitation 3. Preparing for synchronized cardioversion 4. Placing the patient in the Trendelenburg position

1. Assessing the patient for dyspnea Because the patient is awake and responsive, the next action should be to further assess him or her for stability and the possible cause of the dysrhythmia. The nurse should focus the assessment on vital signs such as blood pressure, heart rate, and respiratory status. Initiating cardiopulmonary resuscitation or preparing for synchronized cardioversion would only be an option if the patient were unstable. The Trendelenburg position is inappropriate for a patient with atrial flutter.

A patient calls a nurse complaining of jaw pain. The nurse reviews the patient's electrocardiogram (ECG). This is the present tracing. The nurse should: 1. Call the primary health care provider 2. Give Vicodin (hydrocodone) as prescribed 3. Place the patient in a Trendelenburg position 4. Recognize these ECG changes as digoxin toxicity

1. Call the primary health care provider The ECG tracing is showing ST elevation indicative of a myocardial infarction (MI). The primary health care provider should be notified immediately so appropriate interventions can be prescribed. Morphine sulfate is the drug of choice for a patient experiencing an acute MI. Whenever possible, the patient experiencing an MI should be placed in a position promoting respirations. The Trendelenburg position inhibits respirations. Digoxin toxicity is characterized by ST segment depression, not elevation.

A patient is admitted for placement of a permanent pacemaker. Which health problem does the nurse suspect in this patient? 1. Heart failure 2. Tachydysrhythmias 3. Acute inferior myocardial infarction 4. Complication from open-heart surgery

1. Heart failure A permanent pacemaker is indicated in a patient with heart failure. A temporary pacemaker is indicated in patients recovering from tachydysrhythmias, inferior myocardial infarction, and open-heart surgery.

The ECG monitor of a patient in the cardiac care unit after a myocardial infarction indicates ventricular fibrillation. What would be the nurse's immediate action? 1. Perform cardiopulmonary resuscitation (CPR) 2. Administer intravenous (IV) amiodarone 3. Perform synchronized cardioversion 4. Prepare for insertion of a temporary transvenous pacemaker

1. Perform cardiopulmonary resuscitation (CPR) Treatment consists of immediate initiation of CPR and advanced cardiac life support (ACLS), with the use of defibrillation and definitive drug therapy (e.g., epinephrine, vasopressin). There should be no delay in using a defibrillator once available. Amiodarone, cardioversion, and temporary pacemakers are not used to treat ventricular fibrillation.

What does the T wave in the electrocardiogram represent? 1. Time taken for ventricular repolarization. 2. Time taken for depolarization of both ventricles. 3. Time between ventricular depolarization and repolarization. 4. Time for the passage of the electrical impulse through the atrium.

1. Time taken for ventricular repolarization. The electrocardiogram is commonly used to detect abnormal heart rhythms and to investigate the cause of chest pains. The T wave in the electrocardiogram should be upright; it represents time for ventricular repolarization. Time taken for depolarization of both ventricles is represented by QRS interval. Time between ventricular depolarization and repolarization is represented by ST segment. Time for the passage of the electrical impulse through the atrium is represented by P wave.

When computing a heart rate from the ECG tracing, the nurse counts 15 of the small blocks between the R waves of a patient whose rhythm is regular. From these data, the nurse calculates the patient's heart rate to be 60 beats/min. 75 beats/min. 100 beats/min. 150 beats/min.

100 beats/min. Since each small block on the ECG paper represents 0.04 seconds, 1500 of these blocks represents 1 minute. By dividing the number of small blocks (15, in this case) into 1500, the nurse can calculate the heart rate in a patient whose rhythm is regular (in this case, 100).

A patient with monomorphic ventricular tachycardia is clinically stable. What is the appropriate nursing intervention in this situation? 1. Perform rapid defibrillation 2. Administer amiodarone as prescribed 3. Administer vasopressors as prescribed 4. Initiate cardiopulmonary resuscitation

2. Administer amiodarone as prescribed Amiodarone is an antiarrhythemic agent that corrects various atrial and ventricular dysarrhythmias. Since the patient is clinically stable, amiodarone can be used. Rapid defibrillation is not indicated for this patient. There is no need to administer vasopressors to a clinically stable patient. Cardiopulmonary resuscitation is not performed for this patient.

A patient complains of suddenly feeling dizzy. The ECG tracing is the following. A nurse understands the dizziness is most likely a result of: 1. Inner ear infection 2. Decreased cardiac output 3. Digoxin toxicity 4. Rapid metoprolol administration

2. Decreased cardiac output The patient's ECG tracing is a paroxysmal supraventricular tachycardia (PSVT). Depending on the rate and duration of PSVT, the patient often experiences symptoms related to decreased cardiac output. The cardiac output drops because of decreased ventricular filling time. Although an inner ear infection can cause dizziness, the ECG tracing is more likely to be the source of the dizziness. Digoxin toxicity can cause dizziness, but most often in the presence of bradycardia. Metoprolol is given to treat hypertension and to decrease the heart rate.

A patient has a heart rate of 150 beats per minute. An electrocardiogram shows a normal P wave preceding each QRS complex. The nurse recognizes that the patient is most likely experiencing what condition? 1. Atrial fibrillation 2. Sinus tachycardia 3. Ventricular fibrillation 4. Premature atrial contraction

2. Sinus tachycardia Sinus tachycardia inhibits the vagus nerve or stimulates the sympathetic nervous system. This causes an increase in the heart rate to about 101 beats to 200 beats per minute. The electrocardiographic study of sinus tachycardia shows a normal P wave preceding each QRS complex with normal time and duration. In atrial fibrillation, the P waves are chaotic and fibrillatory and the QRS complex is normal. The electrocardiographic study of ventricular fibrillation elicits the absence of P waves and the PR interval and QRS interval cannot be measured. In premature atrial contraction, there are distorted P waves in the ECG.

A patient undergoing treatment for dysrhythmia is provided with a Holter monitor. Which information or instructions should the nurse provide to the patient using the Holter monitor? Select all that apply. 1. The patient should activate the monitor when experiencing symptoms. 2. The monitor records electrocardiogram (ECG) when the patient is ambulatory. 3. The patient should record activities and symptoms in a diary. 4. The monitor evaluates heart rhythm during exercise. 5. The monitor records ECG when the patient performs daily activities.

2. The monitor records electrocardiogram (ECG) when the patient is ambulatory. 3. The patient should record activities and symptoms in a diary. 5. The monitor records ECG when the patient performs daily activities. The Holter monitor continuously records the ECG while the patient is ambulatory and performing daily activities. The patient should keep a diary and record activities and any symptoms. Event monitors are recorders that the patient activates only when experiencing symptoms. Exercise treadmill testing evaluates the patient's heart rhythm during exercise.

While explaining temporary pacemakers to a patient, what should a nurse include? Select all that apply. 1. All temporary pacemakers are transvenous. 2. Transcutaneous pacemakers pace through the skin. 3. Transvenous pacemakers are inserted into the left ventricle. 4. Epicardial pacemakers leads are passed through the chest wall and attached to the internal power source. 5. Temporary pacemakers have the power source outside the body. 6. The placement of the transcutaneous pacemakers is noninvasive; it is a temporary procedure.

2. Transcutaneous pacemakers pace through the skin. 5. Temporary pacemakers have the power source outside the body. 6. The placement of the transcutaneous pacemakers is noninvasive; it is a temporary procedure. Temporary pacemakers include transcutaneous pacemakers, transvenous pacemakers, and epicardial pacemakers. Transcutaneous pacemakers use electrical stimulation that is delivered through the skin via external electrode pads connected to an external pacemaker (a defibrillator with pacemaker functions). All temporary pacemakers have their power source outside the body. Placement of the transcutaneous pacemaker is noninvasive and a temporary method until a more permanent treatment is sought. With transvenous pacemakers, a pacing catheter is inserted percutaneously into the right ventricle, where it gets connected to the endocardium near the ventricular septum. It is connected to a small external pulse generator by electrode wires. Epicardial pacing wires are inserted into the epicardial wall of the heart during cardiac surgery. The leads are passed through the chest wall and attached to the external power source.

3. 4 (beats per 3 seconds) + 4 = 8 × 10 = 80 bpm

3. A patient with a regular heart rate (HR) has four QRS complexes between every 3-second marker on the ECG paper. Calculate the patient's heart rate. _________ bpm

While ambulating a patient, the ECG tracing changes from a normal sinus rhythm, with a ventricular rate of 90 impulses per minute, to the following tracing. Which action should the nurse take? 1. Notify the primary health care provider 2. Administer digoxin 3. Continue ambulating the patient 4. Place the patient back into bed

3. Continue ambulating the patient Sinus tachycardia is associated with physiologic and psychologic stressors such as exercise. The P wave is normal, precedes each QRS complex, and has a normal shape and duration. The PR interval is normal, and the QRS complex has a normal shape and duration.

A patient admitted with acute coronary syndrome has continuous ECG monitoring. An examination of the rhythm strip reveals the following characteristics: atrial rate 74 beats/min and regular; ventricular rate 62 beats/minute and irregular; P wave normal shape, more P waves than QRS complexes (2:1); PR interval slightly prolonged; and widened QRS, preceded by 2 P waves, with nonconducted (blocked) QRS complex. The priority nursing intervention would be to 1. Perform synchronized cardioversion 2. Administer amiodarone intravenous infusion 3. Observe for symptoms of hypotension or angina 4. Apply transcutaneous pacemaker pads on the patient

3. Observe for symptoms of hypotension or angina The rhythm is a second-degree atrioventricular (AV) block, type II (i.e., Mobitz II). The rhythm is identified by noting P waves that are nonconducted without progressive PR lengthening. This usually occurs when a block in one of the bundle branches is present. On conducted beats, the PR interval is constant. Type II second-degree AV block is a more serious type of block in which a certain number of impulses from the sinoatrial (SA) node are not conducted to the ventricles. This occurs in ratios of 2:1, 3:1, and so on (i.e., two P waves to one QRS complex, three P waves to one QRS complex). The nurse should assess for bradycardia, hypotension, and angina. If the patient becomes symptomatic, atropine or a temporary pacemaker may be needed.

A nurse is monitoring a patient on a wireless electrocardiogram (ECG) monitor. Which observation is a cause for concern? 1. Upright P wave 2. Flat ST segment 3. Prolonged QT interval 4. Upright T wave

3. Prolonged QT interval Prolonged QT interval is a cause for concern. QT disturbance may be caused by drugs, electrolyte imbalances, and changes in heart rate. Upright P wave, flat ST segment, and upright T wave are normal findings.

Which ECG characteristic is consistent with a diagnosis of ventricular tachycardia (VT)? 1. Unmeasurable rate and rhythm 2. Rate 150 beats/minute; inverted P wave 3. Rate 200 beats/minute; P wave not visible 4. Rate 125 beats/minute; normal QRS complex

3. Rate 200 beats/minute; P wave not visible VT is associated with a rate of 150 to 250 beats/minute; the P wave normally is not visible. Rate and rhythm are not measurable in ventricular fibrillation. P wave inversion and a normal QRS complex are not associated with VT.

The nurse notes that a patient has a history of paroxysmal supraventricular tachycardia. What heart rate characterizes this dysrhythmia? 1. Slower than 60 beats/minute 2. Between 60 and 100 beats/minute 3. Between 100 and 150 beats/minute 4. Between 150 and 220 beats/minute

4. Between 150 and 220 beats/minute Paroxysmal supraventricular tachycardia (PSVT) is characterized by a heart rate of 150 to 220 beats/minute. A heart rate of fewer than 60 beats/minute is considered bradycardia. A rate of 100 beats/minute is the upper limit for a normal heart rate, and a rate of 100 to 150 beats/minute is the range for a sinus tachycardia.

A patient found unresponsive has pulseless electrical activity on the ECG. What action should the nurse take first? 1. Apply warm blankets 2. Assist with intubation 3. Assess for pulmonary embolus 4. Initiating cardiopulmonary resuscitation

4. Initiating cardiopulmonary resuscitation The pulseless electrical activity indicates cardiac arrest. The nurse should initiate cardiopulmonary resuscitation. Applying warm blankets would help with hypothermia but can be completed later. Intubation depends upon the patient's response to cardiopulmonary resuscitation. The nurse can assess for pulmonary embolus after stabilizing the patient.

What is the treatment of choice for atrial flutter? 1. Oxygen therapy 2. Maze procedure 3. Electrical cardioversion 4. Radiofrequency catheter ablation

4. Radiofrequency catheter ablation Atrial flutter is an atrial tachydysrhythmia. Radiofrequency catheter ablation is a procedure used to correct disturbances in heart rhythm and is the treatment of choice for atrial flutter. Oxygen therapy is given to treat premature ventricular contraction caused by hypoxia. Maze procedure and electrical cardioversion are treatments for atrial fibrillation.

Which statement related to radiofrequency catheter ablation procedure is accurate? 1. The ablation procedure has a high rate of complications. 2. Ablation therapy is done before electrophysiological study (EPS) has identified the source of the dysrhythmia. 3. Radiofrequency catheter ablation therapy is considered definitive treatment of severe bradycardia heart rhythms. 4. Radiofrequency catheter ablation therapy uses electrical energy to remove problematic areas of the heart's conduction system

4. Radiofrequency catheter ablation therapy uses electrical energy to remove problematic areas of the heart's conduction system Radiofrequency catheter ablation therapy uses electrical energy to "burn" or ablate areas of the conduction system as definitive treatment of tachydysrhythmias. Ablation therapy is done after EPS has identified the source of the dysrhythmia. The ablation procedure is successful with a low complication rate.

(4. 1500 ÷ 20 =) 75 (bpm)

4. The ECG pattern of a patient with a regular HR reveals 20 small squares between each R-R interval. What is the patient's heart rate? ________ bpm

The nurse recognizes which cardiac dysrhythmia as life threatening and necessitating immediate intervention? 1. Sinus tachycardia 2. Atrial fibrillation 3. Junctional tachycardia 4. Ventricular fibrillation

4. Ventricular fibrillation Ventricular fibrillation is a life-threatening dysrhythmia that requires immediate intervention. During ventricular fibrillation, the ventricles are quivering and are no longer able to contract to produce effective cardiac output. Because there is no cardiac output, the body is left without oxygenation. Sinus tachycardia requires treatment to slow the rate to 60 to 100 beats/minute. Atrial fibrillation requires treatment to convert the rhythm back to a normal sinus rhythm with one atrial contraction for every ventricular contraction. Normal sinus rhythm, in which the rate is 60 to 100 beats/minute, requires no treatment.

A nurse, while reading the ECG of a patient, finds that there are 8 R-R intervals in a span of six seconds. What would be the heart rate of this patient? Record your answer using a whole number. __ beats/minute.

80 The heart rate can be calculated from an ECG by counting the number of R-R intervals in six seconds and multiplying that number by 10. In this case, the patient's ECG has eight R-R intervals. Therefore, 8 multiplied by 10 is 80.

d ( In type II second-degree AV block, a P wave is nonconducted without progressive P-R interval lengthening. It is usually from a block in a bundle branch, occurs in a ratio of 2 P waves-to-1 QRS complex, 3:1, and so on. Atrial fibrillation has a chaotic P wave. Asystole is absence of ventricular activity. First-degree AV block is a prolonged AV conduction time, so the P-R interval is prolonged.)

9. What should the nurse reading the monitor strip call a rhythm with a regular PR interval but a blocked QRS complex? a. Asystole b. Atrial fibrillation c. First-degree AV block d. Type II second-degree AV block

After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the drug 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 drug 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.

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. DIF: Cognitive Level: Apply (application) REF: 803 TOP: Nursing Process: Evaluation MSC:

ANS: C The rhythm is a second-degree AV block, type I (Mobitz I or Wenckebach heart block). The rhythm is identified by a gradual lengthening of the PR interval. Type I AV block is usually a result of myocardial ischemia or infarction and typically is transient and well tolerated. You should assess for bradycardia, hypotension, and angina. If the patient becomes symptomatic, atropine or a temporary pacemaker may be needed. Reference: 830

A patient admitted with acute coronary syndrome (ACS) has continuous ECG monitoring. An examination of the rhythm strip reveals the following characteristics: atrial rate of 74 beats/minute and regular; ventricular rate of 62 beats/minute and irregular; P wave with a normal shape; PR interval that lengthens progressively until a P wave is not conducted; and QRS complex with a normal shape. Your priority nursing intervention involves A. performing synchronized cardioversion. B. administering 1 mg of epinephrine by IVP. C. observing for symptoms of hypotension or angina. D. preparing the patient for a transcutaneous pacemaker.

d. an increase in infarct size. Although many factors can cause a sinus tachycardia, in the patient who has had an acute MI, tachycardia increases myocardial oxygen need in a heart that already has impaired circulation and may lead to increasing angina and further ischemia and necrosis.

A patient with an acute MI has sinus tachycardia of 126 bpm. The nurse recognizes that if this dysrhythmia is not treated, the patient is likely to experience a. hypertension. b. escape rhythms. c. ventricular tachycardia. d. an increase in infarct size.

B Third-degree or complete heart block is recognized with the atrial and ventricular dissociation and treated with a pacemaker. Sinus bradycardia does not have atrial and ventricular dissociation. Atrial fibrillation does not have normal P waves, as they are stimulated by ectopic foci. In type 1 second-degree AV heart block the P-R interval gradually lengthens and a QRS complex is dropped. Then the cycle begins again.

A patient with an acute myocardial infarction (MI) develops the following ECG pattern: atrial rate of 82 and regular; ventricular rate of 46 and regular; P wave and QRS complex are normal but there is no relationship between the P wave and the QRS complex. What dysrhythmia does the nurse identify this as and what treatment is expected? a. Sinus bradycardia treated with atropine b. Third-degree heart block treated with a pacemaker c. Atrial fibrillation treated with electrical cardioversion d. Type I second-degree AV block treated with observation

A. A distorted P wave with normal conduction of the impulse through the ventricles is characteristic of a premature atrial contraction. In a normal heart, this dysrhythmia is frequently associated with emotional stress or the use of caffeine, tobacco, or alcohol. Sedatives rarely slow the heart rate (HR). Aerobic conditioning and holding of breath during exertion (Valsalva maneuver) often cause bradycardia.

A patient with no history of heart disease has a rhythm strip that shows an occasional distorted P wave followed by normal AV and ventricular conduction. What should the nurse question the patient about? a. The use of caffeine b. The use of sedatives c. Any aerobic training d. Holding of breath during exertion

A A rhythm pattern that is normal except for a prolonged P-R interval is characteristic of a first-degree heart block. First-degree heart blocks are not treated but are observed for progression to higher degrees of heart block. Atropine is administered for bradycardia. Synchronized cardioversion is used for atrial fibrillation with a rapid ventricular response or supraventricular tachycardia (SVT). Pacemakers are used for higher-degree heart blocks.

A patient's rhythm strip indicates a normal HR and rhythm with normal P waves and QRS complexes, but the PR interval is 0.26 second. What is the most appropriate action by the nurse? a. Continue to assess the patient. b. Administer atropine per protocol. c. Prepare the patient for synchronized cardioversion. d. Prepare the patient for placement of a temporary pacemaker.

A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. Teaching for this patient would include information about a. anticoagulant therapy. c. emergency cardioversion. b. permanent pacemakers. d. IV adenosine (Adenocard).

ANS: A Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant treatment for 3 weeks before attempting cardioversion. This is done to prevent embolization of clots from the atria. Cardioversion may be done after several weeks of anticoagulation therapy. Adenosine is not used to treat atrial fibrillation. Pacemakers are routinely used for patients with bradydysrhythmias. Information does not indicate that the patient has a slow heart rate. DIF: Cognitive Level: Apply (application)

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

ANS: 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.

A 20-yr-old patient 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 mm Hg, 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 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.

ANS: 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. DIF: Cognitive Level: Apply (application)

1. 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.

ANS: 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. DIF: Cognitive Level: Understand (comprehension) REF: 791 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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

ANS: B First-degree atrioventricular 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. DIF: Cognitive Level: Apply (application)

The nurse notes that a patient's cardiac monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm? a. Ventricular couplets b. Ventricular bigeminy c. Ventricular R-on-T phenomenon d. Multifocal premature ventricular contractions

ANS: B Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking. Pairs of wide QRS complexes are described as ventricular couplets. There is no indication that the premature ventricular contractions (PVCs) are multifocal or that the R-on-T phenomenon is occurring. DIF: Cognitive Level: Apply (application) REF: 799 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse notes that a patient's heart monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm? a. Ventricular couplets b. Ventricular bigeminy c. Ventricular R-on-T phenomenon d. Multifocal premature ventricular contractions

ANS: B Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking. Pairs of wide QRS complexes are described as ventricular couplets. There is no indication that the premature ventricular contractions are multifocal or that the R-on-T phenomenon is occurring. DIF: Cognitive Level: Apply (application)

Which action should the nurse perform when preparing a patient with supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm Hg? a. Turn the synchronizer switch to the "off" position. b. Give a sedative before cardioversion is implemented. c. Set the defibrillator/cardioverter energy to 360 joules. d. Provide assisted ventilations with a bag-valve-mask device.

ANS: B When a patient has a nonemergency cardioversion, sedation is used just before the procedure. The synchronizer switch is turned "on" for cardioversion. The initial level of joules for cardioversion is low (e.g., 50). Assisted ventilations are not indicated for this patient.

The patient has an electrocardiographic (ECG) tracing that is 50 beats/minute, the rhythm is regular, and there is a P wave before every QRS complex. The QRS has a normal shape and duration, and the PR interval is normal. What is you response? A. Administer atropine by intravenous push (IVP). B. Administer epinephrine by IVP. C. Monitor the patient for syncope. D. Attach an external pacemaker.

ANS: C The rhythm described is sinus bradycardia. Treatment depends on the patient's response and whether adequate perfusion is occurring. If the patient tolerates the rhythm, no treatment is given. Reference: 824

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/min. Which action should the nurse take next? a. Immediately notify the health care provider. b. Document the rhythm and continue to monitor the patient. c. Prepare to give IV amiodarone per agency dysrhythmia protocol. d. Perform synchronized cardioversion per agency dysrhythmia protocol.

ANS: C 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. Cardioversion is not indicated given that the patient has returned to a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation. DIF: Cognitive Level: Analyze (analysis)

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 teaching about the care of patients with ICDs? a. The nurse administers amiodarone (Cordarone) to the patient. b. The nurse helps the patient fill out the application for obtaining a Medic Alert device. c. The nurse encourages the patient to do active range of motion exercises for all extremities. d. The nurse teaches the patient that sexual activity can be resumed when the incision is healed.

ANS: C The patient should avoid moving the arm on the ICD insertion site until healing has occurred to prevent displacement of the ICD leads. The other actions by the new nurse are appropriate for this patient. DIF: Cognitive Level: Apply (application)

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. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10. d. Calculate the number of small squares between one QRS complex and the next and divide into 1500.

ANS: C This is the quickest way to determine the ventricular rate for a patient with a regular rhythm. All the other methods are accurate, but take longer. DIF: Cognitive Level: Analyze (analysis)

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. c. QT interval of 0.38 second. b. PR interval of 0.18 second. d. QRS interval of 0.14 second.

ANS: D Because the normal QRS interval is less than 0.12 seconds, the patient's QRS interval of 0.14 seconds indicates that the conduction through the ventricular conduction system is prolonged. The PR interval and QT interval are within normal range and ST segment should be isoelectric (flat). DIF: Cognitive Level: Apply (application)

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

ANS: D The absence of P waves, wide QRS, rate greater than 150 beats/min, 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. DIF: Cognitive Level: Apply (application)

The nurse knows that discharge teaching about the management of a new permanent pacemaker has been most effective when the patient states a. "It will be several weeks before I can return to my usual activities." b. "I will avoid cooking with a microwave oven or being near one in use." 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 until I see the health care provider."

ANS: 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.

Automaticity

Ability to initiate an impulse spontaneously and continuously

A patient reports dizziness and shortness of breath and is admitted with a dysrhythmia. Which medication, if ordered, requires the nurse to carefully monitor the patient for asystole? Digoxin Adenosine Metoprolol Atropine sulfate

Adenosine IV adenosine is the first drug of choice to convert supraventricular tachycardia to a normal sinus rhythm. Adenosine is administered IV rapidly (over 1 or 2 seconds) followed by a rapid, normal saline flush. The nurse should monitor the patient's electrocardiogram continuously because a brief period of asystole after adenosine administration is common and expected. Atropine sulfate increases heart rate, whereas lanoxin and metoprolol slow the heart rate.

D Pulseless electrical activity (PEA) occurs when there is electrical activity on the ECG but no mechanical activity on assessment and therefore no heart rate. PEA is the most common dysrhythmia seen after defibrillation and may be caused by hypovolemia, hypoxia, metabolic acidosis, altered potassium level, hypoglycemia, hypothermia, toxins, cardiac tamponade, thrombosis, tension pneumothorax, and trauma. Dissociated atria and ventricles is third-degree AV block.

After defibrillation, the advanced cardiac life support (ACLS) nurse says that the patient has pulseless electrical activity (PEA). What is most important for the nurse to understand about this rhythm? a. The heart rate is 40 to 60 bpm. b. Hypoxemia and hypervolemia are common with PEA. c. There is dissociated activity of the ventricle and atrium. d. There is electrical activity with no mechanical response.

The nurse observes no P waves on the patients monitor strip. 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. What does the nurse determine the rhythm to be? Sinus tachycardia Atrial fibrillation Ventricular fibrillation Ventricular tachycardia

Atrial fibrillation Atrial fibrillation is represented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atria are not truly contracting, just fibrillating. Sinus tachycardia is a sinus rate above 100 beats/min with normal P waves. Ventricular fibrillation is seen on the ECG without a visible P wave; an unmeasurable heart rate, PR or QRS; and the rhythm is irregular and chaotic. Ventricular tachycardia is seen as three or more premature ventricular contractions that have distorted QRS complexes with regular or irregular rhythm, and the P wave is usually buried in the QRS complex without a measurable PR interval.

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 this rhythm as what? Sinus tachycardia Atrial fibrillation Ventricular fibrillation Ventricular tachycardia

Atrial fibrillation Atrial fibrillation is represented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atria are not truly contracting, just fibrillating. Sinus tachycardia is a sinus rate above 100 beats/minute with normal P waves. Ventricular fibrillation is seen on the ECG without a visible P wave; an unmeasurable heart rate, PR or QRS; and the rhythm is irregular and chaotic. Ventricular tachycardia is seen as three or more premature ventricular contractions (PVCs) that have distorted QRS complexes with regular or irregular rhythm, and the P wave is usually buried in the QRS complex without a measurable PR interval.

What describes the refractory phase? a. abnormal electrical impulses b. Period in which heart tissue cannot be stimulated c. areas of the heart do not depolarize at the same rate because of depressed conduction d. Sodium migrates rapidly into the cel, so it is positive compared to the outside of the cell

B Refractory phase is the period in which heart tissue cannot be stimulated. Ectopic foci produce abnormal electrical impulses. Reentrant excitation causing premature beats may occur when areas of the heart do not depolarize simultaneously with depressed conduction. Depolarization of cardiac cells occur when sodium migrates rapidly into the cell.

A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of _____ beats/minute. a. 15 to 20 b. 20 to 40 c. 40 to 60 d. 60 to 100

C If the sinoatrial (SA) node fails to discharge, the atrioventricular (AV) node will automatically discharge at the normal rate of 40 to 60 beats/minute. The slower rates are typical of the bundle of His and the Purkinje system and may be seen with failure of both the SA and AV node to discharge. The normal SA node rate is 60 to 100 beats/minute. DIF: Cognitive Level: Understand (comprehension) REF: 797 TOP: Nursing Process: Assessment MSC:

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

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

Which statement best describes the electrical activity of the heart represented by measuring the PR interval on the ECG? A. The length of time it takes to depolarize the atrium B. The length of time it takes for the atria to depolarize and repolarize C. The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers D. The length of time it takes for the electrical impulse to travel from the SA node to the AV node

C. The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers The electrical impulse in the heart must travel from the SA node through the AV node and into the Purkinje fibers in order for synchronous atrial and ventricular contraction to occur. When measuring the PR interval (the time from the beginning of the P wave to the beginning of the QRS), the nurse is identifying the length of time it takes for the electrical impulse to travel from the SA node to the Purkinje fibers. The P wave represents the length of time it takes for the impulse to travel from the SA node through the atrium causing depolarization of the atria (atrial contraction). Atrial repolarization occurs during ventricular depolarization and is hidden by the QRS complex. The length of time it takes for the electrical impulse to travel from the SA node to the AV node is the flat line between the end of the P wave and the beginning of the Q wave on the ECG and is not usually measured.

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. DIF: Cognitive Level: Apply (application) REF: 798 TOP: Nursing Process: Implementation MSC:

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 This is the quickest way to determine the ventricular rate for a patient with a regular rhythm. All the other methods are accurate, but take longer. DIF: Cognitive Level: Apply (application) REF: 789-790 TOP: Nursing Process: Assessment MSC:

The nurse observes a flat line on the patient's monitor and the patient is unresponsive without pulse. What medications does the nurse prepare to administer? Lidocaine and amiodarone Digoxin and procainamide Epinephrine and/or vasopressin β-adrenergic blockers and dopamine

Epinephrine and/or vasopressin Normally, the patient in asystole cannot be successfully resuscitated. However, administration of epinephrine or vasopressin may prompt the return of depolarization and ventricular contraction. Lidocaine and amiodarone are used for ventricular tachycardia or ventricular fibrillation. Digoxin and procainamide are used for ventricular rate control. β-adrenergic blockers are used to slow heart rate, and dopamine is used to increase heart rate.

The patient has a potassium level of 2.9 mEq/L, and the nurse obtains the following measurements on the rhythm strip: Heart rate of 86 with a regular rhythm, the P wave is 0.06 seconds (sec) and normal shape, the PR interval is 0.24 sec, and the QRS is 0.09 sec. How should the nurse document this rhythm? First-degree AV block Second-degree AV block Premature atrial contraction (PAC) Premature ventricular contraction (PVC)

First-degree AV block In first-degree atrioventricular (AV) block, there is prolonged duration of AV conduction that lengthens the PR interval above 0.20 sec. In type I second-degree AV block, the PR interval continues to increase in duration until a QRS complex is blocked. In type II, the PR interval may be normal or prolonged, the ventricular rhythm may be irregular, and the QRS is usually greater than 0.12 sec. PACs cause an irregular rhythm with a different-shaped P wave than the rest of the beats, and the PR interval may be shorter or longer. PVCs cause an irregular rhythm, and the QRS complex is wide and distorted in shape.

The nurse is monitoring the ECGs of several patients on a cardiac telemetry unit. The patients are directly visible to the nurse, and all of the patients are observed to be sitting up and talking with visitors. Which patient's rhythm would require the nurse to take immediate action?

Frequent premature ventricular contractions (PVCs) (greater than 1 every 10 beats) may reduce the cardiac output and precipitate angina and heart failure, depending on their frequency. Because PVCs in CAD or acute MI indicate ventricular irritability, the patient's physiologic response to PVCs must be monitored. Frequent PVCs most likely must be treated with oxygen therapy, electrolyte replacement, or antidysrhythmic agents.

A 38-year-old teacher who reported dizziness and shortness of breath while supervising recess is admitted with a dysrhythmia. Which medication, if ordered, requires the nurse to carefully monitor the patient for asystole?

IV adenosine (Adenocard) is the first drug of choice to convert supraventricular tachycardia to a normal sinus rhythm. Adenosine is administered IV rapidly (over 1 or 2 seconds) followed by a rapid, normal saline flush. The nurse should monitor the patient's ECG continuously because a brief period of asystole after adenosine administration is common and expected. Atropine sulfate increases heart rate, whereas lanoxin and metoprolol slow the heart rate.

A patient informs the nurse of experiencing syncope. Which nursing action should the nurse prioritize in the patient's subsequent diagnostic workup? Preparing to assist with a head-up tilt-test Preparing an IV dose of a β-adrenergic blocker Assessing the patient's knowledge of pacemakers Teaching the patient about the role of antiplatelet aggregators

Preparing to assist with a head-up tilt-test In patients without structural heart disease, the head-up tilt-test is a common component of the diagnostic workup after episodes of syncope. IV β-blockers are not indicated, although an IV infusion of low-dose isoproterenol may be started in an attempt to provoke a response if the head-up tilt-test did not have a response. Addressing pacemakers is premature and inappropriate at this stage of diagnosis. Patient teaching surrounding antiplatelet aggregators is not directly relevant to the patient's syncope at this time.

The patient has atrial fibrillation with a rapid ventricular response. What electrical treatment option does the nurse prepare the patient for? Defibrillation Synchronized cardioversion Automatic external defibrillator (AED) Implantable cardioverter-defibrillator (ICD)

Synchronized cardioversion Synchronized cardioversion is planned for a patient with supraventricular tachydysrhythmias (atrial fibrillation with a rapid ventricular response). Defibrillation or AEDs are the treatment of choice to end ventricular fibrillation and pulseless ventricular tachycardia (VT). An ICD is used with patients who have survived sudden cardiac death, have spontaneous sustained VT, and are at high risk for future life-threatening dysrhythmias.

ANS: D A premature ventricular contraction (PVC) is a contraction originating in an ectopic focus in the ventricles. When every other beat is a PVC, the rhythm is called ventricular bigeminy. PVCs are usually a benign finding in the patient with a normal heart. In heart disease, PVCs may reduce the cardiac output and precipitate angina and heart failure, depending on the frequency. Because PVCs in coronary artery disease or acute MI indicate ventricular irritability, the patient's physiologic response to PVCs must be monitored. Assessment of the patient's hemodynamic status is important to determine whether treatment with drug therapy is needed. Reference: 830

The ECG monitor of a patient in the cardiac care unit after a myocardial infarction (MI) indicates ventricular bigeminy with a rate of 50 beats/minute. You anticipate A. performing defibrillation. B. treatment with IV lidocaine. C. insertion of a temporary, transvenous pacemaker. D. assessing the patient's response to the dysrhythmia.

ANS: B PSVT is a dysrhythmia originating in an ectopic focus anywhere above the bifurcation of the bundle of His. Treatment includes vagal stimulation (e.g., Valsalva maneuver, coughing) and intravenous (IV) adenosine as the first drug of choice. The drug has a short half-life and is given rapid IVP. Other drugs are β-adrenergic blockers, calcium channel blockers, and amiodarone. Defibrillation is used if the vagal stimulation and drug therapy are ineffective and the patient becomes hemodynamically unstable. Digoxin is not used for this dysrhythmia but typically is used for atrial fibrillation. Reference: 826

The emergency department patient is in paroxysmal supraventricular tachycardia (PSVT) at a rate of 170 beats/minute. Which treatment do you anticipate first? A. Sotalol (Betapace) by slow IVP B. Adenosine (Adenocard) by fast IVP C. Defibrillation D. Digoxin (Lanoxin)

C The premature atrial contraction (PAC) has a distorted P wave that may feel like a skipped beat to the patient. Atrial flutter is an atrial tachydysrhythmia with recurring, regular, saw-toothed flutter waves from the same focus in the right or possibly left atrium. Sinus bradycardia has a regular heart rate less than 60 bpm. Paroxysmal supraventricular tachycardia (PSVT) starts in an ectopic focus above the bundle of His and may be triggered by PAC. If seen, the P wave may have an abnormal shape and has a spontaneous start and termination with a rate of 150 to 220 bpm.

The nurse is evaluating the telemetry ECG rhythm strip. How should the nurse document the distorted P wave causing an irregular rhythm? a. Atrial flutter b. Sinus bradycardia c. Premature atrial contraction (PAC) d. Paroxysmal supraventricular tachycardia (PSVT)

D. Induces dysrhythmias that may require cardioversion or defibrillation to correct. Electrophysiologic testing involves electrical stimulation to various areas of the atrium and ventricle to determine the inducibility of dysrhythmias and frequently induces ventricular tachycardia or ventricular fibrillation. The patient may have "near-death" experiences and requires emotional support if this occurs. Dye and anticoagulants are used for coronary angiograms.

The nurse plans close monitoring for the patient during electrophysiologic testing because this test a. requires the use of dyes that irritate the myocardium. b. causes myocardial ischemia, resulting in dysrhythmias. c. involves the use of anticoagulants to prevent thrombus and embolism. d. induces dysrhythmias that may require cardioversion or defibrillation to correct.

ANS: A In third-degree atrioventricular (AV) block, there is no correlation between the impulse from the atrium to the ventricles and the ventricular rhythm seen. A pacemaker eventually is required. Action must be taken because this usually results in reduced cardiac output with subsequent ischemia if untreated. Carotid massage is vagal stimulation, and it can cause bradycardia. There is a problem in conduction, not abnormal contraction, and defibrillation is not used. Reference: 830

The patient has a heart rate of 40 beats/minute. The P waves are regular, and the Q waves are regular, but there is no relationship between the P wave and QRS complex. What treatment do you anticipate? A. Pacemaker B. Continue to monitor C. Carotid massage D. Defibrillation

ANS: D The chaotic atrial activity results in blood stasis that can lead to embolic events. Patients with chronic AF are given an anticoagulant, most often warfarin (Coumadin), to prevent the formation of emboli. There is no PR interval in AF because the P wave is absent, replaced by chaotic fibrillatory waves. Defibrillation is an elective procedure in chronic AF and is performed at lower levels of electricity. Pulse deficit is a higher-level skill and is not taught to the patient. Reference: 827

The patient has chronic atrial fibrillation (AF). What action do you anticipate? A. Monitoring the PR interval B. Defibrillation with 360 joule C. Teaching the patient to monitor the pulse deficit D. Teaching the patient to take an anticoagulant daily

The nurse determines there is artifact on the patient's telemetry monitor. Which factor should the nurse assess for that could correct this issue? Disabled automaticity Electrodes in the wrong lead Too much hair under the electrodes Stimulation of the vagus nerve fibers

Too much hair under the electrodes Artifact is caused by muscle activity, electrical interference, or insecure leads and electrodes that could be caused by excessive chest wall hair. Disabled automaticity would cause an atrial dysrhythmia. Electrodes in the wrong lead will measure electricity in a different plane of the heart and may have a different wave form than expected. Stimulation of the vagus nerve fibers causes a decrease in heart rate, not artifact.

Cardioversion is attempted for a patient with atrial flutter and a rapid ventricular response. After the delivering 50 joules by synchronized cardioversion, the patient develops ventricular fibrillation. Which action should the nurse take immediately? Administer 250 mL of 0.9% saline solution IV by rapid bolus. Assess the apical pulse, blood pressure, and bilateral neck vein distention. Turn the synchronizer switch to the "off" position and recharge the device. Tell the patient to report any chest pain or discomfort and administer morphine sulfate.

Turn the synchronizer switch to the "off" position and recharge the device. Ventricular fibrillation produces no effective cardiac contractions or cardiac output. If during synchronized cardioversion the patient becomes pulseless or the rhythm deteriorates to ventricular fibrillation, the nurse should turn the synchronizer switch off and initiate defibrillation. Fluids, additional assessment, or treatment of pain alone will not restore an effective heart rhythm.

The nurse prepares to defibrillate a patient. For which dysrhythmia has the nurse observed in this patient? Ventricular fibrillation Third-degree AV block Uncontrolled atrial fibrillation Ventricular tachycardia with a pulse

Ventricular fibrillation 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.

Cardioversion is attempted for a 64-year-old man with atrial flutter and a rapid ventricular response. After the nurse delivers 50 joules by synchronized cardioversion, the patient develops ventricular fibrillation. Which action should the nurse take immediately?

Ventricular fibrillation produces no effective cardiac contractions or cardiac output. If during synchronized cardioversion the patient becomes pulseless or the rhythm deteriorates to ventricular fibrillation, the nurse should turn the synchronizer switch off and initiate defibrillation. Fluids, additional assessment, or treatment of pain alone will not restore an effective heart rhythm.

b. PVC on the T wave When premature ventricular contraction (PVC) falls on the T wave of the preceding beat, R-on-T phenomenon occurs. Because the ventricle is repolarizing and there is increased excitability of cardiac cells, there is an increased risk of ventricular tachycardia or ventricular fibrillation. The other options do not increase this risk.)

Which rhythm abnormality has an increased risk of ventricular tachycardia and ventricular fibrillation? a. PAC b. PVC on the T wave c. Accelerated idioventricular rhythm d. Premature ventricular contraction (PVC) couplet

ANS: C The length of time for the electrical impulse to travel from the sinoatrial (SA) node to the Purkinje fibers The electrical impulse in the heart must travel from the SA node through the AV node and into the Purkinje fibers for synchronous atrial and ventricular contraction to occur. The P wave represents atrial contraction, and the R wave is part of the QRS complex that represents ventricular contraction. When measuring the time from the beginning of the P wave to the beginning of the QRS (PR interval), you are identifying the length of time it takes for the electrical impulse to travel from the SA node to the Purkinje fibers.

Which statement best describes the electrical activity of the heart represented by measuring the PR interval on the ECG? A. The length of time it takes to depolarize the atrium B. The length of time it takes for the atria to depolarize and repolarize C. The length of time for the electrical impulse to travel from the sinoatrial (SA) node to the Purkinje fibers D. The length of time it takes for the electrical impulse to travel from the SA node to the AV node

ANS: C The typical ECG changes seen in myocardial ischemia include ST-segment depression or T-wave inversion, or both.

You are monitoring the electrocardiogram of a patient admitted with ACS. Which ECG characteristics most suggest ischemia? A. Sinus rhythm with a pathologic Q wave B. Sinus rhythm with an elevated ST segment C. Sinus rhythm with a depressed ST segment D. Sinus rhythm with premature atrial contractions

A patient has sought care following a syncopal episode of unknown etiology. Which nursing action should the nurse prioritize in the patient's subsequent diagnostic workup? a) Preparing to assist with a head-up tilt-test b) Preparing an IV dose of a Beta-adrenergic blocker c) Assessing the patient's knowledge of pacemakers d) Teaching the patient about the role of antiplatlet aggregators

a) Preparing to assist with a head-up tilt-test In patients without structural heart disease, the head-up tilt-test is a common component of the diagnostic workup following episodes of syncope. IV β-blockers are not indicated although an IV infusion of low-dose isoproterenol may be started in an attempt to provoke a response if the head-up tilt-test did not have a response. Addressing pacemakers is premature and inappropriate at this stage of diagnosis. Patient teaching surrounding anti platelet aggregators is not directly relevant to the patient's syncope at this time.

For which dysrhythmia is defibrillation primarily indicated? a) Ventricular fibrillation b) Third-degree AV block c) Uncontrolled fibrillation d) Ventricular tachycardia with a pulse

a) Ventricular fibrillation (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.)

The nurse is doing discharge teaching with the patient and spouse of the patient who just received an implantable cardioverter-defibrillator (ICD) in the left side. Which statement by the patient indicates to the nurse that the patient needs more teaching? a) "I will call the cardiologist if my ICD fires." b) "I cannot fly because it will damage the ICD." c) "I cannot move my left arm until it is approved" d) "I cannot drive until my cardiologist says it is okay."

b) "I cannot fly because it will damage the ICD." (The patient statement that flying will damage the ICD indicates misunderstanding about flying. The patient should be taught that informing TSA about the ICD can be done because it may set off the metal detector and if a hand-held screening wand is used, it should not be placed directly over the ICD. The other options indicate the patient understands the teaching.)

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 this rhythm as what? a) Sinus tachycardia b) Atrial fibrillation c) Ventricular fibrillation d) Ventricular tachycardia

b) Atrial Fibrillation (Atrial fibrillation is represented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atria are not truly contracting, just fibrillating. Sinus tachycardia is a sinus rate above 100 beats/minute with normal P waves. Ventricular fibrillation is seen on the ECG without a visible P wave; an unmeasurable heart rate, PR or QRS; and the rhythm is irregular and chaotic. Ventricular tachycardia is seen as three or more premature ventricular contractions (PVCs) that have distorted QRS complexes with regular or irregular rhythm, and the P wave is usually buried in the QRS complex without a measurable PR interval.)

The patient is admitted with acute coronary syndrome (ACS). The ECG shows ST-segment depression and T-wave inversion. What should the nurse know that this indicates? a) Myocardial injury b) Myocardial ischemia c) Myocardial infarction d) A pacemaker is present

b) Myocardial ischemia The ST depression and T wave inversion on the ECG of a patient diagnosed with ACS indicate myocardial ischemia from inadequate supply of blood and oxygen to the heart. Myocardial injury is identified with ST-segment elevation. Myocardial infarction is identified with ST-segment elevation and a widened and deep Q wave. A pacemaker's presence is evident on the ECG by a spike leading to depolarization and contraction.

The patient has atrial fibrillation with a rapid ventricular response. The nurse knows to prepare for which treatment if an electrical treatment is planned for this patient? a) Defibrillation b) Synchronized cardioversion c) Automatic external defibrillator (AED) d) Implantable cardioverter-defibrillator (ICD)

b) Synchronized cardioversion Synchronized cardioversion is planned for a patient with supraventricular tachydysrhythmias (atrial fibrillation with a rapid ventricular response). Defibrillation or AEDs are the treatment of choice to end ventricular fibrillation and pulseless ventricular tachycardia (VT). An ICD is used with patients who have survived sudden cardiac death (SCD), have spontaneous sustained VT, and are at high risk for future life-threatening dysrhythmias.

The nurse obtains a 6-second rhythm strip and charts the following analysis: Tab 1 Tab 2 Tab 3 Atrial data Rate: 70, regular Variable PR interval Independent beats Ventricular data Rate: 40, regular Isolated escape beats Additional data QRS: 0.04 sec P wave and QRS complexes unrelated What is the correct interpretation of this rhythm strip? a) Sinus arrhythmias b) Third-degree heart block c) Wenckebach phenomenon d) Premature ventricular contractions

b) Third-degree heart block (Third-degree heart block represents a loss of communication between the atrium and ventricles from AV node dissociation. This is depicted on the rhythm strip as no relationship between the P waves (representing atrial contraction) and QRS complexes (representing ventricular contraction). The atria are beating totally on their own at 70 beats/min, whereas the ventricles are pacing themselves at 40 beats/min. Sinus dysrhythmia is seen with a slower heart rate with exhalation and an increased heart rate with inhalation. In Wenckebach heart block, there is a gradual lengthening of the PR interval until an atrial impulse is nonconducted and a QRS complex is blocked or missing. Premature ventricular contractions (PVCs) are the early occurrence of a wide, distorted QRS complex.)

Which patient teaching points should the nurse include when providing discharge instructions to a patient with a new permanent pacemaker and the caregiver (select all that apply)? a. Avoid or limit air travel b. Take and record a daily pulse rate c. Obtain and wear a Medic Alert ID device at all times d. Avoid lifting arm on the side of the pacemaker above shoulder e. Avoid microwave ovens because they interfere with pacemaker function

b. Take and record a daily pulse rate c. Obtain and wear a Medic Alert ID device at all times d. Avoid lifting arm on the side of the pacemaker above shoulder Rationale: Pacemaker discharge teaching should include the following instructions: First, air travel is not restricted. The patient should inform airport security of the presence of a pacemaker because it may set off the metal detector. If a hand-held screening wand is used, it should not be placed directly over the pacemaker. Manufacturer information may vary with regard to the effect of metal detectors on the function of the pacemaker. Second, the patient should monitor the pulse and inform the cardiologist if it drops below a predetermined rate. Third, the patient should obtain and wear a Medic Alert ID device at all times. Fourth, the patient must avoid lifting the arm on the pacemaker side above the shoulder until this is approved by the cardiologist. Fifth, microwave ovens are safe to use, and they do not interfere with pacemaker function. Table 35-13 provides additional discharge teaching guidelines for a patient with a pacemaker.

What accurately describes ECG monitoring? a. Depolarization of the cells in the ventricles produces the T wave on the ECG. b. An abnormal cardiac impulse that arises in the atria, ventricles, or AV junction can create a premature beat is known as an artifact. c. Lead placement for V1 includes one lead each for right arm, right leg, and left leg with the fifth lead on the fourth intercostal space to the right of the sternal boarder. d. If the SA node fails to discharge an impulse or discharges very slowly, a secondary pacemaker in the AV node is able to discharge at a rate of 30 to 40 times per minute.

c. The V1 leads are placed toward each limp and centrally at the fourth intercostal space to the right of the sternal border. Depolarization of the ventricular cells produces the QRS interval on the ECG. The T wave is produced by repolarization of the ventricular cells. Abnormal cardiac impulses from the atria, ventricles, or AV junction create ectopic beats. Artifacts are seen with leads or electrodes that are not secure, with muscle activity or electrical interference. The rate produced by the AV node pacing in a junctional escape rhythm is 40 to 60 bpm. IF the His-Purkinje system is blocked, the heart rate is 20 to 40 bpm.

The nurse is monitoring the ECG of a patient admitted with ACS. Which ECG characteristics would be most suggestive of myocardial ischemia? a. Sinus rhythm with a pathologic Q wave b. Sinus rhythm with an elevated ST segment c. Sinus rhythm with a depressed ST segment d. Sinus rhythm with premature atrial contractions

c. Sinus rhythm with a depressed ST segment Rationale: Typical electrocardiographic (ECG) changes that are seen in myocardial ischemia include ST-segment depression and T-wave inversion.

A patient admitted with ACS has continuous ECG monitoring. An examination of the rhythm strip reveals the following characteristics: atrial rate 74 beats/min and regular; ventricular rate 62 beats/min and irregular; P wave normal shape; PR interval lengthens progressively until a P wave is not conducted; QRS normal shape. The priority nursing intervention would be to a. perform synchronized cardioversion b. administer epinephrine 1 mg IV push c. observe for symptoms of hypotension or angina d. apply transcutaneous pacemaker pads on the patient

c. observe for symptoms of hypotension or angina Rationale: The rhythm is a second-degree atrioventricular (AV) block, type I (i.e., Mobitz I or Wenckebach heart block). The rhythm is characterized by a gradual lengthening of the PR interval. Type I AV block is usually a result of myocardial ischemia or infarction and typically is transient and well tolerated. The nurse should assess for bradycardia, hypotension, and angina. If the patient experiences symptoms, atropine or a temporary pacemaker may be needed.

Important teaching for the patient scheduled for a radiofrequency catheter ablation procedure includes explaining that a. ventricular bradycardia may be induced and treated during the procedure b. a catheter will be placed in both femoral arteries to allow double-catheter use c. the procedure will destroy areas of the conduction system that are causing rapid heart rhythms d. a general anesthetic will be given to prevent the awareness of any "sudden cardiac death" experiences

c. the procedure will destroy areas of the conduction system that are causing rapid heart rhythms Rationale: Radiofrequency catheter ablation therapy involves the use of electrical energy to "burn" or ablate areas of the conduction system as definitive treatment of tachydysrhythmias.

What describes the SA node's ability to discharge an electrical impulse spontaneously? a. Excitability b. Contractility c. conductivity d. automaticity

d. Automaticity describes the ability to discharge an electrical impulse spontaneously. Excitability is a property of myocardial tissue that enables it to depolarized by an impulse. Contractility is the ability of the chambers to respond mechanically to an impulse. Conductivity is the ability to transmit an impulse along a membrane.

The autonomic nervous system plays an important role in

the rate of impulse formation, the speed of conduction, and the strength of cardiac contraction.

The patient's PR interval comprises six small boxes on the ECG graph. What does the nurse determine that this indicates? a. a normal finding b. a problem with ventricular depolarization c. a disturbance in the depolarization of the atria d. a problem, with conduction from the SA node to the ventricular cells

d. The normal PR interval is 0.12 to 0.20 seconds and reflects the time taken for the impulse to spread through the atria, AV node and bundle of His, the bundle branches, and Purkinje fibers. A PR interval of six small boxes is 0.24 second and indicates that the conduction if the impulse from the atria tot he Purkinje fibers is delayed.

The ECG monitor of a patient in the cardiac care unit after an MI indicates ventricular bigeminy with a rate of 50 beats/min. The nurse would anticipate a. performing defibrillation b. treating with IV amiodarone c. inserting a temporary transvenous pacemaker d. assessing the patient's response to the dysrhythmia

d. assessing the patient's response to the dysrhythmia Rationale: A premature ventricular contraction (PVC) is a contraction originating in an ectopic focus in the ventricles. When every other beat is a PVC, the rhythm is called ventricular bigeminy. PVCs are usually a benign finding in patients with a normal heart. In patients with heart disease, PVCs may reduce the cardiac output and precipitate angina and heart failure, depending on the frequency. Because PVCs in coronary artery disease (CAD) or acute myocardial infarction indicate ventricular irritability, the patient's physiologic response to PVCs must be monitored. Assessment of the patient's hemodynamic status is important for determining whether treatment with drug therapy is needed.

What accurately describes the PR interval (select all that apply)? a. 0.16 seconds b. <0.12 seconds c. 0.06 to 0.12 d. 0.12 to 0.20 seconds e. time of depolarization and depolarization of ventricles f. measured from beginning of P wave to beginning of QRS complex

d. f. The expected PR interval is 0.12 to 0.20 seconds and is measured from the beginning of the P wave to the beginning of the QRS complex. The T wave is 0.16 seconds, the QRS interval is <0.12 seconds, the P wave is 0.06 to 0.12 seconds, and the QT interval is the time of depolarization and depolarization of the ventricles.

The nurse prepares a patient for synchronized cardioversion knowing that cardioversion differs from defibrillation in that a. defibrillation requires a lower dose of electrical energy b. cardioversion is indicated to treat atrial bradydysrhythmias c. defibrillation is synchronized to deliver a shock during the QRS complex d. patients should be sedated if cardioversion is done on a non-emergency basis

d. patients should be sedated if cardioversion is done on a non-emergency basis Rationale: Synchronized cardioversion is the therapy of choice for patients with hemodynamically unstable ventricular or supraventricular tachydysrhythmias. A synchronized circuit in the defibrillator delivers a countershock that is programmed to occur on the R wave of the QRS complex of the electrocardiogram. The synchronizer switch must be turned on when cardioversion is planned. The procedure for synchronized cardioversion is the same as for defibrillation with the following exceptions: If synchronized cardioversion is performed on a nonemergency basis, the patient is sedated before the procedure, and the initial energy needed for synchronized cardioversion is less than the energy needed for defibrillation.