35- Dysrhymthmias
When analyzing an electrocardiographic (ECG) rhythm strip of a patient with a regular heart rhythm, the nurse counts 30 small blocks from one R wave to the next. The nurse calculates the patient's heart rate as ____.
ANS: 50 There are 1500 small blocks in a minute, and the nurse will divide 1500 by 30.
Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin? a. Instruct the patient to call for assistance before getting out of bed. b. Explain the association between various dysrhythmias and syncope. c. Educate the patient about the need to avoid caffeine and other stimulants. d. Tell the patient about the benefits of implantable cardioverter-defibrillators.
ANS: A A patient with fainting episodes is at risk for falls. The nurse will plan to minimize the risk by having assistance whenever the patient up. The other actions may be needed if dysrhythmias are found to be the cause of the patient's syncope, but are not appropriate for syncope of unknown origin.
Which action by a new registered nurse (RN) who is orienting to the progressive care unit indicates a good understanding of the treatment of cardiac dysrhythmias? a. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia b. Obtains the defibrillator and quickly brings it to the bedside of a patient whose monitor shows asystole c. Turns the synchronizer switch to the "on" position before defibrillating a patient with ventricular fibrillation d. Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second degree AV block
ANS: A Adenosine must be given over 1 to 2 seconds to be effective. The other actions indicate a need for more education about treatment of cardiac dysrhythmias. The RN should hold the diltiazem until talking to the health care provider. The treatment for asystole is immediate CPR. The synchronizer switch should be "off" when defibrillating.
A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. The priority teaching needed for this patient would include information about a. anticoagulant therapy. b. permanent pacemakers. c. electrical cardioversion. 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.
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.
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.
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.
ANS: 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.
A patient's cardiac monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious and pulseless. Which action should the nurse take first? a. Perform immediate defibrillation. b. Give epinephrine (Adrenalin) IV. c. Prepare for endotracheal intubation. d. Give ventilations with a bag-valve-mask device.
ANS: A The patient's rhythm and assessment indicate ventricular fibrillation and cardiac arrest; the initial action should be to defibrillate. If a defibrillator is not immediately available or is unsuccessful in converting the patient to a better rhythm, the other actions may be appropriate.
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.
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.
When preparing to defibrillate a patient, in which order will the nurse perform the following steps? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Turn the defibrillator on. b. Deliver the electrical charge. c. Select the appropriate energy level. d. Place the hands-free, multifunction defibrillator term-33pads on the patient's chest. e. Check the location of other staff and call out "all clear."
ANS: A, C, D, E, B This order will result in rapid defibrillation without endangering hospital staff.
A 19-year-old student comes to the student health center at the end of the semester complaining that, "My heart is skipping beats." An electrocardiogram (ECG) shows occasional premature ventricular contractions (PVCs). What action should the nurse take next? a. Start supplemental O2 at 2 to 3 L/min via nasal cannula. b. Ask the patient about current stress level and caffeine use. c. Ask the patient about any history of coronary artery disease. d. Have the patient taken to the hospital emergency department (ED).
ANS: B In a patient with a normal heart, occasional PVCs are a benign finding. The timing of the PVCs suggests stress or caffeine as possible etiologic factors. It is unlikely that the patient has coronary artery disease, and this should not be the first question the nurse asks. The patient is hemodynamically stable, so there is no indication that the patient needs to be seen in the ED or that oxygen needs to be administered.
A patient has ST segment changes that support an acute inferior wall myocardial infarction. Which lead would be best for monitoring the patient? a. I b. II c. V2 d. V6
ANS: B Leads II, III, and AVF reflect the inferior area of the heart and the ST segment changes. Lead II will best capture any electrocardiographic (ECG) changes that indicate further damage to the myocardium. The other leads do not reflect the inferior part of the myocardial wall and will not provide data about further ischemic changes in that area.
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.
ANS: 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 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.
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.
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.
ANS: 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.
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
ANS: 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.
Which information will the nurse include when teaching a patient who is scheduled for a radiofrequency catheter ablation for treatment of atrial flutter? a. The procedure will prevent or minimize the risk for sudden cardiac death. b. The procedure will use cold therapy to stop the formation of the flutter waves. c. The procedure will use electrical energy to destroy areas of the conduction system. d. The procedure will stimulate the growth of new conduction pathways between the atria.
ANS: C Radiofrequency catheter ablation therapy uses electrical energy to "burn" or ablate areas of the conduction system as definitive treatment of atrial flutter (i.e., restore normal sinus rhythm) and tachydysrhythmias. All other statements regarding the procedure are incorrect.
A patient reports dizziness and shortness of breath for several days. During cardiac monitoring in the emergency department (ED), the nurse obtains the following electrocardiographic (ECG) tracing. The nurse interprets this heart rhythm as: a. junctional escape rhythm. b. accelerated idioventricular rhythm. c. third-degree atrioventricular (AV) block. d. sinus rhythm with premature atrial contractions (PACs).
ANS: C The inconsistency between the atrial and ventricular rates and the variable P-R interval indicate that the rhythm is third-degree AV block. Sinus rhythm with PACs will have a normal rate and consistent P-R intervals with occasional PACs. An accelerated idioventricular rhythm will not have visible P waves.
A patient who is complaining of a "racing" heart and feeling "anxious" comes to the emergency department. The nurse places the patient on a heart monitor and obtains the following electrocardiographic (ECG) tracing. Which action should the nurse take next? a. Prepare to perform electrical cardioversion. b. Have the patient perform the Valsalva maneuver. c. Obtain the patient's vital signs including oxygen saturation. d. Prepare to give a b-blocker medication to slow the heart rate.
ANS: C The patient has sinus tachycardia, which may have multiple etiologies such as pain, dehydration, anxiety, and myocardial ischemia. Further assessment is needed before determining the treatment. Vagal stimulation or b-blockade may be used after further assessment of the patient. Electrical cardioversion is used for some tachydysrhythmias, but would not be used for sinus tachycardia.
Which nursing action can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) working as a telemetry technician on the cardiac care unit? a. Decide whether a patient's heart rate of 116 requires urgent treatment. b. Monitor a patient's level of consciousness during synchronized cardioversion. c. Observe cardiac rhythms for multiple patients who have telemetry monitoring. d. Select the best lead for monitoring a patient admitted with acute coronary syndrome.
ANS: C UAP serving as telemetry technicians can monitor cardiac rhythms for individuals or groups of patients. Nursing actions such as assessment and choice of the most appropriate lead based on ST segment elevation location require RN-level education and scope of practice.
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.
ANS: 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).
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.
ANS: 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.
Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider? a. Blood glucose 243 mg/dL b. Serum chloride 92 mEq/L c. Serum sodium 134 mEq/L d. Serum potassium 2.9 mEq/L
ANS: D Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation. The health care provider will need to prescribe a potassium infusion to correct this abnormality. Although the other laboratory values also are abnormal, they are not likely to be the etiology of the patient's PVCs and do not require immediate correction.
To determine whether there is a delay in impulse conduction through the ventricles, the nurse will measure the duration of the patient's a. P wave. b. Q wave. c. PR interval. d. QRS complex.
ANS: D The QRS complex represents ventricular depolarization. The P wave represents the depolarization of the atria. The PR interval represents depolarization of the atria, atrioventricular node, bundle of His, bundle branches, and the Purkinje fibers. The Q wave is the first negative deflection following the P wave and should be narrow and short.
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.
ANS: 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.
ANS: 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 has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first? a. A patient who is in a sinus rhythm, rate 98, after having electrical cardioversion 2 hours ago b. A patient with new onset atrial fibrillation, rate 88, who has a first dose of warfarin (Coumadin) due c. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating d. A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due
ANS: D The frequent firing of the ICD indicates that the patient's ventricles are very irritable, and the priority is to assess the patient and administer the amiodarone. The other patients may be seen after the amiodarone is administered.
A patient's cardiac monitor shows sinus rhythm, rate 64. The P-R interval is 0.18 seconds at 1:00 AM, 0.22 seconds at 2:30 PM, and 0.28 seconds at 4:00 PM. Which action should the nurse take next? a. Place the transcutaneous pacemaker pads on the patient. b. Administer atropine sulfate 1 mg IV per agency dysrhythmia protocol. c. Document the patient's rhythm and assess the patient's response to the rhythm. d. Call the health care provider before giving the next dose of metoprolol (Lopressor).
ANS: D The patient has progressive first-degree atrioventricular (AV) block, and the b-blocker should be held until discussing the medication with the health care provider. Documentation and assessment are appropriate but not fully adequate responses. The patient with first-degree AV block usually is asymptomatic, and a pacemaker is not indicated. Atropine is sometimes used for symptomatic bradycardia, but there is no indication that this patient is symptomatic.
A patient develops sinus bradycardia at a rate of 32 beats/minute, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which actions should the nurse take next? a. Recheck the heart rhythm and BP in 5 minutes. b. Have the patient perform the Valsalva maneuver. c. Give the scheduled dose of diltiazem (Cardizem). d. Apply the transcutaneous pacemaker (TCP) pads.
ANS: D The patient is experiencing symptomatic bradycardia, and treatment with TCP is appropriate. Continued monitoring of the rhythm and BP is an inadequate response. Calcium channel blockers will further decrease the heart rate, and the diltiazem should be held. The Valsalva maneuver will further decrease the rate.
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."
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.
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.
ANS: 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.
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 seconds, and the QRS is 0.09 seconds. How should the nurse document this rhythm? a. First-degree AV block b. Second-degree AV block c. Premature atrial contraction (PAC) d. Premature ventricular contraction (PVC)
a. First-degree AV block Rationale: In first-degree atrioventricular (AV) block, there is prolonged duration of AV conduction that lengthens the PR interval above 0.20 seconds. 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 seconds. 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.
A patient informs the nurse of experiencing syncope. Which prioitiy nursing action should the nurse anticipate in the patient's subsequent diagnostic workup? a. Preparing to assist with a head-up tilt-test b. Assessing the patient's knowledge of pacemakers c. Administering an IV dose of a β-adrenergic blocker d. Teaching the patient about antiplatelet aggregators
a. Preparing to assist with a head-up tilt-test Rationale: 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 nurse has obtained this rhythm strip from her patient's monitor. What should the nurse document this rhythm indicates? a. Sinus tachycardia b. Sinus bradycardia c. Ventricular fibrillation d. Ventricular tachycardia
a. Sinus tachycardia Rationale: This rhythm strip shows sinus tachycardia because the rate on this strip is above 101 beats/min, and it displays normal P wave, PR interval, and QRS complex. Sinus bradycardia would look similar to sinus tachycardia but with a rate less than 60 beats/min. Ventricular fibrillation does not have a measureable heart rate, PR interval, or QRS. The P wave is not visible, and the rhythm is irregular and chaotic. Ventricular tachycardia has a rate of 150 to 250 beats/min, with a regular or irregular rhythm and P waves occurring independently of the QRS complex.
The nurse prepares to defibrillate a patient. Which dysrhythmia has the nurse observed in this patient? a. Ventricular fibrillation b. Third-degree AV block c. Uncontrolled atrial fibrillation d. Ventricular tachycardia with a pulse
a. Ventricular fibrillation Rationale: 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 (if 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 who received an implantable cardioverter-defibrillator (ICD) in the left side. Which statement by the patient indicates that further teaching is required? 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." Rationale: The patient statement that flying will damage the ICD indicates misunderstanding about flying. The patient should be taught to inform TSA security screening agents at the airport about the ICD 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.
Evolve A patient reporting dizziness and shortness of breath is admitted with a dysrhythmia. Which medication, if ordered, requires the nurse to carefully monitor the patient for asystole? a. Digoxin b. Adenosine c. Metoprolol d. Atropine sulfate
b. Adenosine Rationale: 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, while lanoxin and metoprolol slow the heart rate.
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 seconds (narrow), but they occur irregularly with a rate of 120 beats/min. What does the nurse determine the rhythm to be? a. Sinus tachycardia b. Atrial fibrillation c. Ventricular fibrillation d. Ventricular tachycardia
b. Atrial fibrillation Rationale: 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.
3. In the patient with supraventricular tachycardia, which assessment indicates decreased cardiac output? a. Hypertension and dyspnea b. Chest pain and palpitations c. Abdominal distention and tachypneaterm-35 d. Bounding pulses and a systolic murmur
b. Chest pain and palpitations Rationale: Manifestations of decreased cardiac output in the patient with supraventricular tachycardia include hypotension, angina, palpitations, and dyspnea.
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. Myocardia injury b. Myocardial ischemia c. Myocardial infarction d. Normal pacemaker function.
b. Myocardial ischemia Rationale: 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. What electrical treatment option does the nurse prepare the patient for? a. Defibrillation b. Synchronized cardioversion c. Automatic external defibrillator (AED) d. Implantable cardioverter-defibrillator (ICD)
b. Synchronized cardioversion Rationale: 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.
5. 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: Air travel is not restricted. The patient should tell airport security of the presence of a pacemaker because it may set off the metal detector. A hand-held screening wand should not pass directly over the pacemaker. Manufacturer information varies about the effect of metal detectors on pacemaker function. The patient should monitor the pulse and tell the HCP if it drops below a predetermined rate. The patient should have and wear a Medic Alert ID device at all times. The patient must avoid lifting the arm on the pacemaker side above the shoulder until approved by the HCP. Microwave ovens are safe to use. They do not interfere with pacemaker function.
What is the correct interpretation of this rhythm strip? a. Sinus dysrhythmia b. Third-degree heart block c. Wenckebach phenomenon d. Premature ventricular contractions
b. Third-degree heart block Rationale: Third-degree heart block represents a loss of communication between the atrium and ventricles from atrioventricular 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). Whereas the atria are beating totally on their own at 70 beats/min, 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 are the early occurrence of a wide, distorted QRS complex.
When computing a heart rate from the electrocardiography (ECG) tracing, the nurse counts 15 of the small blocks between the R waves of a patient whose rhythm is regular. What does the nurse calculate the patient's heart rate to be? a. 60 beats/min b. 75 beats/min c. 100 beats/min d. 150 beats/min
c. 100 beats/min Rationale: Because 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).
The nurse is monitoring the electrocardiograms of several patients on a cardiac telemetry unit. The patients are directly visible to the nurse, and all the patients are observed to be sitting up and talking with visitors. Which patient's rhythm would require the nurse to take immediate action? a. A 62-yr-old man with a fever and sinus tachycardia with a rate of 110 beats/min b. A 72-yr-old woman with atrial fibrillation with 60 to 80 QRS complexes per minute c. A 52-yr-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute d. A 42-yr-old woman with first-degree AV block and sinus bradycardia at a rate of 56 beats/min
c. A 52-yr-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute Rationale: Frequent premature ventricular contractions (PVCs) (>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 myocardial infarction indicate ventricular irritability, the patient's physiologic response to PVCs must be monitored. Frequent PVCs may be treated with oxygen therapy, electrolyte replacement, or antidysrhythmic agents.
The nurse is caring for a patient who is 24 hours after pacemaker insertion. Which nursing intervention is 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. Assessing the incision for any redness, swelling, or discharge Rationale: 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.
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? a. Lidocaine or amiodarone b. Digoxin and procainamide c. Epinephrine or vasopressin d. β-Adrenergic blockers and dopamine
c. Epinephrine or vasopressin Rationale: 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 nurse observes ventricular tachycardia (VT) on the patient's monitor. What evaluation made by the nurse led to this interpretation? 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. Rate 200 beats/min; P wave not visible Rationale: VT is associated with a rate of 150 to 250 beats/min; the P wave is not normally 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 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
The nurse determines there is artifact on the patient's telemetry monitor. Which factor should the nurse assess for that could correct this issue? a. Disabled automaticity b. Electrodes in the wrong lead c. Too much hair under the electrodes d. Stimulation of the vagus nerve fibers
c. Too much hair under the electrodes Rationale: 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 delivering 50 joules by synchronized cardioversion, the patient develops ventricular fibrillation. Which action should the nurse take immediately? a. Administer 250 mL of 0.9% saline solution IV by rapid bolus. b. Assess the apical pulse, blood pressure, and bilateral neck vein distention. c. Turn the synchronizer switch to the "off" position and recharge the device. d. Ask the patient if there is any chest pain or discomfort and administer morphine sulfate.
c. Turn the synchronizer switch to the "off" position and recharge the device. Rationale: 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.
Back of Book 1. 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). It is characterized by a gradual lengthening of the PR interval. Type I AV block is usually a result of myocardial ischemia or infarction. It is typically transient and well tolerated. The nurse should assess for bradycardia, hypotension, and angina. The symptomatic patient may need atropine or a temporary pacemaker.
6. 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.
The nurse performs discharge teaching for a patient with an implantable cardioverter-defibrillator (ICD). Which statement by the patient indicates that further teaching is needed? a. "The device may set off the metal detectors in an airport." b. "My family needs to keep up to date on how to perform CPR." c. "I should not stand next to antitheft devices at the exit of stores." d. "I can expect redness and swelling of the incision site for a few days."
d. "I can expect redness and swelling of the incision site for a few days." Rationale: 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 the presence of the 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? a. "The device will convert your heart rate and rhythm back to normal." b. "The device uses overdrive pacing to slow the heart to a normal rate." c. "The device is inserted through a large vein and threaded into your heart." d. "The device delivers a current through your skin that can be uncomfortable."
d. "The device delivers a current through your skin that can be uncomfortable." Rationale: 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.
Which statement best describes the electrical activity of the heart represented by measuring the PR interval on the electrocardiogram (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 sinoatrial (SA) node to the atrioventricular (AV) node.
d. The length of time for the electrical impulse to travel from the sinoatrial (SA) node to the Purkinje fibers. Rationale: 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.
2. 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. Assessing the patient's hemodynamic status is important for deciding the need for drug therapy.
4. 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 nonemergency basis.
d. patients should be sedated if cardioversion is done on a nonemergency 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 a few exceptions: If synchronized cardioversion is done 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.
