QUIZ: Chapter 26: Management of Patients With Dysrhythmias and Conduction Problems - ML7

A healthy adult client is seeing a health care provider for an annual physical examination. While the nurse is taking the client's vital signs, the client states, "Occasionally, my heart skips a beat." The nurse believes that the client is experiencing what condition?

Correct response: Premature atrial complex Explanation: A premature atrial complex (PAC) is a single ECG complex that occurs when an electrical impulse starts in the atrium before the next normal impulse of the sinus node.

A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. Which client statement indicates to the nurse a need for additional teaching?

Correct response: "I can still drink coffee and tea." Explanation: The client requires more teaching if he states that he may drink coffee and tea. Caffeine is a stimulant, which can exacerbate palpitations, and should be avoided by a client with symptomatic mitral valve prolapse. High fluid intake helps maintain adequate preload and cardiac output. Aerobic exercise helps increase cardiac output and decrease heart rate. Protein-rich foods aren't restricted but high-calorie foods are.

The nurse is caring for a client who is being discharged after insertion of a permanent pacemaker. Which question by the client indicates a need for clarification?

Correct response: "I should ask for a handheld device search when I go through airport security." Explanation: At security gates at airports, government buildings, or other secured areas, the client with a permanent pacemaker should show a pacemaker ID card and request a hand (not handheld device) search. The client should obtain and carry a physician's letter about this requirement.

Which ECG waveform characterizes conduction of an electrical impulse through the left ventricle?

Correct response: QRS complex Explanation: The QRS complex represents ventricular depolarization. The P wave is an ECG characteristic reflecting conduction of an electrical impulse through the atria. The PR interval is a component of an ECG tracing reflecting conduction of an electrical impulse through the AV node. The QT interval is an ECG characteristic reflecting the time from ventricular depolarization to repolarization.

When the appropriate electrocardiogram (ECG) complex follows the pacing spike, it is said to be

Correct response: captured. Explanation: Capture is a term used to denote that the appropriate electrocardiogram (ECG) complex followed by the pacing spike. Triggered response means that the pacemaker will respond when it senses intrinsic heart activity. Inhibited response means that the response of the pacemaker is controlled by the activity of the client's heart.

An operating room nurse is caring for a client who is having a pacemaker implanted. The health care provider has requested a demand mode pacemaker for this client. What is this type of pacemaker?

Correct response: Self-activated Explanation: Demand (synchronous) mode pacemakers self-activate when the client's pulse falls below a certain level. A fixed-rate pacemaker is asynchronous and permanent. Temporary pacemakers are used until a permanent pacemaker can be implanted.

Twiddler syndrome

Twiddler's syndrome is a rare complication after pacemaker implantation. It is caused by conscious or unconscious manipulation at the implantation site by the patient with the result of device malfunction. It results in lead dislodgment, diaphragmatic stimulation, and loss of capture.

The nurse recognizes which as being true of cardioversion?

Correct response: Defibrillator should be set to deliver a shock during the QRS complex. Explanation: Cardioversion involves the delivery of a "timed" electrical current. The defibrillator is set to synchronize with the ECG and deliver the impulse during the QRS complex. The synchronization prevents the discharge from occurring during the vulnerable period of repolarization (T wave), which could result in VT or ventricular fibrillation.

Elective cardioversion is similar to defibrillation except that the electrical stimulation waits to discharge until an R wave appears. The nurse knows elective cardioversion prevents what?

Correct response: Disrupting the heart during the critical period of ventricular repolarization. Explanation: It is similar to defibrillation. One difference is that the machine that delivers the electrical stimulation waits to discharge until it senses the appearance of an R wave. By doing so, the machine prevents disrupting the heart during the critical period of ventricular repolarization

Two nursing students are reading EKG strips. One of the students asks the instructor what the P-R interval represents. The correct response should be which of the following?

Correct response: "It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node." Explanation: The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex and represents the time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization. In a normal heart the impulses do not travel backward. The PR interval does not include the time it take to travel through the Purkinje fibers.

The nurse receives a telephone call from a client with an implanted pacemaker who reports a pulse of 68 beats per minute, but the pacemaker rate is set at 72 beats per minute. What is the nurse's best response?

Correct response: "Please come to the clinic right away so that we may interrogate the pacemaker to see if it is malfunctioning." Explanation: A client experiencing pacemaker malfunctioning may develop bradycardia as well as signs and symptoms of decreased cardiac output. The client should check the pulse daily and report immediately any sudden slowing or increasing of the pulse rate, which may indicate pacemaker malfunction. The client needs to be evaluated to avoid cardiac output problems. Walking will not keep the heart rate at a safe level.

A client with a second-degree atrioventricular heart block, Type II is admitted to the coronary care unit. How will the nurse explain the need to monitor the client's electrocardiogram (ECG) strip to the spouse?

Correct response: "The small box will transmit the heart rhythm to the central monitor all the time." Explanation: In telemetry, a small box transmits the client's heart rhythm to the central unit for constant monitoring. Telemetry has nothing to do with the client needing help. A Holter monitor is a device that records the heart's electrical activity and for later review by a physician. The telemetry transmits the heart rhythm regardless of the client's heart rate.

The nurse cares for a 56-year-old client who received an implantable cardioverter defibrillator (ICD) 2 days prior. The client tells the nurse "My wife and I can never have sex again now that I have this ICD." What is the nurse best response by the nurse?

Correct response: "You seem apprehensive about resuming sexual activity." Explanation: The client treated with an electronic device experiences not only lifestyle and physical changes but also emotional changes. At different times during the healing process, the client may feel angry, depressed, fearful, anxious, or a combination of these emotions. It is imperative for the nurse to observe the client's response to the device and provide the client and family members with emotional support and teaching as indicated. Identifying that the client appears apprehensive about resuming sexual activity acknowledges the client's concerns while allowing for further discussion. The remaining responses ignore the client's feelings and do not facilitate an ongoing conversation or explore the client's concern.

The nurse is working with a client with a new onset of atrial fibrillation during a three-month follow-up visit. The healthcare provider is planning a cardioversion, and the client asks the nurse why there is a wait for the treatment. What is the best response by the nurse?

Correct response: "Your atrial chambers may contain blood clots now, so you must take an anticoagulant for a few weeks before the cardioversion." Explanation: Because of the high risk of embolization of atrial thrombi, cardioversion of atrial fibrillation that has lasted longer than 48 hours should be avoided unless the client has received warfarin for at least 3 to 4 weeks prior to cardioversion. The doctor will not wait for a change in rhythm. Resting the heart will not change the rhythm. There is no delay but safer for the clots to be dissolved with the anticoagulant.

A patient has had an implantable cardioverter defibrillator inserted. What should the nurse be sure to include in the education of this patient prior to discharge? (Select all that apply.)

Correct response: -Avoid magnetic fields such as metal detection booths. -Call for emergency assistance if feeling dizzy. -Record events that trigger a shock sensation. Explanation: The nurse should instruct the patient to avoid large magnetic fields such as those created by magnetic resonance imaging, large motors, arc welding, electrical substations, and so forth. Magnetic fields may deactivate the device, negating its effect on a dysrhythmia. The patient should call 911 for emergency assistance if a feeling of dizziness occurs. The patient should maintain a log that records discharges of an implantable cardioverter defibrillator (ICD). Record events that precipitate the sensation of shock. This provides important data for the physician to use in readjusting the medical regimen. Throbbing pain is not normal and should be reported immediately. An initial x-ray is indicated prior to discharge, but monthly x-rays are unnecessary.

A 1-minute electrocardiogram (ECG) tracing of a client with a regular heart rate reveals 25 small, square boxes within an RR interval. The nurse correctly identifies the client heart rate as

Correct response: 60 bpm. Explanation: A client's HR can be obtained from the electrocardiogram (ECG) tracing by several methods. A 1-minute strip contains 300 large boxes and 1500 small boxes. Therefore, an easy and accurate method of determining heart rate with a regular rhythm is to count the number of small boxes within an RR interval and divide by 1,500. In this instance, 1,500/25 = 60.

The nurse is assigned the following client assignment on the clinical unit. For which client does the nurse anticipate cardioversion as a possible medical treatment?

Correct response: A client with atrial arrhythmias Explanation: The nurse is correct to identify a client with atrial arrhythmias as a candidate for cardioversion. The goal of cardioversion is to restore the normal pacemaker of the heart, as well as, normal conduction. A client with a myocardial infarction has tissue damage. The client with poor perfusion has circulation problems. The client with heart block has an impairment in the conduction system and may require a pacemaker.

The licensed practical nurse is setting up the room for a client arriving at the emergency department with ventricular arrhythmias. The nurse is most correct to place which of the following in the room for treatment?

Correct response: A defibrillator Explanation: The nurse is most correct to place a defibrillator close to the client room if not in the room. The nurse realizes that clients with ventricular dysrhythmias are at a high risk for fatal heart dysrhythmia and death. A suction machine is used to remove respiratory secretions. Cardioversion is used in a planned setting for atrial dysrhythmias. An ECG machine records tracings of the heart for diagnostic purposes. Most clients with history of cardiac disorders have an ECG completed.

A client is scheduled for an elective electrical cardioversion for a sustained dysrhythmia lasting for 24 hours. Which intervention is necessary for the nurse to implement prior to the procedure?

Correct response: Administer moderate sedation IV and analgesic medication as prescribed. Explanation: Before an elective cardioversion, the client should receive moderate sedation IV as well as an analgesic medication or anesthesia. In contrast, in emergent situations, the client may not be premedicated. Digoxin is usually withheld for 48 hours before cardioversion to ensure the resumption of sinus rhythm with normal conduction. If the cardioversion is elective and the dysrhythmia has lasted longer than 48 hours, anticoagulation performed for a few weeks before cardioversion may be indicated. The client is instructed not to eat or drink for at least 4 hours before the procedure.

What is the drug of choice for a stable client with ventricular tachycardia?

Correct response: Amiodarone Explanation: Amiodarone administered IV is the antidysrhythmic medication of choice for a stable patient with ventricular tachycardia. Atropine is used for bradycardia. Procainamide is used to treat and prevent atrial and ventricular dysrhythmias. Lidocaine is used for treating ventricular dysrhythmias.

A client has had a pacemaker implanted and the nurse will begin client education upon the client becoming alert. Which postimplantation instructions must be provided to the client with a permanent pacemaker?

Correct response: Avoid sources of electrical interference. Explanation: The nurse must instruct the client with a permanent pacemaker to avoid sources of electrical interference, such as MRI devices, large industrial motors, peripheral nerve stimulators, etc.

A nurse is caring for a client with a history of cardiac disease and type 2 diabetes. The nurse is closely monitoring the client's blood glucose level. Which medication is the client most likely taking?

Correct response: Carvedilol Explanation: The nurse must monitor blood glucose levels closely in clients with type 2 diabetes who are taking beta-adrenergic blockers such as carvedilol, because beta-adrenergic blockers may mask the signs of hypoglycemia. The nurse should monitor QRS duration in clients taking procainamide and pulmonary function in clients taking amiodarone (because the drug may cause pulmonary fibrosis). Diltiazem may cause an increased PR interval or bradycardia.

A nurse is caring for a client who has been admitted to have a cardioverter defibrillator implanted. The nurse knows that implanted cardioverter defibrillators are used in which clients?

Correct response: Clients with recurrent life-threatening tachydysrhythmias Explanation: The automatic implanted cardioverter defibrillator (AICD) is an internal electrical device used for selected clients with recurrent life-threatening tachydysrhythmias. Therefore, options A, B, and C are incorrect.

The nurse knows that a pacemaker is the treatment of choice for what cardiac arrhythmia?

Correct response: Complete heart block Explanation: Pacemaker insertion is the treatment for complete heart block. Treatments for supraventricular tachycardia are: Valsalva maneuver, unilateral carotid massage, immersion of face in ice water, administration of IV adenosine, cardioversion, and radiofrequency ablation. Cardioversion and drug therapy are used for the treatment of atrial flutter. Treatment for ventricular fibrillation is defibrillation preceded by or followed with epinephrine.

You are taking a pre-nursing pharmacology class. Today you are learning about anti-dysrhythmic drugs. What drug is a potassium channel blocker?

Correct response: Cordarone Explanation: Potassium channel blockers include Cordarone and Bretylol. Lidocaine and Tambocor are sodium channel blockers. Isuprel is a beta blocker.

The nurse analyzes the electrocardiogram (ECG) strip of a stable patient admitted to the telemetry unit. The client's ECG strip demonstrates PR intervals that measure 0.24 seconds. What is the nurse's most appropriate action?

Correct response: Document the findings and continue to monitor the patient Explanation: The client's electrocardiogram (ECG) tracing indicates a first-degree atrioventricular (AV) block. First-degree AV block rarely causes any hemodynamic effect; the other blocks may result in decreased heart rate, causing a decrease in perfusion to vital organs, such as the brain, heart, kidneys, lungs, and skin. The most appropriate action by the nurse is to document the findings and continue to monitor the client.

The nurse is preparing a client for upcoming electrophysiology (EP) studies and possible ablation for treatment of atrial tachycardia. What information will the nurse include in the teaching?

Correct response: During the procedure, the dysrhythmia will be reproduced under controlled conditions. Explanation: During EP studies, the patient is awake and may experience symptoms related to the dysrhythmia. The client does not receive general anesthesia. The EP procedure time is not easy to determine. EP studies do not always include ablation of the dysrhythmia.

The nurse is caring for a client with atrial fibrillation. What procedure would be recommended if drug therapies did not control the arrhythmia?

Correct response: Elective cardioversion Explanation: Atrial fibrillation is treated with elective cardioversion or digitalis if the ventricular rate is not too slow. Defibrillation is used for a ventricular problem. Maze procedures are used for clients who are not candidates for cardiodiversion; these procedures use scar-forming techniques to eliminate rapid firing of ectopic pacemaker sites, thus restoring the normal conduction pathways in the atria. A Maze procedure might be considered for this client only after determining ineligibility for cardiodiversion. Pacemakers are implanted for bradycardia.

Which diagnostic study best evaluates different medications ability to restore normal heart rhythm?

Correct response: Electrophysiology study Explanation: An electrophysiology study is a procedure that enables the physician to examine the electrical activity of the heart, produce actual dysrhythmias, and determine the best method for care. Cardioversion uses synchronized electricity to change the rhythm pattern. Electrocardiogram and echocardiograms provide diagnostic information.

Which rhythm is also termed a ventricular escape rhythm?

Correct response: Idioventricular rhythm Explanation: Idioventricular rhythm is also called a ventricular escape rhythm.

Which nursing intervention is required to prepare a client with cardiac dysrhythmia for an elective electrical cardioversion?

Correct response: Instruct the client to restrict food and oral intake Explanation: The nurse should instruct the client to restrict food and oral intake before the cardioversion procedure. Digitalis and diuretics are withheld for 24 to 72 hours before cardioversion. The presence of digitalis and diuretics in myocardial cells decreases the ability to restore normal conduction and increases the chances of a fatal dysrhythmia developing after cardioversion. When the client is in cardiopulmonary arrest, the nurse should facilitate CPR until the client is prepared for defibrillation and not for cardioversion. Monitoring blood pressure every 4 hours is not required to prepare a client with cardiac dysrhythmia.

The nurse is caring for a client with an arrhythmia. While assessing the data in the history of the chart, the nurse anticipates the cause of the arrhythmia to be which of the following?

Correct response: Ischemic heart disease Explanation: The nurse realizes that the most common cause of arrhythmias is ischemic heart disease. When the heart does not obtain sufficient blood to meet demands, the heart works harder to circulate body fluids and becomes inefficient in the process. Problems with the peripheral vessels, narrowing of the aorta and plaque buildup in the vessels may be a component of the disease process but not the best answer.

Which nursing intervention must a nurse perform when administering prescribed vasopressors to a client with a cardiac dysrhythmia?

Correct response: Monitor vital signs and cardiac rhythm Explanation: The nurse should monitor the client's vital signs and cardiac rhythm for effectiveness of the medication and for side effects and should always have emergency life support equipment available when caring for an acutely ill client. The side effects of vasopressor drugs are hypertension, dysrhythmias, pallor, and oliguria. It is not necessary to place a client flat during or after vasopressor administration. When administering cholinergic antagonists, documentation of the heart rate is necessary.

The nurse analyzes the electrocardiogram (ECG) tracing of a client newly admitted to the cardiac step-down unit with a diagnosis of chest pain. Which finding indicates the need for follow-up?

Correct response: QT interval that is 0. 46 seconds long Explanation: The QT interval that is 0.46 seconds long needs to be investigated. The QT interval is usually 0.32 to 0.40 seconds in duration if the heart rate is 65 to 95 bpm. If the QT interval becomes prolonged, the client may be at risk for a lethal ventricular dysrhythmia, called torsades de pointes. The other findings are normal.

A 28-year-old client presents to the emergency department, stating severe restlessness and anxiety. Upon assessment, the client's heart rate is 118 bpm and regular, the client's pupils are dilated, and the client appears excitable. Which action should the nurse take next?

Correct response: Question the client about alcohol and illicit drug use. Explanation: The client is experiencing sinus tachycardia. Since the client's findings of tachycardia, dilated pupils, restlessness, anxiety, and excitability can indicate illicit drug use (cocaine), the nurse should question the client about alcohol and illicit drug use. This information will direct the client's plan of care. Causes of tachycardia include medications that stimulate the sympathetic response, stimulants, and illicit drugs. The treatment goals for sinus tachycardia is usually determined by the severity of symptoms and directed at identifying and abolishing its cause. The other interventions may be implemented, but determining the cause of the tachycardia is essential.

The nurse is placing electrodes for a 12-lead electrocardiogram (ECG). The nurse would be correct in placing an electrode on which area for V1?

Correct response: Right side of sternum, fourth intercostal space Explanation: view V1, the electrodes would be placed on the right side of the sternum, fourth intercostal space. V2 is the left side of the sternum, fourth intercostal space. V3 is midway between V2 and V4. V4 is at the mid-clavicular line, fifth intercostal space.

The licensed practical nurse is co-assigned with a registered nurse in the care of a client admitted to the cardiac unit with chest pain. The licensed practical nurse is assessing the accuracy of the cardiac monitor, which notes a heart rate of 34 beats/minute. The client appears anxious and states not feeling well. The licensed practical nurse confirms the monitor reading. When consulting with the registered nurse, which of the following is anticipated?

Correct response: The registered nurse administering atropine sulfate intravenously Explanation: The licensed practical nurse and registered nurse both identify that client's bradycardia. Atropine sulfate, a cholinergic blocking agent, is given intravenously (IV) to increase a dangerously slow heart rate. Lanoxin is not administered when the pulse rate falls under 60 beats/minute. It is dangerous to wait until the pulse rate increases without nursing intervention or administering additional medications until the imminent concern is addressed.

When no atrial impulse is conducted through the AV node into the ventricles, the client is said to be experiencing which type of AV block?

Correct response: Third degree Explanation: In third degree heart block, two impulses stimulate the heart, one impulse stimulates the ventricles and other stimulates the atria. In first degree heart block, all the atrial impulses are conducted through the AV node into the ventricles at a rate slower than normal. In second degree AV block, type I, all but one of the atrial impulses are conducted through the AV node into the ventricles. In second degree AV block, type II, only some of the atrial impulses are conducted through the AV node into the ventricles.

A client asks the nurse about complications associated with use of a cardiac pacemaker. What does the nurse include in their response? Select all that apply.

Correct response: Twiddler syndrome Hiccupping Localized infection Explanation: Complications associated with pacemakers include infection at entry site, pneumothorax, bleeding and hematoma, hemothorax, ventricular ectopy and tachycardia, phrenic nerve/diaphragmatic(hiccupping)/skeletal stimulation, cardiac perforation, Twiddler syndrome, and hemodynamic instability. A positive Kernig's sign is an indication of meningitis. A positive Babinski reflex is normal in neonates, but indicates a central nervous system disorder in adults.

A patient who had a myocardial infarction is experiencing severe chest pain and alerts the nurse. The nurse begins the assessment but suddenly the patient becomes unresponsive, no pulse, with the monitor showing a rapid, disorganized ventricular rhythm. What does the nurse interpret this rhythm to be?

Correct response: Ventricular fibrillation Explanation: The most common dysrhythmia in patients with cardiac arrest is ventricular fibrillation, which is a rapid, disorganized ventricular rhythm that causes ineffective quivering of the ventricles. No atrial activity is seen on the ECG. The most common cause of ventricular fibrillation is coronary artery disease and resulting acute myocardial infarction. Ventricular fibrillation is always characterized by the absence of an audible heartbeat, a palpable pulse, and respirations.

A client has an irregular heart rate of around 100 beats/minute and a significant pulse deficit. What component of the client's history would produce such symptoms?

Correct response: atrial fibrillation Explanation: In atrial fibrillation, several areas in the right atrium initiate impulses resulting in disorganized, rapid activity. The atria quiver rather than contract, producing a pulse deficit due to irregular impulse conduction to the AV node. The ventricles respond to the atrial stimulus randomly, causing an irregular ventricular heart rate, which may be too infrequent to maintain adequate cardiac output. Atrial flutter, heart block, and bundle branch block would not produce these symptoms.

Which is not a likely origination point for cardiac dysrhythmias?

Correct response: bundle of His Explanation: Cardiac dysrhythmias may originate in the atria, atrioventricular node, or ventricles. They do not originate in the Bundle of His.

A client has a heart rate greater than 155 beats/minute and the ECG shows a regular rhythm with a rate of 162 beats/minute. The client is intermittently alert and reports chest pain. P waves cannot be identified. What condition would the nurse expect the physician to diagnose?

Correct response: supraventricular tachycardia Explanation: Supraventricular tachycardia (SVT) is a dysrhythmia in which the heart rate has a consistent rhythm but beats at a dangerously high rate (over 150 beats/minute). P waves cannot be identified on the ECG. Diastole is shortened and the heart does not have sufficient time to fill. These symptoms do not suggest sinus tachycardia, heart block, or atrial flutter.