Chapter 22: Management of Patients with Arrhythmias and Conduction Problems
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? "It shows the time it takes the AV node impulse to depolarize the septum and travel through the Purkinje fibers." "It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node." "It shows the time it takes the AV node impulse to depolarize the atria and travel through the SA node." "It shows the time it takes the AV node impulse to depolarize the ventricles and travel through the SA node."
"It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node." 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 client asks the nurse to explain what is meant by a ventricular bigeminy cardiac rhythm. What is the best response by the nurse? "It is when the heart conduction is primarily from the atrioventricular node." "The rhythm has a normal beat, then a premature beat pattern." "The rhythm is regular but fast." "The heart rate is between 150 to 250 bpm."
"The rhythm has a normal beat, then a premature beat pattern." Bigeminy is a rhythm in which every other complex is a premature ventricular contraction (PVC). In trigeminy, every third complex is a PVC. The rhythm is not regular and the rate should not be 150-250 bpm.
The nursing student asks the nurse how to tell the difference between ventricular tachycardia and ventricular fibrillation on an electrocardiogram strip. What is the best response? "The QRS complex in ventricular fibrillation is always narrow, while in ventricular tachycardia the QRS is of normal width." "The two look very much alike; it is difficult to tell the difference." "The P-R interval will be prolonged in ventricular fibrillation, while in ventricular tachycardia the P-R interval is normal." "Ventricular fibrillation is irregular with undulating waves and no QRS complex. Ventricular tachycardia is usually regular and fast, with wide QRS complexes."
"Ventricular fibrillation is irregular with undulating waves and no QRS complex. Ventricular tachycardia is usually regular and fast, with wide QRS complexes." Ventricular fibrillation is irregular with undulating waves and no QRS complex, while ventricular tachycardia is usually regular and fast with wide QRS complexes. The rhythms look different on the electrocardiogram strip. The QRS is wide and bizarre or undefined in ventricular fibrillation. The P-R interval is not present in the ventricular dysrhythmias.
A client is admitted to the emergency department reporting chest pain and shortness of breath. The nurse notes an irregular rhythm on the bedside electrocardiograph monitor. The nurse counts 9 RR intervals on the client's 6-second rhythm tracing. The nurse correctly identifies the client's heart rate as 70 bpm. 80 bpm. 90 bpm. 100 bpm.
90 bpm. An alternative but less accurate method for estimating heart rate, which is usually used when the rhythm is irregular, is to count the number of RR intervals in 6 seconds and multiply that number by 10. The RR intervals are counted, rather than QRS complexes, because a computed heart rate based on the latter might be inaccurately high. The same methods may be used for determining atrial rate, using the PP interval instead of the RR interval. In this instance, 9 × 10 = 90.
The nurse is monitoring a patient in the postanesthesia care unit (PACU) following a coronary artery bypass graft, observing a regular ventricular rate of 82 beats/min and "sawtooth" P waves with an atrial rate of approximately 300 beat/min. How does the nurse interpret this rhythm? Atrial fibrillation Ventricular tachycardia Ventricular fibrillation Atrial flutter
Atrial flutter Atrial flutter occurs because of a conduction defect in the atrium and causes a rapid, regular atrial rate, usually between 250 and 400 bpm and results in P waves that are saw-toothed. Because the atrial rate is faster than the AV node can conduct, not all atrial impulses are conducted into the ventricle, causing a therapeutic block at the AV node. This is an important feature of this dysrhythmia. If all atrial impulses were conducted to the ventricle, the ventricular rate would also be 250 to 400 bpm, which would result in ventricular fibrillation, a life-threatening dysrhythmia. Atrial flutter often occurs in patients with chronic obstructive pulmonary disease, pulmonary hypertension, valvular disease, and thyrotoxicosis, as well as following open heart surgery and repair of congenital cardiac defects (Fuster, Walsh et al., 2011).
The nurse is providing discharge instructions to a client after a permanent pacemaker insertion. Which safety precaution will the nurse communicate to the client? Stay at least 5 feet away from microwave ovens. Never engage in activities that require vigorous arm and shoulder movement. Avoid going through airport metal detectors. Avoid undergoing magnetic resonance imaging (MRI).
Avoid undergoing magnetic resonance imaging (MRI). A client with a pacemaker should avoid undergoing an MRI because the magnet could disrupt pacemaker function and cause injury to the client. Disruption is less likely to occur with newer microwave ovens. The client must avoid vigorous arm and shoulder movement only for the first 6 weeks after pacemaker implantation. Airport metal detectors don't harm pacemakers; however, the client should notify airport security guards that he has a pacemaker because its metal casing and programming magnet could trigger the metal detector.
The nurse knows that what PR interval presents a first-degree heart block? 0.16 seconds 0.24 seconds 0.18 seconds 0.14 seconds
0.24 seconds In adults, the normal range for the PR is 0.12 to 0.20 seconds. A PR internal of 0.24 seconds would indicate a first-degree heart block.
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? "I should increase my fluid intake." "I should eat foods rich in protein." "I'll enroll in an aerobic exercise program." "I can still drink coffee and tea."
"I can still drink coffee and tea." 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.
A nurse has provided discharge instructions to a client who received an implantable cardioverter defibrillator (ICD). Which statement, made by the client, indicates the need for further teaching? "I can play golf with my son in about 2 or 3 weeks." "I need to take a cardiopulmonary resuscitation (CPR) class now that I have an ICD." "I should tell close friends and family members that I have an ICD." "I will document the date and time if my ICD fires."
"I need to take a cardiopulmonary resuscitation (CPR) class now that I have an ICD." The client does not need to take a CPR class. However, it is recommended that the family members and friends of a client who has an ICD learn CPR. The other statements indicate that the nurse's teaching was effective.
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? "This is okay as long as you are not having any symptoms." "Don't worry. The pacemaker's rate is often higher than the client's actual heart rate." "Try walking briskly for about 5 minutes to see if that gets your heart rate to increase." "Please come to the clinic right away so that we may interrogate the pacemaker to see if it is malfunctioning."
"Please come to the clinic right away so that we may interrogate the pacemaker to see if it is malfunctioning." 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? "The heart's electrical activity will be recorded when the heart rate exceeds 60 beats per minute." "The box is recording the heart's electrical activity, and a physician will review the tracing later." "When your spouse needs help, an alarm will go off at the desk." "The small box will transmit the heart rhythm to the central monitor all the time."
"The small box will transmit the heart rhythm to the central monitor all the time." 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.
After performing an ECG on an adult client, the nurse reports that the PR interval reflects normal sinus rhythm. What is the PR interval for a normal sinus rhythm? 0.15 and 0.3 seconds. 0.05 and 0.1 seconds. 0.12 and 0.2 seconds. 0.25 and 0.4 seconds.
0.12 and 0.2 seconds. The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex. It measures the time needed for conduction through the AV node before ventricular depolarization. The normal range in adults is 0.12 to 0.2 seconds.
The ECG of a new patient shows a P wave slightly different than normal. The nurse is considering the possibility of premature atrial contractions (PAC). The nurse will ask about which factors when taking this client's history? nicotine hyperthyroidism or other metabolic disorders All options are correct. caffeine
All options are correct. There are a number of causes of premature atrial contractions (PAC), which is why it is so important to know and review a patient's complete history when examining for arrhythmias.
Which of the following medication classifications is more likely to be expected when the nurse is caring for a client with atrial fibrillation? Antihypertensive Anticoagulant Diuretic Potassium supplement
Anticoagulant Clients with persistent atrial fibrillation are prescribed anticoagulation therapy to reduce the risk of emboli formation associated with ineffective circulation. The other options may be prescribed but not expected in most situations.
A nurse provides evening care for a client wearing a continuous telemetry monitor. While the nurse is giving the client a back rub, the client 's monitor alarm sounds and the nurse notes a flat line on the bedside monitor system. What is the nurse's first response? Call for assistance and begin CPR. Administer a pericardial thump. Assess the client and monitor leads. Call a code and obtain the crash cart.
Assess the client and monitor leads. The nurse should assess the client and monitor leads first. It is important that the nurse "treat the client, not the monitor." Ventricular asystole may often appear on the monitor when leads are displaced. The other interventions are not necessary.
A client's electrocardiogram (ECG) tracing reveals a atrial rate between 250 and 400, with saw-toothed P waves. The nurse correctly identifies this dysrhythmia as Ventricular fibrillation Atrial fibrillation Atrial flutter Ventricular tachycardia
Atrial flutter The nurse correctly identifies the electrocardiogram (ECG) tracing as atrial flutter. Atrial flutter occurs in the atrium and creates impulses at a regular atrial rate between 250 and 400 times per minute. The P waves are saw-toothed in appearance. Atrial fibrillation causes a rapid, disorganized, and uncoordinated twitching of atrial musculature. The atrial rate is 300 to 600, and the ventricular rate is usually 120 to 200 in untreated atrial fibrillation. There are no discernible P waves. Ventricular fibrillation is a rapid, disorganized ventricular rhythm that causes ineffective quivering of the ventricles. The ventricular rate is greater than 300 per minute and extremely irregular, without a specific pattern. The QRS shape and duration is irregular, undulating waves without recognizable QRS complexes. Ventricular tachycardia is defined as three or more PVCs in a row, occurring at a rate exceeding 100 beats per minute.
The nurse knows that electrocardiogram (ECG) characteristics of atrial fibrillation include what? P wave resent before each QRS Regular rhythm Atrial rate of 300 to 400 Normal PR interval
Atrial rate of 300 to 400 ECG characteristics of atrial fibrillation include an atrial rate of 300 to 400, a nonmeasurable PR interval, irregular rhythm, and no discernible P waves.
A nurse is caring for a client who has had an automatic cardiac defibrillator implanted. What instructions should the nurse provide to the client? Avoid using microwave ovens. Avoid devices with a magnetic field. Avoid driving for at least 3 months. Use digital cellular telephones.
Avoid devices with a magnetic field. The nurse should instruct the client to avoid devices with a magnetic field. Examples include magnetic resonance imaging devices, extracorporeal shock wave lithotripsy machines, electrocautery and diathermy devices, peripheral nerve stimulators, large industrial electrical motors, and arc welding equipment. Electrical signals from digital cellular telephones may mimic an abnormal heart rhythm, activating the automatic implanted cardiac defibrillator. The nurse should instruct the client to use analog cellular telephones and to restrict driving for at least 6 months. Microwave ovens have shields or are grounded, making them safe for use by clients with an automatic implanted cardiac defibrillator.
The licensed practical nurse is monitoring the waveform pattern on the cardiac monitor of the client admitted following a myocardial infarction. The nurse notes that every other beat includes a premature ventricular contraction (PVC). The nurse notes which of the following in the permanent record? Couplets Multifocal PVCs Bigeminy R-on-T phenomenon
Bigeminy The nurse is correct to note bigeminy on the permanent record when every other beat is a PVC. Couplets are two PVCs in a row. Multifocal PVCs originate from more than one location. R-on-T phenomenon occurs when the R wave falls on the T wave.
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? Clients with recurrent life-threatening bradycardias Clients with sinus tachycardia Clients with ventricular bradycardia Clients with recurrent life-threatening tachydysrhythmias
Clients with recurrent life-threatening tachydysrhythmias 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? Complete heart block Ventricular fibrillation Supraventricular tachycardia Atrial flutter
Complete heart block 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.
A client has been living with an internal, fixed-rate pacemaker. When checking the client's readings on a cardiac monitor the nurse notices an absence of spikes. What should the nurse do? Double-check the monitoring equipment. Suggest the need for a new beta-blocker to the doctor. Do nothing; there is no cause for alarm. Measure the client's blood pressure.
Double-check the monitoring equipment. One of the reasons for lack of pacemaker spikes is faulty monitoring equipment.
The nurse is caring for a client with atrial fibrillation. What procedure would be recommended if drug therapies did not control the arrhythmia? Maze procedure Pacemaker implantation Elective cardioversion Defibrillation
Elective cardioversion 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.
The nurse reads an athletic client's electrocardiogram. What finding will be consistent with a sinus bradycardia? PR interval of 0.24 seconds. P-to-QR ratio of 1:2. QR interval of 0.25 seconds. Heart rate of 42 beats per minute (bpm).
Heart rate of 42 beats per minute (bpm). The heart rate of 42 bpm is slow but normal when it occurs in athletes with a sinus bradycardia. The PR interval is prolonged at 0.24 seconds, indicating a heart block. The QR interval is prolonged and indicates ventricular delay. The ratio of P to QR should be 1:1 in sinus bradycardia.
A 43-year-old male came into the emergency department where you practice nursing and was diagnosed with atrial fibrillation. It's now 48 hours since his admittance and the dysrhythmia persists. Which of the following medications will the client's healthcare provider most likely order? Warfarin (Coumadin) Heparin Flecainide (Tambocor) Dabigatran (Pradaxa)
Heparin Heparin is generally prescribed initially if the dysrhythmia persists longer than 48 hours.
The nurse identifies which of the following as a potential cause of premature ventricular complexes (PVCs)? Hypovolemia Alkalosis Bradycardia Hypokalemia
Hypokalemia PVCs can be caused by cardiac ischemia or infarction, increased workload on the heart (e.g., exercise, fever, hypervolemia, heart failure, tachycardia), digitalis toxicity, acidosis, or electrolyte imbalances, especially hypokalemia.
A patient is 2 days postoperative after having a permanent pacemaker inserted. The nurse observes that the patient is having continuous hiccups as the patient states, "I thought this was normal." What does the nurse understand is occurring with this patient? Fracture of the lead wire Faulty generator Sensitivity is too low Lead wire dislodgement
Lead wire dislodgement Phrenic nerve, diaphragmatic (hiccupping may be a sign), or skeletal muscle stimulation may occur if the lead is dislocated or if the delivered energy (mA) is set high. The occurrence of this complication is avoided by testing during device implantation.
Which nursing intervention must a nurse perform when administering prescribed vasopressors to a client with a cardiac dysrhythmia? Monitor vital signs and cardiac rhythm Administer every five minutes during cardiac resuscitation Document heart rate before and after administration Keep the client flat for one hour after administration
Monitor vital signs and cardiac rhythm 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 is assessing vital signs in a patient with a permanent pacemaker. What should the nurse document about the pacemaker? Date and time of insertion Model number Pacer rate Location of the generator
Pacer rate After a permanent pacemaker is inserted, the patient's heart rate and rhythm are monitored by ECG.
A client admitted to the telemetry unit has a serum potassium level of 6.6 mEq/L. Which electrocardiographic (ECG) characteristic is commonly associated with this laboratory finding? Prolonged QT interval Occasional U waves Peaked T waves Flattened P waves
Peaked T waves The client's serum potassium level is high. The T wave is an ECG characteristic reflecting repolarization of the ventricles. It may become tall or "peaked" if a client's serum potassium level is high. The U wave is an ECG waveform characteristic that may reflect Purkinje fiber repolarization. It is usually seen when a client's serum potassium level is low. The P wave is an ECG characteristic reflecting conduction of an electrical impulse through the atria and is not affected by a client's serum potassium level. The QT interval is an ECG characteristic reflecting the time from ventricular depolarization to repolarization, and is not affected by a client's serum potassium level.
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? Premature atrial contraction Atrial flutter Ventricular fibrillation Sinus tachycardia
Premature atrial contraction A premature atrial contraction (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.
The nurse is preparing to defibrillate a client with no breathing or pulse. Which nursing action precedes the nurse's pressing the discharge button? Shouting "Clear!" Stating "Charging." Checking the ECG rhythm Placing gel on the chest
Shouting "Clear!" Before pressing the discharge button, the nurse shouts "Clear!" or "All clear!" to ensure that no one is in contact with the client. The nurse may call this warning multiple times. The other options are also performed but not immediately before discharging the defibrillator.
A patient comes to the emergency department with reports of chest pain after using cocaine. The nurse assesses the patient and obtains vital signs with results as follows: blood pressure 140/92, heart rate 128, respiratory rate 26, and an oxygen saturation of 98%. What rhythm on the monitor does the nurse anticipate viewing? Sinus tachycardia Sinus bradycardia Normal sinus rhythm Ventricular tachycardia
Sinus tachycardia Sinus tachycardia occurs when the sinus node creates an impulse at a faster-than-normal rate. Causes include medications that stimulate the sympathetic response (e.g., catecholamines, aminophylline, atropine), stimulants (e.g., caffeine, nicotine), and illicit drugs (e.g., amphetamines, cocaine, Ecstasy).
The nurse is caring for a client with dysrhythmia. What would be an important procedure to teach a client with dysrhythmia to perform to evaluate his or her response to treatment? Technique for monitoring cardiac response Technique for palpating and counting the radial pulse Technique for monitoring blood pressure Technique for monitoring drug toxicity
Technique for palpating and counting the radial pulse The nurse should teach the client the technique for palpating and counting the radial pulse. An accurate pulse assessment helps the client evaluate his or her response to treatment measures. Monitoring drug toxicity, cardiac response, and blood pressure will not help a client with dysrhythmia to evaluate his or her response to treatment measures.
The nurse knows which heart rhythm occurs when the atrial and ventricular rhythms are both regular, but independent of each other? Second-degree heart block Asystole First-degree AV block Third-degree atrioventricular (AV) heart block
Third-degree atrioventricular (AV) heart block In third-degree AV heart block there is no relationship or synchrony between the atrial and ventricular contraction. Each is beating at its own inherent rate and is independent of each other, thus the cardiac output is affected. Second-degree AV block occurs when only some of the atrial impulses are conducted through the AV node into the ventricles. First-degree AV block occurs when atrial conduction is delayed through the AV node, resulting in a prolonged PR interval. During asystole, there is no electrical activity.
A patient with hypertension has a newly diagnosed atrial fibrillation. What medication does the nurse anticipate administering to prevent the complication of atrial thrombi? Adenosine Warfarin Atropine Amiodarone
Warfarin Because atrial function may be impaired for several weeks after cardioversion, warfarin is indicated for at least 4 weeks after the procedure. Patients may be given amiodarone, flecainide, ibutilide, propafenone, or sotalol prior to cardioversion to enhance the success of cardioversion and prevent relapse of the atrial fibrillation (Fuster, Rydén et al., 2011).
The nurse is caring for a client with second-degree atrioventricular block, Type I with symptomatic bradycardia. What is the most likely medication the nurse will administer? atenolol nadolol atropine sulfate diltiazem
atropine sulfate Atropine blocks acetylcholine at parasympathetic neuroeffector sites and blocks vagal stimulation. The client will be treated with an anticholinergic that blocks the effects of the vagal nerve. Atenolol and nadolol are beta blockers that are used for chest pain, myocardial infarction, and hypertension. Diltiazem is a calcium channel blocker used to treat angina or slow the heart rate.
A client tells the nurse "my heart is skipping beats again; I'm having palpitations." After completing a physical assessment, the nurse concludes the client is experiencing occasional premature atrial complexes (PACs). The nurse should instruct the client to apply supplemental oxygen. lie down and elevate the feet. request sublingual nitroglycerin. avoid caffeinated beverages.
avoid caffeinated beverages. If premature atrial complexes (PACs) are infrequent, no medical interventions are necessary. Causes of PACs include caffeine, alcohol, nicotine, stretched atrial myocardium (e.g., as in hypervolemia), anxiety, hypokalemia (low potassium level), hypermetabolic states (e.g., with pregnancy), or atrial ischemia, injury, or infarction. The nurse should instruct the client to avoid caffeinated beverages.
Which is not a likely origination point for cardiac arrhythmias? bundle of His atria ventricles atrioventricular node
bundle of His Cardiac arrhythmias may originate in the atria, atrioventricular node, or ventricles. They do not originate in the Bundle of His.
When the appropriate electrocardiogram (ECG) complex follows the pacing spike, it is said to be inhibited. captured. nonsynchronous. triggered.
captured. 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.
A client asks the nurse what causes the heart to be an effective pump. The nurse informs the client that this is due to the: inherent rhythmicity of cardiac muscle tissue. sufficient blood pressure. inherent electrons in muscle tissue. inherent rhythmicity of all muscle tissue.
inherent rhythmicity of cardiac muscle tissue. Cardiac rhythm refers to the pattern (or pace) of the heartbeat. The conduction system of the heart and the inherent rhythmicity of cardiac muscle produce a rhythm pattern, which greatly influences the heart's ability to pump blood effectively.
When the nurse observes that the client's heart rate increases during inspiration and decreases during expiration, the nurse reports that the client is demonstrating sinus bradycardia. normal sinus rhythm. sinus arrhythmia. sinus tachycardia.
sinus arrhythmia. Sinus arrythmia occurs when the sinus node creates an impulse at an irregular rhythm. Normal sinus rhythm occurs when the electrical impulse starts at a regular rate and rhythm in the SA node and travels through the normal conduction pathway. Sinus bradycardia occurs when the sinus node regularly creates an impulse at a slower-than-normal rate. Sinus tachycardia occurs when the sinus node regularly creates an impulse at a faster-than-normal rate.
A nurse is teaching the client about the causes of fast heart rates. What client statement indicates the client requires more teaching? "If I take my metoprolol daily, I will be able to control my heart rate." "I will drink coffee with only two of my meals." "I will cut back on my smoking and drinking alcohol." "I will take my levothyroxine daily."
"I will drink coffee with only two of my meals." Stimulation of the sympathetic nervous system with caffeinated beverages, smoking, and drinking alcohol increases heart rate. The client is still drinking caffeine with two meals, increasing the risk for a fast heart rate. Taking medications such as metoprolol and levothyroxine will help the client maintain a normal heart rate by decreasing stimulation of the sympathetic nervous system.
A nurse is performing discharge teaching with a client who has an implantable cardioverter defibrillator (ICD) placed. Which client statement indicates effective teaching? "I need to stay at least 10 inches away from the microwave." "I have an appointment for magnetic resonance imaging of my knee scheduled for next week." "I'll keep a log of each time my ICD discharges." "I can't wait to get back to my football league."
"I'll keep a log of each time my ICD discharges." The client stating that he should keep a log of all ICD discharges indicates effective teaching. This log helps the client and physician identify activities that may cause the arrhythmias that make the ICD discharge. He should also record the events right before the discharge. Clients with ICDs should avoid contact sports such as football. They must also avoid magnetic fields, which could permanently damage the ICD. Household appliances don't interfere with the ICD.
A client is unconscious on arrival to the emergency department. The nurse in the emergency department identifies that the client has a permanent pacemaker due to which characteristic? Scar on the chest Vibration under the skin "Spike" on the rhythm strip Quality of the pulse
"Spike" on the rhythm strip Confirmation that the client has a permanent pacemaker is the characteristic "spike" identified by a thin, straight stroke on the rhythm strip. The scar on the chest is suggestive of pacer implantation but not definitive. There should be no change in pulse quality, and no vibration under the skin.
The nursing student asks the nurse to describe the difference between sinus rhythm and sinus bradycardia on the electrocardiogram strip. What is the nurse's best reply? "The QRS complex will be smaller in sinus bradycardia." "The P waves will be shaped differently." "The P-R interval will be prolonged in sinus bradycardia." "The only difference is the heart rate."
"The only difference is the heart rate." All characteristics of sinus bradycardia are the same as those of normal sinus rhythm except for the rate, which will be below 60 in sinus bradycardia. The P waves will be shaped differently in other dysrhythmias. The QRS is the same voltage for sinus rhythms. The P-R interval is prolonged in atrioventricular blocks.
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? A client with third-degree heart block A client with atrial arrhythmias A new myocardial infarction client A client with poor kidney perfusion
A client with atrial arrhythmias 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? A defibrillator A suction machine An ECG machine Cardioversion equipment
A defibrillator 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.
The nurse is working on a telemetry unit, caring for a client who develops dizziness and a second-degree heart block, Mobitz Type 1. What will be the initial nursing intervention? Prepare to client for cardioversion. Review the client's medication record. Send the client to the cardiac catheterization laboratory. Administer an IV bolus of atropine.
Administer an IV bolus of atropine. Atropine 0.5 mg given rapidly as an intravenous bolus every 3 to 5 minutes to a maximum total dose of 3.0 mg is the medication of choice in treating symptomatic second-degree heart block. The client may need to be sent to the cardiac catheterization lab for a temporary pacemaker, but atropine should be tried first. Cardioversion is used to treat a fast heart rate. Reviewing the medication record will not help the client initially.
A client's Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minute. What other conditions can cause this response in a healthy heart? elevated temperature strenuous exercise All options are correct. shock
All options are correct. There are a variety of causes that can create an elevated heart rate in an otherwise healthy heart, including fever, shock, and strenuous exercise.
A client presents to the emergency department via ambulance with a heart rate of 210 beats/minute and a sawtooth waveform pattern per cardiac monitor. The nurse is most correct to alert the medical team of the presence of a client with which disorder? Ventricular fibrillation Premature ventricular contraction Asystole Atrial flutter
Atrial flutter Atrial flutter is a disorder in which a single atrial impulse outside the SA node causes the atria to contract at an exceedingly rapid rate. The atrioventricular (AV) node conducts only some impulses to the ventricle, resulting in a ventricular rate slower than the atrial rate, thus forming a sawtooth pattern on the heart monitor. Asystole is the absence of cardiac function and can indicate death. Premature ventricular contraction indicates an early electric impulse and does not necessarily produce an exceedingly rapid heart rate. Ventricular fibrillation is the inefficient quivering of the ventricles and indicative of a dying heart.
Which dysrhythmia has an atrial rate between 250 and 400, with saw-toothed P waves? Ventricular fibrillation Atrial fibrillation Atrial flutter Ventricular tachycardia
Atrial flutter Atrial flutter occurs in the atrium and creates impulses at a regular atrial rate between 250 and 400 times per minute. The P waves are saw-toothed in shape. Atrial fibrillation causes a rapid, disorganized, and uncoordinated twitching of atrial musculature. Ventricular fibrillation is a rapid, disorganized ventricular rhythm that causes ineffective quivering of the ventricles. Ventricular tachycardia is defined as three or more PVCs in a row, occurring at a rate exceeding 100 beats per minute.
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? Avoid sources of electrical interference. Keep moving the arm on the side where the pacemaker is inserted. Keep the arm on the side of the pacemaker higher than the head. Delay activities such as swimming and bowling for at least 3 weeks.
Avoid sources of electrical interference. 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.
After evaluating a client for hypertension, a health care provider orders atenolol, 50 mg P.O. daily. Which therapeutic effect should atenolol have in treating hypertension? Increased cardiac output and increased systolic and diastolic blood pressure Decreased peripheral vascular resistance Decreased cardiac output and decreased systolic and diastolic blood pressure Decreased blood pressure with reflex tachycardia
Decreased cardiac output and decreased systolic and diastolic blood pressure As a long-acting, selective beta1-adrenergic blocker, atenolol decreases cardiac output and systolic and diastolic blood pressure; however, like other beta-adrenergic blockers, it increases peripheral vascular resistance at rest and with exercise. Atenolol may cause bradycardia, not tachycardia.
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? The procedure will occur in the operating room under general anesthesia. The procedure takes less time than a cardiac catheterization. After the procedure, the dysrhythmia will not recur. During the procedure, the dysrhythmia will be reproduced under controlled conditions.
During the procedure, the dysrhythmia will be reproduced under controlled conditions. 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 enters the client's room and finds the client pulseless and unresponsive. What would be the treatment of choice for this client? Immediate defibrillation Chemical cardioversion IV lidocaine Electric cardioversion
Immediate defibrillation Defibrillation is used during pulseless ventricular tachycardia and ventricular fibrillation.
Which nursing intervention is required to prepare a client with cardiac dysrhythmia for an elective electrical cardioversion? Monitor blood pressure every 4 hours Instruct the client to restrict food and oral intake Administer digitalis and diuretics 24 hours before cardioversion Facilitate CPR until the client is prepared for cardioversion
Instruct the client to restrict food and oral intake 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.
Which ECG waveform characterizes conduction of an electrical impulse through the left ventricle? P wave QT interval QRS complex PR interval
QRS complex 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.
The nurse documents that a client is having a normal sinus rhythm. What characteristics of this rhythm has the nurse assessed? Impulse travels to the atrioventricular (AV) node in 0.15 to 0.5 seconds. The ventricles depolarize in 0.5 seconds or less. The sinoatrial (SA) node initiates the impulse. Heart rate between 60 and 150 beats per minute.
The sinoatrial (SA) node initiates the impulse. The characteristics of normal sinus rhythm are heart rate between 60 and 100 beats per minute; the SA node initiates the impulse; the impulse travels to the AV node in 0.12 to 0.2 seconds; the ventricles depolarize in 0.12 seconds or less; and each impulse occurs regularly.
A patient has been scheduled for cardioversion in the treatment of a tachyarrhythmia but is unclear about the particulars of the procedure after signing the necessary informed consent. How can the nurse best explain this procedure to the patient? "Cardioversion will essentially 'reset' the cells in your heart that control the electrical activity." "Cardioversion will provide an electrical signal that will boost the strength of your heart's electrical activity." "Cardioversion replaces your heart's self-conduction with an electrical signal that is provided artificially." "The essence of cardioversion is the destruction of some of the misfiring cells that are throwing off your heart's rhythm."
"Cardioversion will essentially 'reset' the cells in your heart that control the electrical activity." Cardioversion is used to treat tachyarrhythmias by delivering an electrical current that depolarizes a critical mass of myocardial cells. When the cells repolarize, the sinus node is usually able to recapture its role as the heart's pacemaker. The procedure does not destroy malfunctioning cells or "boost" the heart's electrical activity. As well, it does not replace any of the misfiring cells.
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? "I will be sure to share your concerns with the physician." "You really should speak to your wife about your concerns." "Sex is permitted following the implantation of an ICD." "You seem apprehensive about resuming sexual activity." SUBMIT ANSWER
"You seem apprehensive about resuming sexual activity." 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 caring for a client who is being discharged after insertion of a permanent pacemaker. The client, an avid tennis player, is scheduled to play in a tournament in 1 week. What is the best advice the nurse can give related to this activity? "You should avoid tennis; basketball or football would be a good substitute." "You may resume all normal activity in 1 week; if you are used to playing tennis, you may proceed with this activity." "You will need to cancel this activity; you must restrict arm movement above your head for 2 weeks." "Cancel your tennis tournament and wait until fall, then try hockey; skating is much easier on pacemakers."
"You will need to cancel this activity; you must restrict arm movement above your head for 2 weeks." It is important to restrict movement of the arm until the incision heals. The client should not raise the arm above the head for 2 weeks afterward to avoid dislodging the leads. The client must avoid contact sports (e.g., basketball, football, hockey).
The staff educator is teaching a class in arrhythmias. What statement is correct for defibrillation? The client is sedated before the procedure. It is used to eliminate ventricular arrhythmias. It is a scheduled procedure 1 to 10 days in advance. It uses less electrical energy than cardioversion.
It is used to eliminate ventricular arrhythmias. Because atrial function may be impaired for several weeks after cardioversion, warfarin is indicated for at least 4 weeks after the procedure. Patients may be given amiodarone, flecainide, ibutilide, propafenone, or sotalol prior to cardioversion to enhance the success of cardioversion and prevent relapse of the atrial fibrillation (Fuster, Rydén et al., 2011).
A nurse provides morning care for a client in the intensive care unit (ICU). Suddenly, the bedside monitor shows ventricular fibrillation and the client becomes unresponsive. After calling for assistance, what action should the nurse take next? Begin cardiopulmonary resuscitation Provide electrical cardioversion Administer intravenous epinephrine Prepare for endotracheal intubation
Begin cardiopulmonary resuscitation In the acute care setting, when ventricular fibrillation is noted, the nurse should call for assistance and defibrillate the client as soon as possible. If defibrillation is not readily available, CPR is begun until the client can be defibrillated, followed by advanced cardiovascular life support (ACLS) intervention, which includes endotracheal intubation and administration of epinephrine. Electrical cardioversion is not indicated for a client in ventricular fibrillation.
A patient converts from normal sinus rhythm at 80 beats/min to atrial fibrillation with a ventricular response at 166 beats/min. Blood pressure is 162/74. Respiratory rate is 20/min with normal chest expansion and clear lungs bilaterally. IV heparin and Cardizem are given. The nurse caring for the patient understands that the primary goal of treatment is what? Maintain anticoagulation Improve oxygenation Decrease SA node conduction Control ventricular rate
Control ventricular rate Treatment for atrial fibrillation is to terminate the rhythm or to control ventricular rate. A rapid ventricular response reduces the time for ventricular filling, resulting in a smaller stroke volume. Control of rhythm is the initial treatment of choice followed by anticoagulation with heparin and then Coumadin.
The nurse recognizes which as being true of cardioversion? Defibrillator should be set in the non-synchronous mode so the nurse can hit the button at the right time. Amount of voltage used should exceed 400 watts/second. Defibrillator should be set to deliver a shock during the QRS complex. Electrical impulse can be discharged during the T wave.
Defibrillator should be set to deliver a shock during the QRS complex. 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.
The nurse is observing the monitor of a patient with a first-degree atrioventricular (AV) block. What is the nurse aware characterizes this block? Delayed conduction, producing a prolonged PR interval An irregular rhythm P waves hidden with the QRS complex A variable heart rate, usually fewer than 60 bpm
Delayed conduction, producing a prolonged PR interval First-degree AV block occurs when all the atrial impulses are conducted through the AV node into the ventricles at a rate slower than normal. Thus the PR interval is prolonged (>0.20 seconds).
A nurse evaluates a client with a temporary pacemaker. The client's ECG tracing shows each P wave followed by the pacing spike. What is the nurse's best response? Obtain a 12-lead ECG and a portable chest x-ray Check the security of all connections and increase the milliamperage Reposition the extremity and turn the client to left side Document the findings and continue to monitor the client
Document the findings and continue to monitor the client Capture is a term used to denote that the appropriate complex is followed by the pacing spike. In this instance, the patient's temporary pacemaker is functioning appropriately; all Ps wave followed by an atrial pacing spike. The nurse should document the findings and continue to monitor the client. Repositioning the client, placing the client on the left side, checking the security of all connections, and increasing the milliamperage are nursing interventions used when the pacemaker has a loss of capture. Obtaining a 12-lead ECG and chest x-ray are indicated when there is a loss of pacing-total absence of pacing spikes or when there is a change in pacing QRS shape.
A client with an atrial dysrhythmia has come to the clinic for a follow-up appointment and to talk with the health care provider about options to stop this dysrhythmia. What procedure could be used to treat this client? Chemical cardioversion Elective electrical cardioversion Elective electrical defibrillation Mace procedure
Elective electrical cardioversion Elective electrical cardioversion is a nonemergency procedure done by a physician to stop rapid, but not necessarily life-threatening, atrial dysrhythmias. Chemical cardioversion is not a procedure; it is drug therapy. A Mace procedure is a distractor for this question. Defibrillation is not an elective procedure.
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? Place the client on supplemental oxygen. Question the client about alcohol and illicit drug use. Prepare to administer a calcium channel blocker. Instruct the client to hold the breath and bear down.
Question the client about alcohol and illicit drug use. 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.
A client with dilated cardiomyopathy is having frequent episodes of ventricular fibrillation. What medical treatment does the nurse anticipate the client will have to terminate the episode of ventricular fibrillation? internal cardioverter defibrillator insertion electrophysiological study pacemaker insertion radiofrequency ablation
internal cardioverter defibrillator insertion The implantable cardioverter defibrillator (ICD) is an electronic device that detects and terminates life-threatening episodes of tachycardia or fibrillation, especially those that are ventricular in origin. Patients at high risk of ventricular tachycardia (VT) or ventricular fibrillation who would benefit from an ICD are those who have survived sudden cardiac death syndrome, which usually is caused by ventricular fibrillation, or who have experienced spontaneous, symptomatic VT (syncope secondary to VT) not due to a reversible cause (called a secondary prevention intervention). Radiofrequency ablation destroys a small area of heart tissue that is causing rapid and irregular heartbeats, and is used to reduce pain. A cardiac electrophysiology study is an invasive procedure that tests the electrical conduction system of the heart to assess the electrical activity and conduction pathways of the heart.
