Chapter 26: Management of Patients with Dysrhythmias and Conduction Problems
A nurse is performing discharge teaching with a client who has an implantable cardioverter defibrillator (ICD) placed. Which client statement indicates effective teaching? "I'll keep a log of each time my ICD discharges." "I can't wait to get back to my football league." "I have an appointment for magnetic resonance imaging of my knee scheduled for next week." "I need to stay at least 10 inches away from the microwave."
"I'll keep a log of each time my ICD discharges." Rationale: 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.
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 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 it takes the AV node impulse to depolarize the septum and travel through the Purkinje fibers."
"It shows the time it takes the AV node impulse to depolarize the atria and travel through the SA node." Rationale: 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.
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 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 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." Rationale: 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.
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 "Spike" on the rhythm strip Quality of the pulse Vibration under the skin
"Spike" on the rhythm strip Rationale: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.
Which postimplantation instruction must a nurse provide to a client with a permanent pacemaker? 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 Keep moving the arm on the side where the pacemaker is inserted Avoid sources of electrical interference
Avoid sources of electrical interference Rationale:The nurse must instruct the client with a permanent pacemaker to avoid sources of electrical interference. The nurse should also instruct the client to avoid strenuous movement (especially of the arm on the side where the pacemaker is inserted), to keep the arm on the side of the pacemaker lower than the head except for brief moments when dressing or performing hygiene, and to delay for at least 8 weeks activities such as swimming, bowling, tennis, vacuum cleaning, carrying heavy objects, chopping wood, mowing, raking, and shoveling snow.
The nurse knows which heart rhythm occurs when the atrial and ventricular rhythms are both regular, but independent of each other? Third-degree atrioventricular (AV) heart block Second-degree heart block First-degree AV block Asystole
Third-degree atrioventricular (AV) heart block Rationale: 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 nursing instructor is reviewing the parts of an EKG strip with a group of students. One student asks about the names of all the EKG cardiac complex parts. Which of the following items are considered a part of the cardiac complex on an EKG strip? Choose all that apply. QRT wave P wave S-Q segment P-R interval T wave
P wave P-R interval T wave Rationale:The EKG cardiac complex waves include the P wave, the QRS complex, the T wave, and possibly the U wave. The intervals and segments include the PR interval, the ST segment, and the QT interval.
Which ECG waveform characterizes conduction of an electrical impulse through the left ventricle? P wave QRS complex PR interval QT interval
QRS complex Rationale: 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 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? QT interval that is 0. 46 seconds long PR interval that is 0.18 seconds long QRS complex that is 0.10 seconds long ST segment that is isoelectric in appearance
QT interval that is 0. 46 seconds long Rationale: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.
Which dysrhythmia is common in older clients? Sinus bradycardia Sinus tachycardia Sinus arrhythmia Ventricular tachycardia
Sinus bradycardia Rationale: Sinus bradycardia and atrial fibrillation are common dysrhythmia in older clients. Sinus tachycardia, sinus arrhythmia, and ventricular tachycardia are not common dysrhythmias in older clients.
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? During the procedure, the dysrhythmia will be reproduced under controlled conditions. 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. Rationale: 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 participates in the care of a client requiring emergent defibrillation. Arrange the steps in the order the nurse should complete them. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Apply the multifunction conductor pads to the client's chest. 5Deliver the prescribed electrical charge. 2Turn on the defibrillator and place it in "not sync" mode. 3Charge the defibrillator to the prescribed voltage. 4Call "clear" three times ensuring client and environmental s
Apply the multifunction conductor pads to the client's chest. Turn on the defibrillator and place it in "not sync" mode. Charge the defibrillator to the prescribed voltage. Call "clear" three times ensuring client and environmental safety. Deliver the prescribed electrical charge. Rationale: The nurse should: 1. Apply multifunction conductor pads or paddles with a conducting medium between the paddles and the skin in the proper locations. 2. Turn on the defibrillator in "not-sync" mode (most machines default to this setting). 3. Charge the device to the prescribed voltage. When using a manual discharge device, it must not be charged until ready to shock. 4. Call "clear" three times while visually checking to be sure the nurse and others are not touching the client, bed, or equipment. 5. Deliver the charge.
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? Assess the client and monitor leads. Administer a pericardial thump. Call for assistance and begin CPR. Call a code and obtain the crash cart.
Assess the client and monitor leads. Rationale: 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 patient with mitral valve stenosis and coronary artery disease (CAD) is in the telemetry unit with pneumonia. The nurse assesses a 6-second rhythm strip and determines that the ventricular rhythm is highly irregular at a rate of 150 bpm, with no discernible P waves. What does the nurse determine this rhythm to be? Atrial fibrillation Ventricular fibrillation Sinus tachycardia Nonparoxysmal junctional tachycardia
Atrial fibrillation Rationale: Atrial fibrillation results from abnormal impulse formation that occurs when structural or electrophysiological abnormalities alter the atrial tissue causing a rapid, disorganized, and uncoordinated twitching of the atrial musculature. Characteristics of Atrial fibrillation: Atrial rate is typically 300 to 600 bpm; ventricular rate is 120 to 200 bpm. The ventricular and atrial rhythms are both highly irregular. No discernable P waves. PR interval cannot be measured. P:QRS ratio = many:1.
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 only difference is the heart rate." "The P waves will be shaped differently." "The QRS complex will be smaller in sinus bradycardia." "The P-R interval will be prolonged in sinus bradycardia."
"The only difference is the heart rate." Rationale: 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.
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? 0.05 and 0.1 seconds. 0.12 and 0.2 seconds. 0.15 and 0.3 seconds. 0.25 and 0.4 seconds.
0.12 and 0.2 seconds. Rationale: 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 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? "Ventricular fibrillation is irregular with undulating waves and no QRS complex. Ventricular tachycardia is usually regular and fast, with wide QRS complexes." "The two look very much alike; it is difficult to tell the difference." "The QRS complex in ventricular fibrillation is always narrow, while in ventricular tachycardia the QRS is of normal width." "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." Rationale: 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.
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? "The doctor wants to see if your heart will switch back to its normal rhythm by itself." "Your atrial chambers may contain blood clots now, so you must take an anticoagulant for a few weeks before the cardioversion." "We have to allow your heart to rest for a few weeks before it is stressed by the cardioversion." "There is a long list of clients in line to be cardioverted."
"Your atrial chambers may contain blood clots now, so you must take an anticoagulant for a few weeks before the cardioversion." Rationale: 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.
The nurse is defibrillating a patient in ventricular fibrillation with paddles on a monophasic defibrillator. How much paddle pressure should the nurse apply when defibrillating? 5 to 10 lbs 10 to 15 lbs 15 to 20 lbs 20 to 25 lbs
20 to 25 lbs Rationale: When using paddles, 20 to 25 lb of pressure must be used in order to ensure good skin contact.
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 Atrial flutter Ventricular tachycardia Ventricular fibrillation
Atrial flutter Rationale: 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).
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 Prepare for endotracheal intubation Provide electrical cardioversion Administer intravenous epinephrine
Begin cardiopulmonary resuscitation Rationale: 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.
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? Document the findings and continue to monitor the patient Apply oxygen via nasal cannula and obtain a 12-lead ECG Notify the client's primary care provider of the findings Instruct the client to bear down as if having a bowel movement
Document the findings and continue to monitor the patient Rationale: 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.
A client receives a pacemaker to treat a recurring arrhythmia. When monitoring the cardiac rhythm strip, the nurse observes extra pacemaker spikes that don't precede a beat. Which condition should the nurse suspect? Failure to pace Failure to capture Failure to sense Asystole
Failure to capture Rationale: Extra pacemaker spikes that don't precede a beat may indicate failure to capture, in which the pacemaker fires but the heart doesn't conduct the beat. In failure to pace, the pacemaker doesn't fire when it should; this causes hypotension and other signs of low cardiac output accompanied by bradycardia or a heart rate slower than the pacemaker's preset rate. In failure to sense, the pacemaker can't sense the client's intrinsic heartbeat; on the rhythm strip, spikes may fall on T waves, or they may fall regularly but at points at which they shouldn't appear. An absent heart rate or rhythm, reflected as a flat line on the rhythm strip, characterizes asystole.
Which rhythm is also termed a ventricular escape rhythm? Idioventricular rhythm Ventricular asystole First degree AV block Ventricular fibrillation
Idioventricular rhythm Rationale: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? 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 Monitor blood pressure every 4 hours
Instruct the client to restrict food and oral intake Rationale: 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 nursing intervention must a nurse perform when administering prescribed vasopressors to a client with a cardiac dysrhythmia? Keep the client flat for one hour after administration Administer every five minutes during cardiac resuscitation Document heart rate before and after administration Monitor vital signs and cardiac rhythm
Monitor vital signs and cardiac rhythm Rationale: 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.
To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform? P wave PR interval QRS complex T wave
P wave Rationale: The P wave depicts atrial depolarization, or spread of the electrical impulse from the sinoatrial node through the atria. The PR interval represents spread of the impulse through the interatrial and internodal fibers, atrioventricular node, bundle of His, and Purkinje fibers. The QRS complex represents ventricular depolarization. The T wave depicts the relative refractory period, representing ventricular repolarization.
The nurse observes an electrocardiogram (ECG) tracing on a cardiac monitor with a pattern in lead II as well as a bizarre, abnormal shape to the QRS complex. The nurse has likely observed which ventricular dysrhythmia? Ventricular bigeminy Ventricular tachycardia Premature ventricular contraction Ventricular fibrillation
Premature ventricular contraction Rationale:A premature ventricular contraction (PVC) is an impulse that starts in a ventricle before the next normal sinus impulse. Ventricular bigeminy is a rhythm in which every other complex is a PVC. Ventricular tachycardia is defined as three or more PVCs in a row, occurring at a rate exceeding 100 beats per minute. Ventricular fibrillation is a rapid but disorganized ventricular rhythm that causes ineffective quivering of the ventricles.
Which ECG waveform characterizes conduction of an electrical impulse through the left ventricle? P wave QRS complex PR interval QT interval
QRS complex Rationale: 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.
Which ECG waveform characterizes conduction of an electrical impulse through the left ventricle? P wave QRS complex PR interval QT interval
QT interval Rationale: 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 checks the synchronizer switch before using a defibrillator to terminate ventricular fibrillation for what important reason? The delivered shock must be synchronized with the client's QRS complex. The defibrillator won't deliver a shock if the synchronizer switch is turned on. The defibrillator won't deliver a shock if the synchronizer switch is turned off. The shock must be synchronized with the client's T wave.
The defibrillator won't deliver a shock if the synchronizer switch is turned on. Rationale:The nurse needs to check the synchronizer switch to ensure the switch is turned off. The defibrillator won't deliver a shock to the client in ventricular fibrillation if the synchronizer switch is turned on because the defibrillator needs to recognize a QRS complex when the switch is turned on. The synchronizer switch should be turned on when attempting to terminate arrhythmias that contain QRS complexes, such as rapid atrial fibrillation that's resistant to pharmacologic measures. A synchronized shock should occur with the QRS complex, not the T wave, to avoid inducing ventricular fibrillation and allow for a lower shock dose.
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 Amiodarone Warfarin Atropine
Warfarin Rationale: 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 providing discharge instructions for a client with a new arrhythmia. Which statement should the nurse include? Your family and friends may want to take a CPR class. It is not necessary to learn how to take your own pulse. If you miss a dose of your antiarrhythmic medication, double up on the next dose. Do not be concerned if you experience symptoms of lightheadedness and dizziness.
Your family and friends may want to take a CPR class. Rationale:Having friends and family learn to perform CPR will help the client manage the arrhythmia. Monitoring pulse rate at home also helps the client manage the condition. Antiarrhythmic medication should be taken on time. Lightheadedness and dizziness should be reported to the provider.
The nurse is caring for a client who is displaying a third-degree AV block on the EKG monitor. What is the priority nursing intervention for the client? assessing blood pressure and heart rate frequently identifying a code-level status maintaining intravenous fluids alerting the healthcare provider of the third-degree heart block
alerting the healthcare provider of the third-degree heart block Rationale: The client may experience low cardiac output with third-degree AV block. The healthcare provider needs to intervene to preserve the client's cardiac output. Monitoring the blood pressure and heart rate are important, but not a priority. The identification of a code status during a heart block is not appropriate. IV fluids are not helpful if the heart is not perfusing.
A client experiences a faster-than-normal heart rate when drinking more than two cups of coffee in the morning. What does the nurse identify on the electrocardiogram as an indicator of sinus tachycardia? heart rate of 118 bpm PR interval of 0.1 seconds QRS duration of 0.16 seconds Q wave of 0.04 seconds
heart rate of 118 bpm Rationale: The sinus node creates an impulse at a faster-than-normal rate. The PR interval of 0.1 seconds, QRS duration of 0.16 seconds and Q wave of 0.04 seconds are consistent with a normal sinus rhythm. Sinus tachycardia occurs when the heart rate is over 100 bpm.
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 pacemaker insertion radiofrequency ablation electrophysiological study
internal cardioverter defibrillator insertion Rationale: 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.
