Atrial fibrillation and other dysrhythmias

1 3 4 2 (Because atrial fibrillation causes a decrease in cardiac output, the HR increases in response to this drop. As a result of an increased HR the O2 demands of the heart increase. It is important O2 is administered first to compensate for the increased workload and o2 demand. Placing the client on a cardiac monitor will help confirm a diagnosis of atrial fibrillation. Performing VS will determine the client response to the abnormal rhythm and responses to treatment. If the rhythm is determined to be atrial fibrillation it will be necessary for an IV to be inserted so medication can be administered)

A client has atrial fibrillation and a HR of 165 bpm. In which order from first to last should the nurse implement these prescriptions? Use all options, no commas 1. admin o2 via nasal cannula 2.. gather supplies for IV insertion 3. place the client on ECG monitor 4. obtain VS including BP, HR, RR, T and O2 sat

1 (transcutaneous pacemaker therapy provides an adequate HR for a client in emergency situation. Defibrillation and a lidocaine infusion are not indicated for the treatment of third-degree heart block. Transcutaneous pacing is used temporarily until a transvenous or permanent pacemaker may be inserted)

A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the clients cardiac monitor. The client has a BP of 90/60. The nurse should first: 1 prepare for transcutaneous pacing 2. prepare to defibrillate the client at 200 J 3. administer an IV lidocaine infusion 4 schedule the OR for insertion of a permanent pacemaker

a (Explanation: This is the most appropriate initial action for heart block. Turning the patient on the side (answer B) is an inappropriate action. Answers C and D are appropriate, but should not be the initial action.)

A nurse is caring for a client in the critical care unit who is complaining of chest pain. Nursing assessment reveals a BP of 78/40, shortness of breath, and third-degree AV block on the heart monitor. What is the most appropriate initial action? a Provide trancutaneous pacing. b Turn the client on his side. c Reassess the blood pressure. d Consult with cardiology.

f

Atrial fibrillation is characterized by random p-waves on the EKG. t. True f. False

2 1 3 4 (To decrease myocardial workload and promote timely intervention, the client should be assisted to the bed. Assessing the VS provides the data needed to determine client tolerance. Early initiation of an IV access will enable timely medication administration if it is emergently needed. While a 12 lead ECG is needed it can be obtained after the IV is initiated)

Cardiac telemetry shows that a client who is up to the bathroom has converted from normal sinus rhythm with a rate of 72 to atrial fibrillation with a ventricular response rate of 100 bpm. In what order from first to last should the nurse perform these interventions? Use all and no commas 1. assess the VS 2 assist the client to bed 3. initiate IV access 4. obtain a 12 lead electrocardiogram stat

2 (Characteristics of atrial fib include pulse rate >100 bpm, totally irregular rhythm, and no definite P waves on ECG. During assessment the nurse is likely to note the irregular rate and should report it to the HCP. A weak thready pulse is characteric of a client in shock. Two regular beats followed by an irregular beat may indicate a premature ventricular contraction)

During physical assessment the nurse should further assess the client for signs of atrial fibrillation when palpation of the radial pulse reveals: 1. two regular beats followed by one irregular beat 2. an irregular rhythm with pulse rate >100 3.. pulse rate below 60 4 a weak thready pulse

t

P-waves are absent in atrial flutter. t True f False

f

The R waves in atrial fibrillation are regular. t. True f. False

d (In complete atrioventricular block, the ventricles take over the pacemaker function in the heart but at a much slower rate than that of the SA node. As a result there is decreased cerebral circulation, causing syncope.)

The adaptations of a client with complete heart block would most likely include: A Nausea and vertigo B Flushing and slurred speech C Cephalalgia and blurred vision D Syncope and slow ventricular rate

1,2,4 (Explanation: If the client is experiencing hypovolemic shock related to blood loss in surgery, the hemoglobin (oxygen carrying capacity) will be lowered. The central venous pressure will drop with hypovolemic shock. Pulmonary artery wedge pressure indicates left ventricular function. The hematocrit is the number of red blood cells per cubic millimeter. The troponin is elevated, but indicates cardiac muscle damage, not hypovolemia.)

The client is admitted to the intensive care unit following a coronary artery bypass graft. The nurse checks the vital signs and notes a heart rate of 120 beats per minute, blood pressure of 70/40, and respiration of 32 breaths per minute. The nurse hypovolemic shock. Which assessment tools would contribute to a diagnosis of hypovolemic shock? Select all that apply. 1 Hemoglobin of 5g 2 Central venous pressure of 2mm of mercury 3 Pulmonary artery wedge pressure of 16mm of mercury 4 Hematocrit of 22% 5 Troponin (T 1) level of 4mcg/L

3 (education is a major component of the discharge plan for a client with an artificial pacemaker. The client needs to be able to state specific info about safety precautions such as refrain from lifting more than 3 lbs, or stretching and bending. The client should know how to count the pulse and do so daily or as instructed by the HCP. The client will not necessarily be placed on low cholesterol diet. The client should resume activities and does not need bed rest. The client should know the sign of MI, but is not at risk because of the pacemaker)

The client who had a permanent pacemaker implanted 2 days ago is being discharged from the hospital. The nurse knows that the client understands the discharge plans when the client: 1. selects a low cholesterol diet to control CAD 2. states a need for bed rest for 1 week after discharge 3. verbalizes safety precautions needed to prevent pacemaker malfunction. 4. explains the S/S of myocardial infarction (MI)

t

The hallmark of atrial flutter are "saw-tooth" waves, sometimes called F-waves. t True f False

c (Explanation: The client must be able to check the heart rate and report any rate that differs from the preset rate. Answers A and D are not required or have no effect on the pacemaker. Answer B would be contraindicated because the lack of movement could cause an inability to move the shoulder.)

The nurse is performing discharge instruction for a client with an implantable permanent pacemaker. What discharge instruction is an essential part of the plan? a "You cannot eat food prepared in a microwave." b "You should avoid moving the shoulder on the side of the pacemaker site for six weeks." c "You will have to learn to take your own pulse." d "You will not be able to fly on a commercial airliner with the pacemaker in place."

a,b (The consistency of the RR interval indicates regular rhythm. A normal P wave before each complex indicates the impulse originated in the SA node. The number of complexes in a 6 second strip is multiplied by 10 to approximate the heart rate; normal sinus rhythm is 60 to 100. Elevation of the ST segment is a sign of cardiac ischemia and is unrelated to the rhythm. The QRS duration should be less than 0.12 second; the PR interval should be 0.12 to 0.20 second.)

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Check all that apply. A The RR intervals are relatively consistent B One P wave precedes each QRS complex C Four to eight complexes occur in a 6 second strip D The ST segment is higher than the PR interval E The QRS complex ranges from 0.12 to 0.20 second

c (In atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions.)

When auscultating the apical pulse of a client who has atrial fibrillation, the nurse would expect to hear a rhythm that is characterized by: A The presence of occasional coupled beats B Long pauses in an otherwise regular rhythm C A continuous and totally unpredictable irregularity D Slow but strong and regular beats

1,5 (The nurse must teach the client how to take and record the pulse daily The client should be instructed to avoid lifting the operative side arm above the shoulder level for 1 week post insertion. It takes up to 2 months for the incision site to heal and full range of motion to return The client should avoid heavy lifting until approved by the HCP. The pacemaker metal casing does not set off airport security alarms so there are no travel restrictions. Prolonged immobilization is not required. Microwave ovens are safe to use and do not alter pacemaker function)

When teaching a client about self-care following placement of a new permanent pacemaker to the left upper chest, the nurse should include which information? SATA 1. take and record daily pulse rate 2. avoid air travel because of airport security 3. immobilize the affected arm for 4-6 weeks 4. avoid using a microwave oven 5. avoid lifting anything heavier than 3 lbs

b (Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (usually greater than 0.14 second), and a rate between 100 and 250 impulses per minute. The rhythm is usually regular.)

A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but over 100. The nurse determines that the client is experiencing: A Premature ventricular contractions B Ventricular tachycardia C Ventricular fibrillation D Sinus tachycardia

b (Ventricular fibrillation is a death-producing dysrhythmia and, once identified, must be terminated immediately by precordial shock (defibrillation). This is usually a standing physician's order in a CCU.)

When ventricular fibrillation occurs in a CCU, the first person reaching the client should: A Administer oxygen B Defibrillate the client C Initiate CPR D Administer sodium bicarbonate intravenously

d

Which of the following conditions are not thought to cause atrial fibrillation?* A. Mitral stenosis B. Mitral regurgitation C. Tricuspid regurgitation D. Peripheral vascular disease

b (PVCs are often a precursor of life-threatening dysrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than 5 or 6 per minute in the post MI client, the physician should be notified immediately. More than 6 PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability.)

While caring for a client who has sustained an MI, the nurse notes eight PVCs in one minute on the cardiac monitor. The client is receiving an IV infusion of D5W and oxygen at 2 L/minute. The nurse's first course of action should be to: A Increase the IV infusion rate B Notify the physician promptly C Increase the oxygen concentration D Administer a prescribed analgesic

a (The client with uncontrolled atrial fibrillation with a ventricular rate more than 150 beats a minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.)

A client has developed atrial fibrillation, which a ventricular rate of 150 beats per minute. A nurse assesses the client for: A Hypotension and dizziness B Nausea and vomiting C Hypertension and headache D Flat neck veins

4 (The purpose of EPS is to study the hearts electrical system. During this invasive procedure a special wire is introduced into the heart to produce dysrhythmia To prepare for this procedure, the client should be NPO for 6-8 hrs before the test, and all antidysrhythmics held for at least 24 hrs. before the test in order to study the dysrhythmia without the influence of medications. Because the clients verbal responses to the rhythm changes are extremely important, sedation is avoided if possible)

A client is admitted to the hospital for evaluation of recurrent episodes of ventricular tachycardia as observed on Holter monitoring. The client is scheduled for electrophysiology studies (EPS) the following morning. Which statement should the nurse include in a teaching plan for this client? 1. you will continue to take your meds until the morning of the test 2. you might be sedated during the procedure and will not remember what has happened 3 this test is noninvasive method of determining the effectiveness of your medication regimen 4 during the procedure the health care provider will insert a special wire to increase the heart rate and produce the irregular beats that caused your signs and symptoms

d (Bundle branch block interferes with the conduction of impulses from the AV node to the ventricle supplied by the affected bundle. Conduction through the ventricles is delayed, as evidenced by a widened QRS complex.)

A client with a bundle branch block is on a cardiac monitor. The nurse should expect to observe: A Sagging ST segments B Absence of P wave configurations C Inverted T waves following each QRS complex D Widening of QRS complexes to 0.12 second or greater

b (Cough cardiopulmonary resuscitation (CPR) sometimes is used in the client with unstable ventricular tachycardia. The nurse tells the client to use cough CPR, if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds. Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented.)

A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs the client to do which of the following, if prescribed, during an episode of ventricular tachycardia? A Breathe deeply, regularly, and easily B Inhale deeply and cough forcefully every 1 to 3 seconds C Lie down flat in bed D Remove any metal jewelry

a (Premature ventricular contractions can cause hemodynamic compromise. The shortened ventricular filling time with the ectopic beats leads to decreased stroke volume and, if frequent enough, to decreased cardiac output. The client may be asymptomatic or may feel palpitations. PVCs can be caused by cardiac disorders or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by the intake of caffeine, alcohol, or nicotine.)

A client is having frequent premature ventricular contractions. A nurse would place priority on assessment of which of the following items? A Blood pressure and peripheral perfusion B Sensation of palpitations C Causative factors such as caffeine D Precipitating factors such as infection

3 (The spouse can have physical contact with the client. If the ICD were to discharge while the spouse had contact with the client, the spouse would feel a tingle but would not be harmed. There is no warning device on the ICD.)

A client is scheduled for the insertion of an implantable cardioverter-defibrillator (ICD). the spouse expresses anxiety about what would happen if the device discharges during physical contact. What should the nurse tell the spouse? 1. Physical contact should be avoided whenever possible 2. They will not feel the countershock 3. The shock would feel like a tingle but would not cause any harm 4. a warning device sounds before countershock so there is time to move away

2,4,5 (This ECG strip indicates the client has atrial fibrillation. There is no P wave and PR interval. these are replaced with fine wavy lines. In atrial fibrillation, the ventricular rate may be normal, slow, or fast. Clients with atrial fibrillation may have palpitations secondary to a fast and irregular atrial rhythm. Because atrial fibrillation also may result in a sudden decrease in cardiac output, the client may also experience light headedness and SOB. A carotid bruit, nausea and a systolic murmur are not manifestations of new onset atrial fib)

A client with a normal sinus rhythm converts to the pictured rhythm on the cardiac monitor. For which symptoms should the nurse assess the client? 1. carotid bruit 2.. light-headedness 3. nausea 4 palpitations 5.. shortness of breath 6. systolic murmur

a (Carotid sinus massage is one of the maneuvers used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The others include inducing the gag reflex and asking the client to strain or bear down. Medication therapy often is needed as an adjunct to keep the rate down or maintain the normal rhythm)

A client with rapid rate atrial fibrillation asks a nurse why the physician is going to perform carotid massage. The nurse responds that this procedure may stimulate the: A Vagus nerve to slow the heart rate B Vagus nerve to increase the heart rate; overdriving the rhythm C Diaphragmatic nerve to slow the heart rate D Diaphragmatic nerve to overdrive the rhythm

a (measurements are normal, measuring 0.12 to 0.20 second and 0.4 to 0.10 second, respectively.)

A nurse is assessing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats per minute. The nurse assesses the cardiac rhythm as: A Normal sinus rhythm B Sinus bradycardia C Sick sinus syndrome D First-degree heart block

c (First-line treatment of ventricular tachycardia in a client who is hemodynamically stable is the use of anti-dysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm (cardioversion is recommended for stable ventricular tachycardia). Defibrillation is used with pulseless ventricular tachycardia. Epinephrine would stimulate and already excitable ventricle and is contraindicated.)

A nurse is viewing the cardiac monitor in a client's room and notes that the client has just gone into ventricular tachycardia. The client is awake and alert and has good skin color. The nurse would prepare to do which of the following? A Immediately defibrillate B Prepare for pacemaker insertion C Administer amiodarone (Cordarone) intravenously D Administer epinephrine (Adrenaline) intravenously

b (Atrial fibrillation is characterized by a loss of P waves; an undulating, wavy baseline; QRS duration that is often within normal limits; and an irregular ventricular rate, which can range from 60 to 100 beats per minute (when controlled with medications) to 100 to 160 beats per minute (when uncontrolled))

A nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead there are wavy lines. The QRS complexes measure 0.08 second, but they are irregular, with a rate of 120 beats a minute. The nurse interprets this rhythm as: A Sinus tachycardia B Atrial fibrillation C Ventricular tachycardia D Ventricular fibrillation

b (Ventricular fibrillation is characterized by irregular, chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles.)

A nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves or definable QRS complexes. Instead there are coarse wavy lines of varying amplitude. The nurse assesses this rhythm to be: A Ventricular tachycardia B Ventricular fibrillation C Atrial fibrillation D Asystole

b (Motion artifact, or "noise," can be caused by frequent client movement, electrode placement on limbs, and insufficient adhesion to the skin, such as placing electrodes over hairy areas of the skin. Electrode placement over bony prominences also should be avoided. Signal interference can also occur with electrode removal and cable disconnection.)

A nurse notices frequent artifact on the ECG monitor for a client whose leads are connected by cable to a console at the bedside. The nurse examines the client to determine the cause. Which of the following items is unlikely to be responsible for the artifact? A Frequent movement of the client B Tightly secured cable connections C Leads applied over hairy areas D Leads applied to the limbs

1,3,4 (The client has atrial fibrillation and will have an irregularly irregular pulse and will commonly be tachycardic, with rapid ventricular responses (HR) typically in the 110 to 140 range, but rarely over 150-170. The goal of treatment is the restoration of sinus rhythm. With a heart rate >150 and symptoms of sob, dizziness and syncope, and chest pain, synchronized cardioversion will most likely be the treatment of choice. With more controlled HR and more minor S/S, chemical conversion with drugs such as diltiazem and digoxin prior to other interventions such as synchronized cardioversion with appropriate anticoagulation may be attempted. Because of the decreased cardiac output, monitoring is essential. Obtaining consent for cardioversion requires a prescription from the HCP, but with the current HR having cardioversion is a very strong possibility for this client. Defib is used for ventricular fibrillation, not atrial fibrillation. Teaching the client about warfarin will be a possibility, but not an immediate intervention. Clients in continued atrial fib usually require some form of anticoagulation. Drawing labs for CBC's to detect anemia or infection, and thyroid function studies (to determine thyrotoxicosis a rare but not to be missed cause, especially in older adults) serum electrolytes and BUN/creatinine (looking for electrolyte disturbances or renal failure) are commonly drawn for determining the cause of the atrial fibrillation, they are not an immediate action)

An 85 year old client is admitted to the ER at 2000 hrs with syncope, shortness of breath, and reported palpitations. (see notes below) At 2015 the nurse places the client on the ECG monitor and identifies the following rhythm (see picture) What should the nurse do? SATA Admitted: 2000 hours HR 150 BP 90/62 O2 sat 92% room air RR 22 client is sob states "heart is jumping out of my chest and hurts some, I am having trouble catching my breath, I dont want to faint again" 1. apply oxygen 2.. prepare to defibrillate 3. monitor VS 4. have the client sign the consent for cardioversion as prescribed 5. teach the client about warfarin treatment and the need for frequent blood testing 6. draw a CBC count and thyroid function study

2 (maintaining a cardiac conduction stability to prevent arrhythmias is a priority immed after artificial pacemaker implantation. The client should have continuous ECG monitoring until proper pacemaker function is verified. The pacemaker is used to increase HR and cardiac output, not decrease it. The client should limit activity for the first 24-48 hrs after insertion. The client should also restrict activity of the affected extremity for 24 hrs.)

An older adult is admitted to the telemetry unit for placement of a permanent pacemaker because of sinus bradycardia. What is the priority goal for the client within 24 hrs after insertion of a permanent pacemaker? 1. maintain skin integrity 2. maintain cardiac conduction stability 3. decrease cardiac output 4. increase activity level