Ch 22. Cardiac procedures (TB)

11. A nurse is caring for a client who is exhibiting ventricular tachycardia (VT). Because the client is pulseless, the nurse should prepare for what intervention? A. Defibrillation B. ECG monitoring C. Implantation of a cardioverter defibrillator D. Angioplasty

ANS: A Rationale: Any type of VT in a client who is unconscious and without a pulse is treated in the same manner as ventricular fibrillation: Immediate defibrillation is the action of choice. ECG monitoring is appropriate, but this is an assessment, not an intervention, and will not resolve the problem. An ICD and angioplasty do not address the dysrhythmia. PTS: 1 REF: p. 707 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

15. A client is brought to the ED and determined to be experiencing symptomatic sinus bradycardia. The nurse caring for this client is aware the medication of choice for treatment of this dysrhythmia is the administration of atropine. What guidelines will the nurse follow when administering atropine? A. Administer atropine 0.5 mg as an IV bolus every 3 to 5 minutes to a maximum of 3.0 mg. B. Administer atropine as a continuous infusion until symptoms resolve. C. Administer atropine as a continuous infusion to a maximum of 30 mg in 24 hours. D. Administer atropine 1.0 mg sublingually.

ANS: A Rationale: Atropine 0.5 mg given rapidly as an intravenous (IV) bolus every 3 to 5 minutes to a maximum total dose of 3.0 mg is the medication of choice in treating symptomatic sinus bradycardia. By this guideline, the other listed options are inappropriate. PTS: 1 REF: p. 696 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

30. The nurse is caring for a client who has had a biventricular pacemaker implanted. When planning the client's care, the nurse should recognize what goal of this intervention? A. Resynchronization B. Defibrillation C. Angioplasty D. Ablation

ANS: A Rationale: Biventricular (both ventricles) pacing, also called resynchronization therapy, may be used to treat advanced heart failure that does not respond to medication. This type of pacing therapy is not called defibrillation, angioplasty, or ablation therapy. PTS: 1 REF: p. 715 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

17. The nurse is caring for a client who has just undergone catheter ablation therapy. The nurse in the step-down unit should prioritize what assessment? A. Cardiac monitoring B. Monitoring the implanted device signal C. Pain assessment D. Monitoring the client's level of consciousness (LOC)

ANS: A Rationale: Following catheter ablation therapy, the client is closely monitored to ensure the dysrhythmia does not reemerge. This is a priority over monitoring of LOC and pain, although these are valid and important assessments. Ablation does not involve the implantation of a device. PTS: 1 REF: p. 702 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

33. The nurse is caring for a client who is in the recovery room following the implantation of an ICD. The client has developed ventricular tachycardia (VT). What should the nurse assess and document? A. ECG to compare time of onset of VT and onset of device's shock B. ECG so health care provider can see what type of dysrhythmia the client has C. Client's level of consciousness (LOC) at the time of the dysrhythmia D. Client's activity at time of dysrhythmia

ANS: A Rationale: If the client has an ICD implanted and develops VT or ventricular fibrillation, the ECG should be recorded to note the time between the onset of the dysrhythmia and the onset of the device's shock or antitachycardia pacing. This is a priority over LOC or activity at the time of onset. PTS: 1 REF: p. 721 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

27. A client is undergoing preoperative teaching before his cardiac surgery and the nurse is aware that a temporary pacemaker will be placed later that day. What is the nurse's responsibility in the care of the client's pacemaker? A. Monitoring for pacemaker malfunction or battery failure B. Determining when it is appropriate to remove the pacemaker C. Making necessary changes to the pacemaker settings D. Selecting alternatives to future pacemaker use

ANS: A Rationale: Monitoring for pacemaker malfunctioning and battery failure is a nursing responsibility. The other listed actions are health care provider responsibilities. PTS: 1 REF: p. 715 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

9. A client who is a candidate for an implantable cardioverter defibrillator (ICD) asks the nurse about the purpose of this device. What would be the nurse's best response? A. "To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia." B. "To detect and treat bradycardia, which is an excessively slow heart rate." C. "To detect and treat atrial fibrillation, in which your heart beats too quickly and inefficiently." D. "To shock your heart if you have a heart attack at home."

ANS: A Rationale: The ICD is a device that detects and terminates life-threatening episodes of ventricular tachycardia and ventricular fibrillation. It does not treat atrial fibrillation, MI, or bradycardia. PTS: 1 REF: p. 719 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

7. A client the nurse is caring for has a permanent pacemaker implanted, with the identification code beginning with VVI. What does this indicate? A. Ventricular paced, ventricular sensed, inhibited B. Variable paced, ventricular sensed, inhibited C. Ventricular sensed, ventricular situated, implanted D. Variable sensed, variable paced, inhibited

ANS: A Rationale: The identification of VVI indicates ventricular paced, ventricular sensed, inhibited. PTS: 1 REF: p. 717 NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice

8. The nurse is caring for an adult client who has gone into ventricular fibrillation. When assisting with defibrillating the client, what must the nurse do? A. Maintain firm contact between paddles and the client's skin. B. Apply a layer of water as a conducting agent. C. Call "all clear" once before discharging the defibrillator. D. Ensure the defibrillator is in the sync mode.

ANS: A Rationale: When defibrillating an adult client, the nurse should maintain good contact between the paddles and the client's skin. To prevent arcing, apply an appropriate conducting agent (not water) between the skin and the paddles, and ensure the defibrillator is in the nonsync mode. "Clear'' should be called three times before discharging the paddles. PTS: 1 REF: p. 712 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

6. A client has returned to the cardiac care unit after having a permanent pacemaker implantation. For which potential complication should the nurse most closely assess this client? A. Chest pain B. Bleeding at the implantation site C. Malignant hyperthermia D. Bradycardia

ANS: B Rationale: Bleeding, hematomas, local infections, perforation of the myocardium, and tachycardia are complications of pacemaker implantations. The nurse should monitor for chest pain and bradycardia, but bleeding is a more common immediate complication. Malignant hyperthermia is unlikely because it is a response to anesthesia administration. PTS: 1 REF: p. 717 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

24. A client is scheduled for catheter ablation therapy. When describing this procedure to the client's family, the nurse should address which aspect of the treatment? A. Resetting of the heart's contractility B. Destruction of specific cardiac cells C. Correction of structural cardiac abnormalities D. Clearance of partially occluded coronary arteries

ANS: B Rationale: Catheter ablation destroys specific cells that are the cause or central conduction route of a tachydysrhythmia. It does not "reset" the heart's contractility and it does not address structural or vascular abnormalities. PTS: 1 REF: p. 702 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

31. When planning the care of a client with an implanted pacemaker, what assessment should the nurse prioritize? A. Core body temperature B. Heart rate and rhythm C. Blood pressure D. Oxygen saturation level

ANS: B Rationale: For clients with pacemakers, close monitoring of the heart rate and rhythm is a priority, even though each of the other listed vital signs must be assessed. PTS: 1 REF: p. 720 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

28. The nurse caring for a client whose sudden onset of sinus bradycardia is not responding adequately to atropine. What might be the treatment of choice for this client? A. Implanted pacemaker B. Transcutaneous pacemaker C. ICD D. Asynchronous defibrillator

ANS: B Rationale: If a client suddenly develops bradycardia, is symptomatic but has a pulse, and is unresponsive to atropine, emergency pacing may be started with transcutaneous pacing, which most defibrillators are now equipped to perform. An implanted pacemaker is not a time-appropriate option. An asynchronous defibrillator or ICD would not provide relief. PTS: 1 REF: p. 716 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

18. The ED nurse is caring for a client who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform? A. Place gel pads over the apex and posterior chest for better conduction. B. Ensure no one is touching the client at the time shock is delivered. C. Continue to ventilate the client via endotracheal tube during the procedure. D. Allow at least 3 minutes between shocks.

ANS: B Rationale: In external defibrillation, both paddles may be placed on the front of the chest, which is the standard paddle placement. Whether using pads or paddles, the nurse must observe two safety measures. First, maintain good contact between the pads or paddles and the client's skin to prevent leaking. Second, ensure that no one is in contact with the client or with anything that is touching the client when the defibrillator is discharged, to minimize the chance that electrical current will be conducted to anyone other than the client. Ventilation should be stopped during defibrillation. PTS: 1 REF: p. 713 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

35. During a CPR class, a participant asks about the difference between cardioversion and defibrillation. What would be the instructor's best response? A. "Cardioversion is done on a beating heart; defibrillation is not." B. "The difference is the timing of the delivery of the electric current." C. "Defibrillation is synchronized with the electrical activity of the heart, but cardioversion is not." D. "Cardioversion is always attempted before defibrillation because it has fewer risks."

ANS: B Rationale: One major difference between cardioversion and defibrillation is the timing of the delivery of electrical current. In cardioversion, the delivery of the electrical current is synchronized with the client's electrical events; in defibrillation, the delivery of the current is immediate and unsynchronized. Both can be done on beating heart (i.e., in a dysrhythmia). Cardioversion is not necessarily attempted first. PTS: 1 REF: p. 712 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

2. The nurse is analyzing a rhythm strip. What component of the ECG corresponds to the resting state of the client's heart? A. P wave B. T wave C. U wave D. QRS complex

ANS: B Rationale: The T wave specifically represents ventricular muscle depolarization, also referred to as the resting state. Ventricular muscle depolarization does not result in the P wave, U wave, or QRS complex. PTS: 1 REF: p. 694 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice

21. The nurse is caring for a client with complex cardiac history. How should the nurse best explain the process of depolarization to a colleague? A. Mechanical contraction of the heart muscles B. Electrical stimulation of the heart muscles C. Electrical relaxation of the heart muscles. D. Mechanical relaxation of the heart muscles

ANS: B Rationale: The electrical stimulation of the heart is called depolarization, and the mechanical contraction is called systole. Electrical relaxation is called repolarization, and mechanical relaxation is called diastole. PTS: 1 REF: p. 691 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort | Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand NOT: Multiple Choice

34. The staff educator is teaching a CPR class. Which of the following aspects of defibrillation should the educator stress to the class? A. Apply the paddles directly to the client's skin. B. Use a conducting medium between the paddles and the skin. C. Always use a petroleum-based gel between the paddles and the skin. D. Any available liquid can be used between the paddles and the skin.

ANS: B Rationale: Use multifunction conductor pads or paddles with a conducting medium between the paddles and the skin (the conducting medium is available as a sheet, gel, or paste). Do not use gels or pastes with poor electrical conductivity. PTS: 1 REF: p. 713 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

10. The nurse is caring for a client who has just had an implantable cardioverter defibrillator (ICD) placed. What is the priority area for the nurse's assessment? A. Assessing the client's mobility B. Facilitating transthoracic echocardiography C. Vigilant monitoring of the client's ECG D. Close monitoring of the client's peripheral perfusion

ANS: C Rationale: After a permanent electronic device (pacemaker or ICD) is inserted, the client's heart rate and rhythm are monitored by ECG. This is a priority over peripheral circulation and mobility because the consequences of abnormalities are more serious. Echocardiography is not indicated. PTS: 1 REF: p. 720 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

14. The nurse is planning discharge teaching for a client with a newly inserted permanent pacemaker. What is the priority teaching point for this client? A. Start lifting the arm above the shoulder right away to prevent chest wall adhesion. B. Avoid cooking with a microwave oven. C. Avoid exposure to strong electromagnetic fields D. Avoid walking through store and library antitheft devices.

ANS: C Rationale: High-output electrical generators can reprogram pacemakers and should be avoided. Recent pacemaker technology allows clients to safely use most household electronic appliances and devices (e.g., microwave ovens). The affected arm should not be raised above the shoulder for 1 week following placement of the pacemaker. Antitheft alarms may be triggered so clients should be taught to walk through them quickly and avoid standing in or near these devices. These alarms generally do not interfere with pacemaker function. PTS: 1 REF: p. 719 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

25. A client has undergone diagnostic testing and received a diagnosis of sinus bradycardia attributable to sinus node dysfunction. When planning this client's care, which nursing diagnosis is most appropriate? A. Risk for acute pain B. Risk for unilateral neglect C. Risk for activity intolerance D. Risk for fluid volume excess

ANS: C Rationale: Sinus bradycardia causes decreased cardiac output that is likely to cause activity intolerance. It does not typically cause pain, fluid imbalances, or neglect of a unilateral nature. PTS: 1 REF: p. 696 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

3. The nursing educator is presenting a case study of an adult client who has abnormal ventricular depolarization. This pathologic change would be most evident in what component of the ECG? A. P wave B. T wave C. QRS complex D. U wave

ANS: C Rationale: The QRS complex represents the depolarization of the ventricles and, as such, the electrical activity of that ventricle. PTS: 1 REF: p. 694 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Choice

29. The nurse is caring for a client who has had a dysrhythmic event. The nurse is aware of the need to assess for signs of diminished cardiac output (CO). What change in status may signal to the nurse a decrease in cardiac output? A. Increased blood pressure B. Bounding peripheral pulses C. Changes in level of consciousness D. Skin flushing

ANS: C Rationale: The nurse conducts a physical assessment to confirm the data obtained from the history and to observe for signs of diminished cardiac output (CO) during the dysrhythmic event, especially changes in level of consciousness. Blood pressure tends to decrease with lowered CO and bounding peripheral pulses are inconsistent with this problem. Pallor, not skin flushing, is expected. PTS: 1 REF: p. 710 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

16. An ECG has been ordered for a newly admitted client. What should the nurse do prior to electrode placement? A. Clean the skin with povidone-iodine solution. B. Ensure that the area for electrode placement is dry. C. Apply tincture of benzoin to the electrode sites and wait for it to become "tacky." D. Gently abrade the skin by rubbing the electrode sites with dry gauze or cloth.

ANS: D Rationale: An ECG is obtained by slightly abrading the skin with a clean dry gauze pad and placing electrodes on the body at specific areas. The abrading of skin will enhance signal transmission. Disinfecting the skin is unnecessary and conduction gel is used. PTS: 1 REF: p. 692 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

32. The nurse is assessing a client who had a pacemaker implanted 4 weeks ago. During the client's most recent follow-up appointment, the nurse identifies data that suggest the client may be socially isolated and depressed. What nursing diagnosis is suggested by these data? A. Decisional conflict related to pacemaker implantation B. Deficient knowledge related to pacemaker implantation C. Spiritual distress related to pacemaker implantation D. Ineffective coping related to pacemaker implantation

ANS: D Rationale: Depression and isolation may be symptoms of ineffective coping with the implantation. These psychosocial symptoms are not necessarily indicative of issues related to knowledge or decisions. Further data would be needed to determine a spiritual component to the client's challenges. PTS: 1 REF: p. 721 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

36. A client with an ICD calls the cardiologist's office and talks to the nurse. The client is concerned about being defibrillated too often. The nurse tells the client to come to the office to be evaluated because the nurse knows that the most frequent complication of ICD therapy is what issue? A. Infection B. Failure to capture C. Premature battery depletion D. Oversensing of dysrhythmias

ANS: D Rationale: Inappropriate delivery of ICD therapy, usually due to oversensing of atrial and sinus tachycardias with a rapid ventricular rate response, is the most frequent complication of ICD. Infections, failure to capture, and premature battery failure are less common. PTS: 1 REF: p. 718 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders

19. A group of nurses is participating in orientation to a telemetry unit. The nurse who is providing the education should tell the class that ST segments: A. are the part of an ECG that reflects systole. B. are the part of an ECG used to calculate ventricular rate and rhythm. C. are the part of an ECG that reflects the time from ventricular depolarization through repolarization. D. represent early ventricular repolarization.

ANS: D Rationale: ST segment is the part of an ECG that reflects the end of the QRS complex to the beginning of the T wave. The part of an ECG that reflects repolarization of the ventricles is the T wave. The part of an ECG used to calculate ventricular rate and rhythm is the RR interval. The part of an ECG that reflects the time from ventricular depolarization through repolarization is the QT interval. PTS: 1 REF: p. 694 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 22: Management of Clients with Arrhythmias and Conduction Disorders KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice