Chapter 26: Management of Patients with Dysrhythmias and Conduction Problems
A nurse is teaching the client about the causes of fast heart rates. What client statement indicates the client requires more teaching? "I will drink coffee with only two of my meals." "I will cut back on my smoking and drinking alcohol." "If I take my metoprolol daily, I will be able to control my heart rate." "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'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." 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.
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." 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 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 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? "You seem apprehensive about resuming sexual activity." "Sex is permitted following the implantation of an ICD." "You really should speak to your wife about your concerns." "I will be sure to share your concerns with the physician."
"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.
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. 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.
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 90 bpm. 80 bpm. 70 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 assigned the following client assignment on the clinical unit. For which client does the nurse anticipate cardioversion as a possible medical treatment? A new myocardial infarction client A client with poor kidney perfusion A client with third-degree heart block A client with atrial dysrhythmias
A client with atrial dysrhythmias
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 new myocardial infarction client A client with poor kidney perfusion A client with third-degree heart block A client with atrial dysrhythmias
A client with atrial dysrhythmias The nurse is correct to identify a client with atrial dysrhythmias 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.
Which of the following medication classifications is more likely to be expected when the nurse is caring for a client with atrial fibrillation? Diuretic Anticoagulant Antihypertensive Potassium supplement
Anticoagulant
Which of the following medication classifications is more likely to be expected when the nurse is caring for a client with atrial fibrillation? Diuretic Anticoagulant Antihypertensive 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? 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. 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.
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 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 recognizes which as being true of cardioversion? Amount of voltage used should exceed 400 watts/second. Electrical impulse can be discharged during the T wave. Defibrillator should be set to deliver a shock during the QRS complex. Defibrillator should be set in the non-synchronous mode so the nurse can hit the button at the right time.
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 assessing a patient with a probable diagnosis of first-degree AV block. The nurse is aware that this dysrhythmia is evident on an ECG strip by what indication? Variable heart rate, usually fewer than 90 bpm Irregular rhythm Delayed conduction, producing a prolonged PR interval P waves hidden within the QRS complex
Delayed conduction, producing a prolonged PR interval First-degree AV block may occur without an underlying pathophysiology, or it can result from medications or conditions that increase parasympathetic tone. It occurs when atrial conduction is delayed through the AV node, resulting in a prolonged PR interval.
Which of the following medications does the nurse anticipate administering to a client preparing for cardioversion? Atropine Digoxin Enalapril Diazepam
Diazepam Prior to cardioversion, cardiac medications are held, and the client is sedated with a medication such as diazepam.
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 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 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. Do nothing; there is no cause for alarm. Suggest the need for a new beta-blocker to the doctor. 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 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. 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 reads an athletic client's electrocardiogram. What finding will be consistent with a sinus bradycardia? PR interval of 0.24 seconds. Heart rate of 42 beats per minute (bpm). QR interval of 0.25 seconds. P-to-QR ratio of 1:2.
Heart rate of 42 beats per minute (bpm).
The staff educator is teaching a class in dysrhythmias. What statement is correct for defibrillation? It is a scheduled procedure 1 to 10 days in advance. The client is sedated before the procedure. It is used to eliminate ventricular dysrhythmias. It uses less electrical energy than cardioversion.
It is used to eliminate ventricular dysrhythmias. The only treatment for a life-threatening ventricular dysrhythmia is immediate defibrillation, which has the exact same effect as cardioversion, except that defibrillation is used when there is no functional ventricular contraction. It is an emergency procedure performed during resuscitation. The client is not sedated but is unresponsive. Defibrillation uses more electrical energy (200 to 360 joules) than cardioversion.
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 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 is assessing vital signs in a patient with a permanent pacemaker. What should the nurse document about the pacemaker? Date and time of insertion Location of the generator Model number Pacer rate
Pacer rate After a permanent pacemaker is inserted, the patient's heart rate and rhythm are monitored by ECG.
The nurse is preparing to administer adenosine for a patient diagnosed with atrial flutter. How should the nurse administer this medication? The dose is administered rapid IV push. The dose is administered slow IV push. The medication is followed by a slow saline flush. The medication is followed by a rapid lactated Ringer's (LR) flush
The dose is administered rapid IV push. The dose is administered by rapid IV push (1 to 2 seconds), followed with a rapid saline flush. LR is not used during administration of this medication.
The nurse reads an athletic client's electrocardiogram. What finding will be consistent with a sinus bradycardia? PR interval of 0.24 seconds. Heart rate of 42 beats per minute (bpm). QR interval of 0.25 seconds. P-to-QR ratio of 1:2.
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.
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 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.
The nurse is admitting a client to a telemetry unit with an atrial dysrhythmia. What symptoms will the nurse further evaluate? chest pain hypertension leg pain hypocarbia
chest pain Clients with atrial dysrhythmias may have chest pain, shortness of breath, and low blood pressure. Leg pain is not common with atrial dysrhythmias. Hypocarbia is seen with reduced carbon dioxide, not common with chr pulmonary disease.
The nurse is administering propranolol to a client on a telemetry unit. What will the nurse monitor the client for? heart block tachycardia bleeding change in level of consciousness
heart block Propranolol and other beta blockers can interfere with conduction and the client should be evaluated for heart block. Propranolol has a desired effect of lowering heart rate, not tachycardia. Bleeding and change in consciousness level are not common side effects of propranolol.
The nurse assesses a client with a heart rate of 120 beats per minute. What are the known causes of sinus tachycardia? hypovolemia vagal stimulation hypothyroidism digoxin
hypovolemia The causes of sinus tachycardia include physiologic or psychological stress (acute blood loss, anemia, shock, hypovolemia, fever, and exercise). Vagal stimulation, hypothyroidism, and digoxin will cause a sinus bradycardia.
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. inherent rhythmicity of all muscle tissue. sufficient blood pressure. inherent electrons in 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.
The nurse analyzes a 6-second electrocardiogram (ECG) tracing. The P waves and QRS complexes are regular. The PR interval is 0.18 seconds long, and the QRS complexes are 0.08 seconds long. The heart rate is calculated at 70 bpm. The nurse correctly identifies this rhythm as normal sinus rythnm sinus tachycardia. junctional tachycardia. first-degree atrioventricular block.
normal sinus rythnm The electrocardiogram (ECG) tracing shows normal sinus rhythm (NSR). NSR has the following characteristics: ventricular and atrial rate: 60 to 100 beats per minute (bpm) in the adult; ventricular and atrial rhythm: regular; and QRS shape and duration: usually normal, but may be regularly abnormal; P wave: normal and consistent shape, always in front of the QRS; PR interval: consistent interval between 0.12 and 0.20 seconds and P:QRS ratio: 1:1.
The client returns to the clinic for a follow-up appointment following a permanent pacemaker insertion and reports tenderness and throbbing around the incision. The nurse observes mild swelling, erythema, and warmth at the pacemaker insertion site. What does the nurse suspect? pacemaker site infection normal postoperative healing postoperative site hematoma internal bleeding at pacemaker site
pacemaker site infection Postoperative care for a pacemaker insertion includes observing for symptoms of infection. These symptoms include swelling, unusual tenderness, drainage, and increased warmth. When the site is healing normally, there will be no tenderness and throbbing. A hematoma forms a lump at the pacemaker insertion site. Mild bleeding will be drainage.
