Chapter 26: Management of Patients With Dysrhythmias and Conduction Problems

A healthy adult client is seeing a health care provider for an annual physical examination. While the nurse is taking the client's vital signs, the client states, "Occasionally, my heart skips a beat. Is this normal?" What is the nurse's best response? A. Premature atrial complex B. Atrial flutter C. Sinus tachycardia D. Ventricular fibrillation

A A premature atrial complex (PAC) is a single ECG complex that occurs when an electrical impulse starts in the atrium before the next normal impulse of the sinus node.

The nurse knows that electrocardiogram (ECG) characteristics of atrial fibrillation include what? A. Atrial rate of 300 to 400 B. Normal PR interval C. Regular rhythm D. P wave resent before each QRS

A ECG characteristics of atrial fibrillation include an atrial rate of 300 to 400, a nonmeasurable PR interval, irregular rhythm, and no discernible P waves.

The nurse enters the client's room and finds the client pulseless and unresponsive. What would be the treatment of choice for this client? A. IV lidocaine B. Chemical cardioversion C. Immediate defibrillation D. Electric cardioversion

C Defibrillation is used during pulseless ventricular tachycardia and ventricular fibrillation.

A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. Which client statement indicates to the nurse a need for additional teaching? A. "I should increase my fluid intake." B. "I'll enroll in an aerobic exercise program." C. "I can still drink coffee and tea." D. "I should eat foods rich in protein."

C The client requires more teaching if he states that he may drink coffee and tea. Caffeine is a stimulant, which can exacerbate palpitations, and should be avoided by a client with symptomatic mitral valve prolapse. High fluid intake helps maintain adequate preload and cardiac output. Aerobic exercise helps increase cardiac output and decrease heart rate. Protein-rich foods aren't restricted but high-calorie foods are.

Which dysrhythmia has an atrial rate between 250 and 400, with saw-toothed P waves? A. Atrial flutter B. Atrial fibrillation C. Ventricular fibrillation D. Ventricular tachycardia

A Atrial flutter occurs in the atrium and creates impulses at a regular atrial rate between 250 and 400 times per minute. The P waves are saw-toothed in shape. Atrial fibrillation causes a rapid, disorganized, and uncoordinated twitching of atrial musculature. Ventricular fibrillation is a rapid, disorganized ventricular rhythm that causes ineffective quivering of the ventricles. Ventricular tachycardia is defined as three or more PVCs in a row, occurring at a rate exceeding 100 beats per minute.

A client has started to exhibit dangerous PVCs in the cardiac postoperative unit. The client has been given a bolus of lidocaine and is under continuous IV infusion, but serious side effects, including hypotension during administration, could occur. What should the nurse be ready to do? A. Adjust the IV infusion. B. Administer additional lidocaine. C. Prepare for defibrillation. D. Call for the doctor and just wait.

A Call for the physician while adjusting the IV infusion to the slowest possible rate until the physician can examine the patient.

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? A. During the procedure, the dysrhythmia will be reproduced under controlled conditions. B. The procedure will occur in the operating room under general anesthesia. C. The procedure takes less time than a cardiac catheterization. D. After the procedure, the dysrhythmia will not recur.

A 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 is caring for a client who has premature ventricular contractions. What sign or symptom is observed in this client? A. Fluttering B. Nausea C. Hypotension D. Fever

A Premature ventricular contractions usually cause a flip-flop sensation in the chest, sometimes described as "fluttering." Associated signs and symptoms include pallor, nervousness, sweating, and faintness. Symptoms of premature ventricular contractions are not nausea, hypotension, and fever.

A nurse is teaching the client about the causes of fast heart rates. What client statement indicates the client requires more teaching? A. "I will drink coffee with only two of my meals." B. "I will cut back on my smoking and drinking alcohol." C. "If I take my metoprolol daily, I will be able to control my heart rate." D. "I will take my levothyroxine daily."

A 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.

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? A. "It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node." B. "It shows the time it takes the AV node impulse to depolarize the atria and travel through the SA node." C. "It shows the time it takes the AV node impulse to depolarize the ventricles and travel through the SA node." D. "It shows the time it takes the AV node impulse to depolarize the septum and travel through the Purkinje fibers."

A The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex and represents the time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization. In a normal heart the impulses do not travel backward. The PR interval does not include the time it take to travel through the Purkinje fibers.

The nurse analayzes 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? A. QT interval that is 0. 46 seconds long B. PR interval that is 0.18 seconds long C. QRS complex that is 0.10 seconds long D. ST segment that is isoelectric in appearance

A 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.

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? A. internal cardioverter defibrillator insertion B. pacemaker insertion C. radiofrequency ablation D. electrophysiological study

A 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.

A client's electrocardiogram (ECG) tracing reveals a atrial rate between 250 and 400, with saw-toothed P waves. The nurse correctly identifies this dysrhythmia as A. Atrial flutter B. Atrial fibrillation C. Ventricular fibrillation D. Ventricular tachycardia

A The nurse correctly identifies the electrocardiogram (ECG) tracing as atrial flutter. Atrial flutter occurs in the atrium and creates impulses at a regular atrial rate between 250 and 400 times per minute. The P waves are saw-toothed in appearance. Atrial fibrillation causes a rapid, disorganized, and uncoordinated twitching of atrial musculature. The atrial rate is 300 to 600, and the ventricular rate is usually 120 to 200 in untreated atrial fibrillation. There are no discernible P waves. Ventricular fibrillation is a rapid, disorganized ventricular rhythm that causes ineffective quivering of the ventricles. The ventricular rate is greater than 300 per minute and extremely irregular, without a specific pattern. The QRS shape and duration is irregular, undulating waves without recognizable QRS complexes. Ventricular tachycardia is defined as three or more PVCs in a row, occurring at a rate exceeding 100 beats per minute.

The nurse is placing electrodes for a 12-lead electrocardiogram (ECG). The nurse would be correct in placing an electrode on which area for V1? A. Right side of sternum, fourth intercostal space B. Left side of sternum, fourth intercostal space C. Midway between V2 and V4 D. Mid-clavicular line, fifth intercostal space

A view V1, the electrodes would be placed on the right side of the sternum, fourth intercostal space. V2 is the left side of the sternum, fourth intercostal space. V3 is midway between V2 and V4. V4 is at the mid-clavicular line, fifth intercostal space.

Which is not a likely origination point for cardiac dysrhythmias? A. ventricles B. atria C. atrioventricular node D. bundle of His

D Cardiac dysrhythmias may originate in the atria, atrioventricular node, or ventricles. They do not originate in the Bundle of His.

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? A. Atrial fibrillation B. Atrial flutter C. Ventricular tachycardia D. Ventricular fibrillation

B 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 client asks the nurse to explain what is meant by a ventricular bigeminy cardiac rhythm. What is the best response by the nurse? A. "It is when the heart conduction is primarily from the aterioventricular node." B. "The rhythm has a normal beat, then a premature beat pattern." C. "The rhythm is regular but fast." D. "The heart rate is between 150 to 250 bpm."

B 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.

Which ECG waveform characterizes conduction of an electrical impulse through the left ventricle? A. P wave B. QRS complex C. PR interval D. QT interval

B 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 licensed practical nurse is setting up the room for a client arriving at the emergency department with ventricular arrhythmias. The nurse is most correct to place which of the following in the room for treatment? A. A suction machine B. A defibrillator C. Cardioversion equipment D. An ECG machine

B The nurse is most correct to place a defibrillator close to the client room if not in the room. The nurse realizes that clients with ventricular dysrhythmias are at a high risk for fatal heart dysrhythmia and death. A suction machine is used to remove respiratory secretions. Cardioversion is used in a planned setting for atrial dysrhythmias. An ECG machine records tracings of the heart for diagnostic purposes. Most clients with history of cardiac disorders have an ECG completed.

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. A. QRT wave B. P wave C. S-Q segment D. P-R interval E. T wave

B, D, E 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.

The nurse is caring for a client with second-degree atrioventricular block, Type I with symptomatic bradycardia. What is the most likely medication the nurse will administer? A. nadolol B. diltazem C. atropine sulfate D. atenolol

C Atropine blocks acetylcholine at parasympathetic neuroeffector sites and blocks vagal stimulation. The client will be treated with an anticholinergic that blocks the effects of the vagal nerve. Atenolol and nadolol are beta blockers that are used for chest pain, myocardial infarction, and hypertension. Diltazem is a calcium channel blocker used to treat angina or slow the heart rate.

The nurse is attempting to determine the ventricular rate and rhythm of a patient's telemetry strip. What should the nurse examine to determine this part of the analysis? A. PP interval B. QT interval C. RR interval D. TP interval

C The rhythm is often identified at the same time the rate is determined. The RR interval is used to determine ventricular rhythm and the PP interval to determine atrial rhythm. If the intervals are the same or if the difference between the intervals is less than 0.8 seconds throughout the strip, the rhythm is called regular. If the intervals are different, the rhythm is called irregular.

A client with an atrial dysrhythmia has come to the clinic for a follow-up appointment and to talk with the health care provider about options to stop this dysrhythmia. What procedure could be used to treat this client? A. Chemical cardioversion B. Mace procedure C. Elective electrical defibrillation D. Elective electrical cardioversion

D Elective electrical cardioversion is a nonemergency procedure done by a physician to stop rapid, but not necessarily life-threatening, atrial dysrhythmias. Chemical cardioversion is not a procedure; it is drug therapy. A Mace procedure is a distractor for this question. Defibrillation is not an elective procedure.

The nurse knows that a pacemaker is the treatment of choice for what cardiac dysrhythmia? A. Supraventricular tachycardia B. Atrial flutter C. Ventricular fibrillation D. Complete heart block

D Pacemaker insertion is the treatment for complete heart block. Treatments for supraventricular tachycardia are: valsalva maneuver, unilateral carotid massage, immersion of face in ice water, administration of IV adenosine, cardioversion, and radiofrequency ablation. Cardioversion and drug therapy are used for the treatment of atrial flutter. Treatment for ventricular fibrillation is defibrillation preceded by or followed with epinephrine.

A nurse is caring for a client who has been admitted to have a cardioverter defibrillator implanted. The nurse knows that implanted cardioverter defibrillators are used in which clients? A. Clients with recurrent life-threatening bradycardias B. Clients with sinus tachycardia C. Clients with ventricular bradycardia D. Clients with recurrent life-threatening tachydysrhythmias

D The automatic implanted cardioverter defibrillator (AICD) is an internal electrical device used for selected clients with recurrent life-threatening tachydysrhythmias. Therefore, options A, B, and C are incorrect.

After evaluating a client for hypertension, a health care provider orders atenolol, 50 mg P.O. daily. Which therapeutic effect should atenolol have in treating hypertension? A. Decreased cardiac output and decreased systolic and diastolic blood pressure B. Decreased blood pressure with reflex tachycardia C. Increased cardiac output and increased systolic and diastolic blood pressure D. Decreased peripheral vascular resistance

A As a long-acting, selective beta1-adrenergic blocker, atenolol decreases cardiac output and systolic and diastolic blood pressure; however, like other beta-adrenergic blockers, it increases peripheral vascular resistance at rest and with exercise. Atenolol may cause bradycardia, not tachycardia.

The nurse is caring for a client who is being discharged after insertion of a permanent pacemaker. Which question by the client indicates a need for clarification? A. "I should ask for a handheld device search when I go through airport security." B. "I should avoid large magnetic fields, such as an MRI machine or large motors." C. "I should avoid contact sports." D. "I'll watch the incision for swelling or redness and will report if either occurs."

A At security gates at airports, government buildings, or other secured areas, the client with a permanent pacemaker should show a pacemaker ID card and request a hand (not handheld device) search. The client should obtain and carry a physician's letter about this requirement.

A 28-year-old client presents to the emergency department, stating severe restlessness and anxiety. Upon assessment, the client's heart rate is 118 bpm and regular, the client's pupils are dilated, and the client appears excitable. Which action should the nurse take next? A. Question the client about alcohol and illicit drug use. B. Instruct the client to hold the breath and bear down. C. Prepare to administer a calcium channel blocker. D. Place the client on supplemental oxygen.

A The client is experiencing sinus tachycardia. Since the client's findings of tachycardia, dilated pupils, restlessness, anxiety, and excitability can indicate illicit drug use (cocaine), the nurse should question the client about alcohol and illicit drug use. This information will direct the client's plan of care. Causes of tachycardia include medications that stimulate the sympathetic response, stimulants, and illicit drugs. The treatment goals for sinus tachycardia is usually determined by the severity of symptoms and directed at identifying and abolishing its cause. The other interventions may be implemented, but determining the cause of the tachycardia is essential.

A client admitted to the telemetry unit has a serum potassium level of 6.6 mEq/L. Which electrocardiographic (ECG) characteristic is commonly associated with this laboratory finding? A. Occasional U waves B. Peaked T waves C. Flattened P waves D. Prolonged QT interval

B The client's serum potassium level is high. The T wave is an ECG characteristic reflecting repolarization of the ventricles. It may become tall or "peaked" if a client's serum potassium level is high. The U wave is an ECG waveform characteristic that may reflect Purkinje fiber repolarization. It is usually seen when a client's serum potassium level is low. The P wave is an ECG characteristic reflecting conduction of an electrical impulse through the atria and is not affected by a client's serum potassium level. The QT interval is an ECG characteristic reflecting the time from ventricular depolarization to repolarization, and is not affected by a client's serum potassium level.

The nurse recognizes which as being true of cardioversion? A. Amount of voltage used should exceed 400 watts/second. B. Electrical impulse can be discharged during the T wave. C. Defibrillator should be set to deliver a shock during the QRS complex. D. Defibrillator should be set in the non-synchronous mode so the nurse can hit the button at the right time.

C 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.