Dysrhythmias Practice Questions
A group of nursing students are discussing atrial flutter. These students recognize that which of the following are seen with atrial flutter? Select all that apply: 1) Ventricular rate of 220-300 bpm. 2) Regular rhythm 3) Saw-tooth pattern 4) Measurable PR interval 5) Long QRS interval
Answer(s): 2, 3 The ATRIAL rate is 250-400 bpm. Ventricular is about 75-150. The rhythm is regular, with the P wave appearing as little flutter or a "saw tooth pattern". The PR interval is not measurable r/t this saw-tooth P wave. The QRS is normal.
What teaching does the nurse include for a client with atrial fibrillation who has a new prescription for warfarin? a. It is important to consume a diet high in green leafy vegetables. b. You should take aspirin or ibuprofen for headache. c. Report nosebleeds to your provider immediately. d. Avoid caffeinated beverages.
Answer: C Rationale: Warfarin causes decreased ability to clot; a nosebleed could be indicative of excessive dosing.
How does the nurse recognize that atropine has produced a positive outcome for the client with bradycardia? a. Client states he is dizzy and weak. b. The nurse notes dyspnea. c. The client has a heart rate of 42. d. The monitor shows normal sinus rhythm.
Answer: D Rationale: Sinus rhythm presents with heart rates from 60 to 100 beats/min; by definition, the bradydysrhythmia has resolved.
The nurse is caring for a client on a telemetry unit with a regular heart rhythm and rate of 60; a P wave precedes each QRS complex, and the PR interval is 0.24 second. Additional vital signs are as follows: blood pressure 118/68, respiratory rate 16, and temperature 98.8° F. The following medications are available on the medication record. What action should the nurse take? a. Administer atropine. b. Administer digoxin. c. Administer clonidine. d. Continue to monitor.
Answer: D Rationale: The client is displaying sinus rhythm with first-degree atrioventicular heart block; this is usually asymptomatic and does not require treatment. Atropine is used in emergency treatment of symptomatic bradycardia. This client has normal vital signs. Digoxin is used in the treatment of atrial fibrillation, which is, by definition, an irregular rhythm. Clonidine is used in the treatment of hypertension; a side effect is bradycardia.
The patient is admitted with a heart rate of 144 beats/min and a blood pressure of 88/42 mm Hg. The patient complains of generalized weakness and fatigue. He states, "Just let me sleep." The nurse determines that the presence of the patient's symptoms is due to: 1. Decreased cardiac output. 2. The absence of ischemic heart disease. 3. Improved cardiac filling time, allowing the patient to relax. 4. Increased coronary artery filling time.
1 Rationale: The fast heart rhythm may cause a decrease in cardiac output because of the shorter filling time for the ventricles. Vulnerable populations are those with ischemic heart disease who are adversely affected by the shorter time for coronary filling during diastole.
The nurse notices ventricular tachycardia on the heart monitor. The nurse's first action should be to: 1. Determine patient responsiveness and presence of a pulse. 2. Immediately defibrillate the patient and provide CPR. 3. Administer intravenous amiodarone or lidocaine. 4. Cardiovert electrically into a more sustainable rhythm.
1. Rationale: Determine whether the patient has a pulse. If no pulse is present, provide emergent basic and advanced life-support interventions, including defibrillation. If a pulse is present and the blood pressure is stable, the patient can be treated with intravenous amiodarone or lidocaine. Cardioversion is used as an emergency measure in patients who become hemodynamically unstable but continue to have a pulse. It may also be used in nonemergency situations, such as when a patient has asymptomatic VT.
The nurse is caring for an individual who is admitted for chest pain and shortness of breath. The patient states, "I can't believe I'm having chest pain. I'm a marathon runner and in good shape." During the night, the patient develops a sinus bradycardia with a heart rate of 40 beats/min. The nurse should: 1. Ignore this rate since the patient is an athlete. 2. Assess the patient for signs of decreased cardiac output. 3. Take the patient's temperature and expect to find hyperthermia. 4. Perform carotid massage (a maneuver to stimulate a vasovagal response).
2 Rationale: Bradycardia is defined as a heart rate less than 60 beats/min. Sinus bradycardia may be a normal heart rhythm for some individuals such as athletes, or it may occur during sleep. Although sinus bradycardia may be asymptomatic, it may cause instability in some individuals if it results in a decrease in cardiac output. The key is to assess the patient and determine if the bradycardia is accompanied by signs of instability. Vasovagal response can occur due to: medications such as digoxin or AV nodal blocking agents, including calcium channel blockers and beta blockers; myocardial infarction; normal physiological variant in the athlete; disease of the sinus node; increased intracranial pressure; hypoxemia; and hypothermia. The nurse would not want to perform a vasovagal response, as this would lower the heart rate more.
The patient has a temporary transvenous, demand-type ventricular pacemaker. The rate on the pacemaker is set at 60 beats/min. Which of the following situations would be of concern? 1. A paced rhythm of 60 beats/min is seen on the monitor; no other waveforms are seen. 2. A pacemaker spike is seen on the T wave of the preceding beat. 3. The patient's inherent (own) rate falls to 58 and the pacemaker fires. 4. The patient's inherent rate is 70 beats/min; no pacemaker spikes are seen.
2 Rationale: Failure to sense manifests as pacer spikes that fall earlier than the programmed rate. This can cause an artificial R-on-T phenomenon similar to when a PVC occurs during the T wave, and ventricular tachycardia may occur.
The nurse is interpreting a patient's cardiac rhythm and notes that the PR interval is 0.16 seconds long. The nurse determines that this PR interval indicates: 1. Slower-than-normal conduction from the SA node through the AV node. 2. Normal conduction from the SA node through the AV node. 3. Faster-than-normal conduction from the SA node through the AV node. 4. Abnormally fast depolarization of the atria and ventricles.
2 Rationale: The interval from the beginning of the P wave to the next deflection from the baseline is called the PR interval. The PR interval measures the time it takes for the impulse to depolarize the atria, travel to the AV node, and dwell there briefly before entering the bundle of His. The normal PR interval is 0.12 to 0.20 seconds, three to five small boxes wide. When the PR interval is longer than normal, the speed of conduction is delayed in the AV node. When the PR interval is shorter than normal, the speed of conduction is abnormally fast.
The patient complains of being lightheaded and feeling "fluttering" in his chest. The nurse places the patient on the heart monitor and notices an atrial tachycardia at a rate of 160bpm. The patient's blood pressure has dropped from 128/76 mmHg to 92/46 mmHg but appears stable at the lower pressure. The nurse should: 1. Prepare the patient for asynchronized defibrillation 2. Give the patient digitalis IV and then call the provider 3. Call the provider and prepare the patient for medical or electrical cardioversion 4. Withhold beta blockers and calcium channel blockers
3 Rationale: Atrial tachycardia is a rapid rhythm that arises from an ectopic focus in the atria. Because of the fast rate, atrial tachycardia can be a life-threatening dysrhythmia. Causes include digitalis toxicity, electrolyte imbalances, lung disease, ischemic heart disease, and cardiac valvular abnormalities. Treatment is directed at assessing the patient's tolerance of the tachycardia. If the rate is over 150 beats/min and the patient is symptomatic, emergent cardioversion is considered. Cardioversion is the delivery of a synchronized electrical shock to the heart by an external defibrillator. Medications that may be used include adenosine, beta blockers, calcium channel blockers, and amiodarone.
The nurse is interpreting the rhythm strip of a patient and measures the QRS complex as being three small boxes in width. The nurse interprets this width as: 1. 0.04 sec 2. 0.10 sec 3. 0.12 sec 4. 0.16 sec
3 Rationale: ECG paper contains a standardized grid in which the horizontal axis measures time and the vertical axis measures voltage or amplitude. Larger boxes are circumscribed by darker lines and the smaller boxes by lighter lines. The larger boxes contain 5 smaller boxes on the horizontal line and 5 on the vertical line for a total of 25 per large box. Horizontally, the smaller boxes denote 0.04 seconds each or 40 milliseconds; the larger box contains five smaller boxes and thus equals 0.20 seconds or 200 milliseconds. Along the uppermost aspect of the ECG paper are vertical hash marks that occur every 15 large boxes. The area between these marks equals 3 seconds.
The nurse is speaking with the patient when the monitor shows that the patient is in ventricular fibrillation (VF). The nurse should: 1. Immediately defibrillate the patient. 2. Initiate basic life-support protocols and call for help. 3. Asses the patient and check the patient's monitor leads 4. Initiate advanced life-support protocols as soon as possible
3 Rationale: Ventricular fibrillation (VF) is a chaotic rhythm characterized by a quivering of the ventricles, which results in total loss of cardiac output and pulse. Because this patient was in the process of speaking with the nurse, there is evidence of cardiac output being present, which would not be the case with VF. Because a loose lead or electrical interference can produce a waveform similar to VF, it is always important to immediately assess the patient for pulse and consciousness. The issue here is more likely a loose lead. Immediate BLS and ACLS interventions would only be required if the patient was truly in VF.
The nurse is caring for a client with atrial fibrillation. In addition to an antidysrhythmic, what medication does the nurse plan to administer? a. Heparin b. Atropine c. Dobutamine d. Magnesium sulfate
Answer: A Rationale: Clients with atrial fibrillation are prone to blood pooling in the atrium, clotting, then embolizing. Heparin is used to prevent thrombus development in the atrium and the consequence of embolization (i.e., stroke).
A client admitted after using crack cocaine develops ventricular fibrillation. After determining unresponsiveness, which action should the nurse take next? a. Defibrillate at 200 b. Establish IV access. c. Place an oral airway and ventilate. d. Start cardiopulmonary resuscitation (CPR).
Answer: A Rationale: Defibrillating is of priority before any other resuscitative measures according to Advanced Cardiac Life Support protocols.
The nurse is caring for a client with advanced heart failure who develops asystole. The nurse corrects the new graduate when the graduate offers to perform which intervention? a. Defibrillation b. Cardiopulmonary resuscitation (CPR) c. Administration of atropine d. Administration of oxygen
Answer: A Rationale: Defibrillation interrupts the heart rhythm and allows normal pacemaker cells to take over: in asystole, there is no rhythm to interrupt; therefore this intervention is not used.
A nurse on a CVT unit views the monitor and sees the patient in room 452 has just begun having occasional PVCs. Which action should the nurse take first? 1) Check on the patient 2) Check last magnesium and potassium levels 3) Document the occurrence and watch for further PVCs 4) Contact the physician
Answer: 1 Although electrolytes are likely the culprit, the nurse first needs to first assess the patient. Then, the nurse should look in the patient's chart and evaluate or request an order for electrolyte levels. This may eventually need to be documented, but the nurse can be held liable for neglect if he/she does not assess the patient first. The physician may or may not need to be contacted.
A nursing student is aware that which of the following is the treatment for unstable atrial flutter? 1) Adenosine (Adenocard) 6 mg rapid IVP. 2) Cardioversion with adjacent Heparin therapy 3) Defibrillation STAT followed by CPR. 4) Altemose 3 mg IVP over 1-2 seconds.
Answer: 2 Cardioversion is used if the patient is unstable. Anticoagulants are used if the arrhythmia has stuck around for 48 hr +. Adenosine may be used with a narrow QRS and regular RR interval
A nurse working on a CVT unit receives report from day shift. After receiving report, which patient should the nurse see first? 1) A 23-year-old professional tennis player with a HR of 47 bpm. 2) A 69-year-old male with atrial fibrillation who has new onset confusion. 3) A 72-year-old female with atrial flutter who reports feeling unusually tired today and yesterday. 4) A 33-year-old female with sinus tachycardia who is asking for her at-home Metoprolol.
Answer: 2 Patients with a-fib are at risk for pulmonary and systemic emboli, and new onset of confusion may indicate a stroke in this patient. Patients with atrial flutter may feel more tired some days than others.
A 26-year-old client with atrial fibrillation that has not responded to medication therapy has arrived at the hospital for an elective cardioversion. Which of the following patient statements most concerns the nurse? 1) "I can't wait to stop taking this Coumadin. I've been on this crap for weeks now." 2) "I'm starving. I haven't eaten anything in 3 hours." 3) "I feel really short of breath, can I lie down?" 4) "I haven't taken my Digoxin since 9 o'clock last night. Is that okay?"
Answer: 3 Patients with atrial fibrillation are at incredibly high risk for clots, even with anticoagulation therapy. Shortness of breath could indicate a PE, and this should be immediately investigated by the nurse. The patient should be NPO for at least 4 hr. prior to the procedure related to anesthesia use, but this is not as urgent of a concern. The patient should also withhold Digoxin therapy for 48 hours to ensure that, once cardioverted, NSR returns.
Which of the following does the nursing student realize is the treatment for a stable patient presenting with QRS intervals above 0.12 seconds with a regular rhythm and a rate of 100-250 bpm? 1) Atropine 2) Defibrillation 3) Amiodarone 4) Adenosine
Answer: 3 This is describing ventricular tachycardia (QRS is a giveaway), and the treatment for a stable patient is Amiodarone or cardioversion. If the patient were unstable, we'd go ahead and defibrillate.
The patient who has recently been experiencing runs of ventricular tachycardia suddenly loses consciousness. The patient is defibrillated, and the rate returns as the following. What should the nurse do first? A) Begin compressions B) Shock the client again immediately C) Prepare for intubation D) Administer adenosine
Answer: A Following defibrillation, CPR is immediately initiated if a perfusable rhythm is not initiated. The client may need to be shocked again, but chest compressions must begin first.
For which of the following dysrhythmias is defibrillation primarily indicated? a. Ventricular fibrillation b. Third-degree AV block c. Uncontrolled atrial fibrillation d. Ventricular tachycardia with a pulse
Answer: A Rationale: Defibrillation is always indicated in the treatment of ventricular fibrillation. Drug treatments are normally used in the treatment of uncontrolled atrial fibrillation and for ventricular tachycardia with a pulse (if the patient is stable). Otherwise, synchronized cardioversion is used (as long as the patient has a pulse). Pacemakers are the treatment of choice for third-degree heart block.
A patient in asystole is likely to receive which of the following drug treatments? a. Atropine and epinephrine b. Lidocaine and amiodarone c. Digoxin and procainamide d. β-Adrenergic blockers and dopamine
Answer: A Rationale: Normally the patient in asystole cannot be successfully resuscitated. However, administration of atropine and epinephrine may prompt the return of depolarization and ventricular contraction.
You are the charge nurse on the telemetry unit and are responsible for making client assignments. Which client would be appropriate to assign to the float RN from the medical-surgical unit? a. The 64-year-old admitted for weakness who has a first-degree heart block with a heart rate of 58 beats/min b. The 71-year-old admitted for heart failure who is short of breath and has a heart rate of 120 to 130 beats/min c. The 88-year-old admitted with an elevated troponin level who is hypotensive with a heart rate of 96 beats/min d. The 92-year-old admitted with chest pain who has premature ventricular complexes and a heart rate of 102 beats/min
Answer: A Rationale: This client has a stable, asymptomatic dysrhythmia, which usually requires no treatment; this client can be managed by a nurse with less cardiac dysrhythmia training.
The nurse is preparing to administer adenosine to the patient with the following rhythm which is symptomatic. What should the nurse plan on having in the patient room? Select All That Apply: a) Physician b) Crash cart c) IV pump d) EKG monitor e) Lidocaine
Answer: A, B, and D Adenosine is administered as a very quick IV push. The physician must be present in the room and the crash cart must be on hand. An ekg monitor should be in the room to monitor the effectiveness of the medication.
The nurse is providing discharge teaching to the client who has just received a pacemaker. Which of the following should the nurse include in the plan of care? SATA: A) Use your cell phone on the opposite side of your pacemaker B) You should avoid using a microwave from now on C) For the next week, it would be best to limit activity on the side with your new pacemaker D) You will need to inform airport security about your pacemaker before you fly anywhere E) It would be a good idea to check your pulse daily
Answer: A, C, D, and E. A cellphone should not be used near the pacemaker and it's best to keep the phone about half a foot away from the pacemaker. It is not necessary for the client to avoid using a microwave or other electrical devices. However, magnets should be kept away from the device. In order to prevent disruption of the leads after implantation (the most common complication), patients are often taught to limit activity on the affected side for awhile after implantation. Pulses are a good indicator of whether the pacemaker is supplying the body with enough cardiac output.
The nurse is caring for a client who has developed a bradycardia. Which possible causes should the nurse investigate? Select all that apply a. Bearing down for a bowel movement b. Possible inferior wall myocardial infarction (MI) c. Client stating that he just had a cup of coffee d. Client becoming emotional when visitors arrived e. Diltiazem (Cardizem) administered an hour ago
Answer: A,B,E Rationale: The Valsalva maneuver stimulates the vagus nerve, causing bradycardia. Inferior wall MI is a cause of bradycardia and heart blocks. Calcium channel blockers such as diltiazem may cause bradycardia.
The nurse is caring for a client with heart rate of 143. For which manifestations should the nurse observe? Select all that apply. a. Palpitations b. Increased energy c. Chest discomfort d. Flushing of the skin e. Hypotension
Answer: A,C,E Rationale: Tachycardia, heart rate greater than100 beats/min, produces palpitations, that is, the ability to feel the heart beating in the chest. Chest discomfort may occur because decreased time for diastole results in lower perfusion through the coronary arteries to the myocardium. Hypotension results from decreased time for ventricular filling, secondary to shortened diastole and therefore reduced cardiac output and blood pressure.
The patient with a history of hypertension and diabetes has the following rhythm strip. The patient's vitals are as follows: BP 145/89, HR 90, SpO2 95%, RR 19. Which of the following does the nurse expect to do at this time? a) Prepare the client for cardioversion STAT b) Begin administering anticoagulants c) Grab the crash cart for administration of adenosine d) Teach the client about possibility of pacemaker installation
Answer: B Atrial flutter places the client at high risk for development of clot formation in the atria. Because the client is stable at this time, cardioversion or adenosine would not be performed at this time. Before cardioversion can occur in a patient, anticoagulant therapy should be begun at least 48 hours beforehand if possible.
Which of the following signs and symptoms indicate pacemaker failure? A) excessive thirst B) prolonged hiccups C) flushing of the skin D) increased urine output
Answer: B Prolonged hiccups indicate pacemaker failure. Other signs and symptoms of pacemaker failure are dysrhythmias, dizziness, faintness, chest pain, shortness of breath, increase or decrease in apical rate.
The nurse is watching the cardiac monitor, and a patient's rhythm suddenly changes. There are no P waves. Instead there are fine, wavy lines between the QRS complexes. The QRS complexes measure 0.08 sec (narrow), but they occur irregularly with a rate of 120 beats/min. The nurse correctly interprets that this rhythm is which of the following? a. Sinus tachycardia b. Atrial fibrillation c. Ventricular fibrillation d. Ventricular tachycardia
Answer: B Rationale: Atrial fibrillation is represented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atria are not truly contracting, just fibrillating.
Which teaching is essential for a client who has had a permanent pacemaker inserted? a. Avoid talking on a cell phone. b. Avoid contact sports and blows to the chest. c. Avoid sexual activity. d. Do not take tub baths.
Answer: B Rationale: No pressure should be applied over the generator site.
The nurse is caring for a client with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol (Lopressor). Which monitoring is essential when administering the medication? a. ST segment b. Heart rate c. Troponin d. Myoglobin
Answer: B Rationale: The effects of metoprolol are to decrease heart rate, blood pressure, and myocardial oxygen demand. ST segment elevation is consistent with MI; it does not address monitoring of metoprolol. Elevation in troponin is consistent with a diagnosis of MI but does not address needed monitoring for metoprolol. Elevation in myoglobin is consistent with myocardial injury in ACS but does not address needed monitoring related to metoprolol.
The nurse is caring for a client with unstable angina whose cardiac monitor shows ventricular tachycardia. Which action is appropriate to implement first? a. Defibrillate using 200 J. b. Check the client for a pulse. c. Cardiovert the client at 50 J. d. Administer IV ibutilide (Corvert).
Answer: B Rationale: The nurse needs to assess the pulse and client stability before proceeding with further interventions; pulseless ventricular tachycardia is treated with defibrillation.
The nurse has just administered adenosine via IV push and sees the following rhythm on the monitor. What is the nurse's priority intervention? a) Apply conductive gel and defibrillate the patient b) Document the findings and continue to monitor c) Administer another mg of the medication d) Begin chest compressions
Answer: B This finding would be expected upon administration of adenosine. The rhythm should then begin again in some other rhythm, hopefully normal sinus rhythm. It would be important to document the exact time of this change and continue to monitor the change back to NSR. If this change does not occur, or if another rhythm is produced, appropriate action would then be taken based on the result.
The nurse administers amiodarone (Cordarone) to a client with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? Select all that apply. a. Respiratory rate b. QT interval c. Heart rate and rhythm d. Magnesium level e. Urine output
Answer: B,C,D Rationale: Amiodarone causes prolongation of the QT interval, which can precipitate dysrhythmia. Antidysrhythmic medications cause changes in cardiac rhythm and rate; therefore monitoring of heart rate and rhythm is needed.Electrolyte depletion, specifically potassium and magnesium, may predispose to further dysrhythmia. Although it is always important to monitor vital signs and urine output, these assessments are not specific to amiodarone.
The nurse teaches a client with new-onset atrial fibrillation that risk factors for this dysrhythmia may include which? Select all that apply. a. Use of beta-adrenergic blockers b. Excessive alcohol use c. Advancing age d. High blood pressure e. Palpitations
Answer: B,C,D Rationale: Excessive alcohol use may cause atrial fibrillation. Atrial fibrillation occurs more frequently in older people. Hypertension is a risk factor in the development of atrial fibrillation.
The nurse is determining whether the client's rhythm strip demonstrates proper firing of the sinoatrial (SA) node. Which waveform indicates proper function of the SA node? a. The QRS complex is present. b. The PR interval is 0.24 second. c. A P wave precedes every QRS complex. d. The ST segment is elevated.
Answer: C Rationale: A P wave is generated by the SA node and represents atrial depolarization.
The nurse is caring for a patient who is 24 hours postpacemaker insertion. Which of the following nursing interventions is most appropriate at this time? a. Reinforcing the pressure dressing as needed b. Encouraging range-of-motion exercises of the involved arm c. Assessing the incision for any redness, swelling, or discharge d. Applying wet-to-dry dressings every 4 hours to the insertion site
Answer: C Rationale: After pacemaker insertion, it is important for the patient to limit activity of the involved arm to minimize pacemaker lead displacement. The nonpressure dressing is kept dry until removed, usually 24 hours postoperative. It is important for the nurse to observe signs of infection by assessing for any redness, swelling, or discharge from the incision site.
A client with atrial fibrillation with rapid ventricular response has received medication to slow the ventricular rate. The pulse is now 88. For which additional therapy does the nurse plan? a. Synchronized cardioversion b. Electrophysiology studies (EPS) c. Anticoagulation d. Radiofrequency ablation therapy
Answer: C Rationale: Because of the risk for thromboembolism, anticoagulation is necessary.
The professional nurse is supervising a nursing student performing a 12-lead electrocardiogram (ECG). Under which circumstance does the nurse correct the student? a. The client is semirecumbent in bed. b. Chest leads are placed as for the previous ECG. c. The client is instructed to breathe deeply through the mouth. d. The client is instructed to lie still.
Answer: C Rationale: Normal breathing is required or artifact will be observed, perhaps leading to inaccurate interpretation of the ECG.
The nurse recognizes that which intervention provides safety during cardioversion? a. Using the defibrillator at 200 joules b. Obtaining informed consent c. Setting the defibrillator to the synchronized mode d. Removing oxygen
Answer: C Rationale: Setting the defibrillator to the synchronized mode ensures discharging the shock during the vulnerable period on the T wave, which may cause ventricular fibrillation.
Which of the following statements best describes the electrical activity of the heart represented by measuring the PR interval on the ECG? a. The length of time it takes to depolarize the atrium b. The length of time it takes for the atria to depolarize and repolarize c. The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers d. The length of time it takes for the electrical impulse to travel from the SA node to the AV node
Answer: C Rationale: The electrical impulse in the heart must travel from the SA node through the AV node and into the Purkinje fibers in order for synchronous atrial and ventricular contraction to occur. The P wave represents atrial contraction and the R wave is part of the QRS complex that represents ventricular contraction. Therefore when measuring the time from the beginning of the P wave to the beginning of the QRS (PR interval), the nurse is identifying the length of time it takes for the electrical impulse to travel from the SA node to the Purkinje fibers.
The client's rhythm strip shows a heart rate of 76 beats/min, one P wave occurring before each QRS complex, a PR interval measuring 0.24 second, and a QRS complex measuring 0.08 second. How does the nurse interpret this rhythm strip? a. Normal sinus rhythm b. Sinus bradycardia c. Sinus rhythm with first-degree atrioventricular (AV) block d. Sinus rhythm with premature ventricular contractions
Answer: C Rationale: These are the characteristics of sinus rhythm with first-degree AV block.
Which of the following ECG characteristics is consistent with a diagnosis of ventricular tachycardia (VT)? a. Unmeasurable rate and rhythm b. Rate 150 beats/min; inverted P wave c. Rate 200 beats/min; P wave not visible d. Rate 125 beats/min; normal QRS complex
Answer: C Rationale: VT is associated with a rate of 150 to 250 beats/min; the P wave is not normally visible. P wave inversion and a normal QRS complex are not associated with VT. Rate and rhythm are not measurable in ventricular fibrillation.
You are the nurse working on the telemetry unit and you have finally gotten to sit down to work on some charting. Suddenly the heart monitors at the station start beeping. Patient in room 18 is showing this rhythm on the monitor. The medical team advances together into the room and finds them unconscious. What is priority action by the nurse? A) Prepare to administer adenosine to the patient B) Begin chest compressions C) Prepare for defibrillation D) Check for a pulse
Answer: D A pulse would be assessed for first. Then the patient will be defibrillized and chest compressions will begin immediately.
The nurse is teaching the client with a new permanent pacemaker. Which statement by the client indicates the need for further discharge education? a. "I will be able to shower again soon." b. "I need to take my pulse every day." c. "I might trigger airport security metal detectors." d. "I no longer need my heart pills."'
Answer: D Rationale: All discharge medications are still needed after the pacemaker is implanted.
In teaching clients at risk for bradydysrhythmias, what information does the nurse include? a. "Avoid potassium-containing foods." b. "Stop smoking and avoid caffeine." c. "Take nitroglycerin for a slow heartbeat." d. "Use a stool softener."
Answer: D Rationale: Clients at risk for bradydysrhythmias should avoid bearing down or straining during a bowel movement; the Valsalva maneuver can cause bradycardia. Taking a stool softener helps to prevent this.
Which information would cause the nurse to withhold digoxin in the client with atrial fibrillation and heart failure? A. The client has sinus tachycardia with a rate of 102. B. The cardiac monitor shows atrial fibrillation with a heart rate of 98. C. The client has a creatinine level of 1.0 mg/dL. D. The digoxin level is 2.8 mg/dL.
Answer: D Rationale: The therapeutic range for digoxin is 0.8 to 2.0 ng/mL; hold the medication because this client has digoxin toxicity.
The nurse in the intensive care unit (ICU) hears an alarm sound in the patient's room. Arriving in the room, the patient is unresponsive, without a pulse, and a flat line on the monitor. What is the first action by the nurse? a) Administer atropine 0.5 mg b) Administer epinephrine c) Defibrillate with 360 joules d) Begin cardiopulmonary resuscitation (CPR)
Answer: D We cannot defibrillate asystole
