Med-Surge Nursing Cardio Prep U ch 26

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." 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 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." 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.

The nurse knows that what PR interval presents a first-degree heart block?

0.24 seconds In adults, the normal range for the PR is 0.12 to 0.20 seconds. A PR internal of 0.24 seconds would indicate a first-degree heart block.

What is the drug of choice for a stable client with ventricular tachycardia?

Amiodarone Amiodarone administered IV is the antidysrhythmic medication of choice for a stable patient with ventricular tachycardia. Atropine is used for bradycardia. Procainamide is used to treat and prevent atrial and ventricular dysrhythmias. Lidocaine is used for treating ventricular dysrhythmias.

The nurse cares for a client with a dysrhythmia and understands that the P wave on an electrocardiogram (ECG) represents which phase of the cardiac cycle?

Atrial depolarization The P wave represents atrial depolarization. The QRS complex represents ventricular depolarization. The T wave represents ventricular repolarization. The ST segment represents early ventricular repolarization, and lasts from the end of the QRS complex to the beginning of the T wave.

The licensed practical nurse is monitoring the waveform pattern on the cardiac monitor ofthe client admitted following a myocardial infarction. The nurse notes that every other beat includes a premature ventricular contraction (PVC). The nurse notes which of the following in the permanent record?

Bigeminy The nurse is correct to note bigeminy on the permanent record when every other beat is a PVC. Couplets are two PVCs in a row. Multifocal PVCs originate from more than one location. R-on-T phenomenon occurs when the R wave falls on the T wave.

A nurse is caring for a client with a history of cardiac disease and type 2 diabetes. The nurse is closely monitoring the client's blood glucose level. Which medication is the client most likely taking?

Carvedilol The nurse must monitor blood glucose levels closely in clients with type 2 diabetes who are taking beta-adrenergic blockers such as carvedilol, because beta-adrenergic blockers may mask the signs of hypoglycemia. The nurse should monitor QRS duration in clients taking procainamide and pulmonary function in clients taking amiodarone (because the drug may cause pulmonary fibrosis). Diltiazem may cause an increased PR interval or bradycardia.

The nurse recognizes which as being true of cardioversion?

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.

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. One of the reasons for lack of pacemaker spikes is faulty monitoring equipment.

The nurse is caring for a client with atrial fibrillation. What procedure would be recommended if drug therapies did not control the dysrhythmia?

Elective cardioversion Atrial fibrillation also is treated with elective cardioversion or digitalis if the ventricular rate is not too slow. Defibrillation is used for a ventricular problem. A Maze procedure is only a distractor for this question. Pacemakers are implanted for bradycardia.

The nurse is teaching a beginning EKG class to staff nurses. As the nurse begins to discuss the the parts of the EKG complex, one of the students asks what the normal order of conduction through the heart is. What order does the nurse describe?

Sinoatrial (SA) node, atrioventricular (AV) node, bundle of His, right and left bundle branches, and the Purkinje fibers The correct sequence of conduction through the normal heart is the SA node, AV node, bundle of His, right and left bundle branches, and Purkinje fibers.

A patient who had a myocardial infarction is experiencing severe chest pain and alerts the nurse. The nurse begins the assessment but suddenly the patient becomes unresponsive, no pulse, with the monitor showing a rapid, disorganized ventricular rhythm. What does the nurse interpret this rhythm to be?

Ventricular fibrillation The most common dysrhythmia in patients with cardiac arrest is ventricular fibrillation, which is a rapid, disorganized ventricular rhythm that causes ineffective quivering of the ventricles. No atrial activity is seen on the ECG. The most common cause of ventricular fibrillation is coronary artery disease and resulting acute myocardial infarction. Ventricular fibrillation is always characterized by the absence of an audible heartbeat, a palpable pulse, and respirations.

A patient with hypertension has a newly diagnosed atrial fibrillation. What medication does the nurse anticipate administering to prevent the complication of atrial thrombi?

Warfarin Because atrial function may be impaired for several weeks after cardioversion, warfarin is indicated for at least 4 weeks after the procedure. Patients may be given amiodarone, flecainide, ibutilide, propafenone, or sotalol prior to cardioversion to enhance the success of cardioversion and prevent relapse of the atrial fibrillation

A client has an irregular heart rate of around 100 beats/minute and a significant pulse deficit. What component of the client's history would produce such symptoms?

atrial fibrillation In atrial fibrillation, several areas in the right atrium initiate impulses resulting in disorganized, rapid activity. The atria quiver rather than contract, producing a pulse deficit due to irregular impulse conduction to the AV node. The ventricles respond to the atrial stimulus randomly, causing an irregular ventricular heart rate, which may be too infrequent to maintain adequate cardiac output. Atrial flutter, heart block, and bundle branch block would not produce these symptoms.

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. 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.

A client's Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minute. What type of dysrhythmia would the cardiologist likely diagnose?

sinus tachycardia Sinus tachycardia is a dysrhythmia that proceeds normally through the conduction pathway but at a faster than usual rate (100 to 150 beats/minute).

The nurse is instructing on home care after placement of an automatic implanted cardioverter defibrillator (AICD). Which statement, made by the client, needs clarification by the nurse?

"I need to stay away from microwaves." Similar to hand tools, microwaves have shields or are grounded, making them safe for clients with AICDs. There is no restriction from microwave use. All of the other options are correct.

The nurse would expect which of the following atrial rates to correlate with an idioventricular rhythm?

20 to 40 The rate is 20 to 40. If the rate exceeds 40, the rhythm is known as accelerated idioventricular rhythm (AIVR). The rate is not measurable in asystole. Ventricular tachycardia has a rate of 100 to 250 per minute. Atrial flutter has a rate of 220 to 350.

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 defibrillator 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 client is scheduled for an elective electrical cardioversion for a sustained dysrhythmia lasting for 24 hours. Which intervention is necessary for the nurse to implement prior to the procedure?

Administer moderate sedation IV and analgesic medication as prescribed Before an elective cardioversion, the client should receive moderate sedation IV as well as an analgesic medication or anesthesia. In contrast, in emergent situations, the client may not be premedicated. Digoxin is usually withheld for 48 hours before cardioversion to ensure the resumption of sinus rhythm with normal conduction. If the cardioversion is elective and the dysrhythmia has lasted longer than 48 hours, anticoagulation performed for a few weeks before cardioversion may be indicated. The client is instructed not to eat or drink for at least 4 hours before the procedure.

Which dysrhythmia has an atrial rate between 250 and 400, with saw-toothed P waves?

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 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 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?

Clients with recurrent life-threatening tachydysrhythmias 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.

The nurse knows that a pacemaker is the treatment of choice for what cardiac dysrhythmia?

Complete heart block 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.

Which diagnostic study best evaluates different medications ability to restore normal heart rhythm?

Electrophysiology study An electrophysiology study is a procedure that enables the physician to examine the electrical activity of the heart, produce actual dysrhythmias, and determine the best method for care. Cardioversion uses synchronized electricity to change the rhythm pattern. Electrocardiogram and echocardiograms provide diagnostic information.

Which nursing intervention is required to prepare a client with cardiac dysrhythmia for an elective electrical cardioversion?

Instruct the client to restrict food and oral intake The nurse should instruct the client to restrict food and oral intake before the cardioversion procedure. Digitalis and diuretics are withheld for 24 to 72 hours before cardioversion. The presence of digitalis and diuretics in myocardial cells decreases the ability to restore normal conduction and increases the chances of a fatal dysrhythmia developing after cardioversion. When the client is in cardiopulmonary arrest, the nurse should facilitate CPR until the client is prepared for defibrillation and not for cardioversion. Monitoring blood pressure every 4 hours is not required to prepare a client with cardiac dysrhythmia.

The staff educator is teaching a class in dysrhythmias. What statement is correct for defibrillation?

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.

A patient is 2 days postoperative after having a permanent pacemaker inserted. The nurse observes that the patient is having continuous hiccups as the patient states, "I thought this was normal." What does the nurse understand is occurring with this patient?

Lead wire dislodgement Phrenic nerve, diaphragmatic (hiccuping may be a sign), or skeletal muscle stimulation may occur if the lead is dislocated or if the delivered energy (mA) is set high. The occurrence of this complication is avoided by testing during device implantation.

A client with atrial fibrillation, who does not respond to conventional treatment measures and who is not a candidate for cardioversion, would have what procedure recommended?

Maze procedure Clients who are not candidates for cardioversion and fail to respond to conventional measures may be candidates for a surgical intervention referred to as the Maze procedure. Angiography, open heart surgery, and heart transplantation are not recommended surgeries for these clients.

Which nursing intervention must a nurse perform when administering prescribed vasopressors to a client with a cardiac dysrhythmia?

Monitor vital signs and cardiac rhythm The nurse should monitor the client's vital signs and cardiac rhythm for effectiveness of the medication and for side effects and should always have emergency life support equipment available when caring for an acutely ill client. The side effects of vasopressor drugs are hypertension, dysrhythmias, pallor, and oliguria. It is not necessary to place a client flat during or after vasopressor administration. When administering cholinergic antagonists, documentation of the heart rate is necessary.

The nurse expects to see which of the following characteristics on an ECG strip for a patient who has third-degree AV block?

More P waves than QRS complexes There is no PR interval because there isn't any relationship between the P and R wave. No atrial impulse is conducted through the AV node; atrial and ventricular contractions are independent. With third-degree AV block, two separate impulses stimulate the heart; there is no synchrony or relationship.

To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform?

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?

Pacer rate After a permanent pacemaker is inserted, the patient's heart rate and rhythm are monitored by ECG.

Undersensing occurs as a pacemaker malfunctions. The nurse understands undersensing occurs as a result of which event?

Pacing spike occurs at the preset level Undersensing means that the pacing spike occurs at preset interval despite the patient's intrinsic rhythm. Loss of capture occurs when a complex does not follow a pacing spike. Loss of pacing is total absence of the pacing spike. Oversensing occurs when there is a loss of pacing artifact.

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?

Peaked T waves 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.

Which ECG waveform characterizes conduction of an electrical impulse through the left ventricle?

QRS complex 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 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?

QT interval that is 0. 46 seconds long 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.

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?

RR interval 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 patient comes to the emergency department with reports of chest pain after using cocaine. The nurse assesses the patient and obtains vital signs with results as follows: blood pressure 140/92, heart rate 128, respiratory rate 26, and an oxygen saturation of 98%. What rhythm on the monitor does the nurse anticipate viewing?

Sinus tachycardia Sinus tachycardia occurs when the sinus node creates an impulse at a faster-than-normal rate. Causes include medications that stimulate the sympathetic response (e.g., catecholamines, aminophylline, atropine), stimulants (e.g., caffeine, nicotine), and illicit drugs (e.g., amphetamines, cocaine, Ecstasy).

A client has been diagnosed with atrial fibrillation and has been prescribed warfarin therapy. What should the nurse prioritize when providing health education to the client?

The need to have regular blood levels drawn One drawback of warfarin therapy is the need to have blood levels drawn on a regular basis. The medication does not need to be taken on an empty stomach, and the client does not have to sit upright. Adequate fluid intake is useful in a general way, but the need for fluids is not increased by taking warfarin.

When no atrial impulse is conducted through the AV node into the ventricles, the client is said to be experiencing which type of AV block?

Third degree In third degree heart block, two impulses stimulate the heart, one impulse stimulates the ventricles and other stimulates the atria. In first degree heart block, all the atrial impulses are conducted through the AV node into the ventricles at a rate slower than normal. In second degree AV block, type I, all but one of the atrial impulses are conducted through the AV node into the ventricles. In second degree AV block, type II, only some of the atrial impulses are conducted through the AV node into the ventricles.

The nurse knows which heart rhythm occurs when the atrial and ventricular rhythms are both regular, but independent of each other?

Third-degree atrioventricular (AV) heart block In third-degree AV heart block there is no relationship or synchrony between the atrial and ventricular contraction. Each is beating at its own inherent rate and is independent of each other, thus the cardiac output is affected. Second-degree AV block occurs when only some of the atrial impulses are conducted through the AV node into the ventricles. First-degree AV block occurs when atrial conduction is delayed through the AV node, resulting in a prolonged PR interval. During asystole, there is no electrical activity.

Which electrocardiogram (ECG) characteristic is usually seen when a client's serum potassium level is low?

U wave 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 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 P wave is an ECG characteristic reflecting conduction of an electrical impulse through the atria. The QT interval is an ECG characteristic reflecting the time from ventricular depolarization to repolarization.

A client tells the nurse "my heart is skipping beats again; I'm having palpitations." After completing a physical assessment, the nurse concludes the client is experiencing occasional premature atrial complexes (PACs). The nurse should instruct the client to

avoid caffeinated beverages If premature atrial complexes (PACs) are infrequent, no medical interventions are necessary. Causes of PACs include caffeine, alcohol, nicotine, stretched atrial myocardium (e.g., as in hypervolemia), anxiety, hypokalemia (low potassium level), hypermetabolic states (e.g., with pregnancy), or atrial ischemia, injury, or infarction. The nurse should instruct the client to avoid caffeinated beverages.

Which is not a likely origination point for cardiac dysrhythmias?

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

When the appropriate electrocardiogram (ECG) complex follows the pacing spike, it is said to be

captured. Capture is a term used to denote that the appropriate electrocardiogram (ECG) complex followed by the pacing spike. Triggered response means that the pacemaker will respond when it senses intrinsic heart activity. Inhibited response means that the response of the pacemaker is controlled by the activity of the client's heart.

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?

0.12 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 nurse has provided discharge instructions to a client who received an implantable cardioverter defibrillator (ICD). Which statement, made by the client, indicates the need for further teaching?

"I need to take a cardiopulmonary resuscitation (CPR) class now that I have an ICD." The client does not need to take a CPR class. However, it is recommended that the family members and friends of a client who has an ICD learn CPR. The other statements indicate that the nurse's teaching was effective.

The nurse is caring for a client who is being discharged after insertion of a permanent pacemaker. The client, an avid tennis player, is scheduled to play in a tournament in 1 week. What is the best advice the nurse can give related to this activity?

"You will need to cancel this activity; you must restrict arm movement above your head for 2 weeks." It is important to restrict movement of the arm until the incision heals. The client should not raise the arm above the head for 2 weeks afterward to avoid dislodging the leads. The client must avoid contact sports (eg, basketball, football, hockey).

The nurse knows that electrocardiogram (ECG) characteristics of atrial fibrillation include what?

Atrial rate of 300 to 400 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 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?

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.

The nurse identifies which of the following as a potential cause of premature ventricular complexes (PVCs)?

Hypokalemia PVCs can be caused by cardiac ischemia or infarction, increased workload on the heart (eg, exercise, fever, hypervolemia, heart failure, tachycardia), digitalis toxicity, acidosis, or electrolyte imbalances, especially hypokalemia.

The nurse cares for a client who has developed junctional tachycardia with a heart rate (HR) of 80 bpm. Which action should the nurse complete?

Request a digoxin level be ordered The nurse should request a digoxin level be obtained. Junctional tachycardia generally does not have any detrimental hemodynamic effect; it may indicate a serious underlying condition, such as digitalis toxicity, myocardial ischemia, hypokalemia, or chronic obstructive pulmonary disease (COPD). Potassium supplements do not cause junctional tachycardia. Lidocaine is indicated for the treatment of premature ventricular contractions (PVCs). Because junctional tachycardia is caused by increased automaticity, cardioversion is not an effective treatment; in fact, it causes an increase in ventricular rate.

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?

Right side of sternum, fourth intercostal space 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.

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 rhythm. 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.

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.

1. P wave 2. P-R interval 3. T wave 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 assigned the following client assignment on the clinical unit. For which client does the nurse anticipate cardioversion as a possible medical treatment?

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.

The nurse is caring for a client who has premature ventricular contractions. What sign or symptom is observed in this client?

Fluttering 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.

The nurse recognizes that Premature ventricular contractions (PVCs) are considered precursors of ventricular tachycardia (VT) when they:

occur at a rate of more than six per minute When PVCs occur at a rate of more than six per minute, they indicate increasing ventricular irritability and are considered forerunners of VT. PVCs are dangerous when they occur on the T wave. PVCs are dangerous when they are multifocal (have different shapes). A PVC that is paired with a normal beat is termed bigeminy.

The nurse receives a telephone call from a client with an implanted pacemaker who reports a pulse of 68 beats per minute, but the pacemaker rate is set at 72 beats per minute. What is the nurse's best response?

"Please come to the clinic right away so that we may interrogate the pacemaker to see if it is malfunctioning." A client experiencing pacemaker malfunctioning may develop bradycardia as well as signs and symptoms of decreased cardiac output. The client should check the pulse daily and report immediately any sudden slowing or increasing of the pulse rate. This may indicate pacemaker malfunction. The client needs to be evaluated so do not worry or saying it is ok are not correct to avoid cardiac output problems. Walking will not keep the heart rate at a safe level.

A client's Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minute. What other conditions can cause this response in a healthy heart?

All options are correct There are a variety of causes that can create an elevated heart rate in an otherwise healthy heart, including fever, shock, and strenuous exercise.

Which of the following medication classifications is more likely to be expected when the nurse is caring for a client with atrial fibrillation?

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.

Which postimplantation instruction must a nurse provide to a client with a permanent pacemaker?

Avoid sources of electrical interference The nurse must instruct the client with a permanent pacemaker to avoid sources of electrical interference. The nurse should also instruct the client to avoid strenuous movement (especially of the arm on the side where the pacemaker is inserted), to keep the arm on the side of the pacemaker lower than the head except for brief moments when dressing or performing hygiene, and to delay for at least 8 weeks activities such as swimming, bowling, tennis, vacuum cleaning, carrying heavy objects, chopping wood, mowing, raking, and shoveling snow.

The nurse and student nurse are observing a cardioversion procedure completed by a physician. At which time is the nurse most correct to identify to the student when the electrical current will be initiated?

During ventricular depolarization The electrical current is initiated at the R wave when ventricular depolarization occurs. The electrical current completely depolarizes the entire myocardium with the goal of restoring the normal pacemaker of the heart. The other options focus on an incorrect timing that will not restore the normal electrical conduction.

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?

Elective electrical cardioversion 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.

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?

Premature atrial complex 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 observes an electrocardiogram (ECG) tracing on a cardiac monitor with a pattern in lead II as well as a bizarre, abnormal shape to the QRS complex. The nurse has likely observed which ventricular dysrhythmia?

Premature ventricular contraction A premature ventricular contraction (PVC) is an impulse that starts in a ventricle before the next normal sinus impulse. Ventricular bigeminy is a rhythm in which every other complex is a PVC. Ventricular tachycardia is defined as three or more PVCs in a row, occurring at a rate exceeding 100 beats per minute. Ventricular fibrillation is a rapid but disorganized ventricular rhythm that causes ineffective quivering of the ventricles.

The staff educator is presenting a class on cardiac dysrhythmias. How would the educator describe the characteristic pattern of the atrial waves in atrial flutter?

Sawtooth Sawtooth is the characteristic pattern of the atrial waves in atrial flutter.

A 1-minute electrocardiogram (ECG) tracing of a client with a regular heart rate reveals 25 small, square boxes within an RR interval. The nurse correctly identifies the client heart rate as

60 bpm. A client's HR can be obtained from the electrocardiogram (ECG) tracing by several methods. A 1-minute strip contains 300 large boxes and 1500 small boxes. Therefore, an easy and accurate method of determining heart rate with a regular rhythm is to count the number of small boxes within an RR interval and divide by 1,500. In this instance, 1,500/25 = 60.

The nurse is caring for clients on a telemetry unit. Which nursing consideration best represents concerns of altered rhythmic patterns of the heart?

Altered patterns frequently affect the heart's ability to pump blood effectively. The best representation of a nursing concern related to a cardiac arrhythmia is the inability of the heart to fill the chambers and eject blow flow efficiently. Lack of an efficient method to circulate blood and bodily fluids produces a variety of complications such as tissue ischemia, pulmonary edema, hypotension, decreased urine output, and impaired level of consciousness. The other options can occur with dysrhythmias, but the cause stemming from the altered pattern is the best answer.

The nurse understands that asystole can be caused by several conditions. Select all that apply.

1. Hypoxia 2. Hypovolemia 3. Hypothermia 4. Acidosis Ventricular asystole is treated the same as pulseless electrical activity (PEA), focusing on high-quality cardiopulmonary resuscitation (CPR) with minimal interruptions and identifying underlying and contributing factors. The key to successful treatment is a rapid assessment to identify a possible cause, which is known as the "Hs and Ts": hypoxia, hypovolemia, hydrogen ion (acid/base imbalance), hypo- or hyperglycemia, hypo- or hyperkalemia, hyperthermia, trauma, toxins, tamponade (cardiac), tension pneumothorax, or thrombus (coronary or pulmonary).

The nurse participates in the care of a client requiring emergent defibrillation. The nurse determines the steps should be completed in which order?

1. Turn on the defibrillator and place it in "not sync" mode. 2. Charge the defibrillator to the prescribed voltage. 3. Apply the multifunction conductor pads to the client's chest. 4. Call "clear" three times ensuring client and environmental safety. 5. Deliver the prescribed electrical charge. This is the sequence of events the nurse should implement when delivering emergent defibrillation. If not followed correctly, the client and health care team may be placed in danger.

A nurse evaluates a client with a temporary pacemaker. The client's ECG tracing shows each P wave followed by the pacing spike. What is the nurse's best response?

Document the findings and continue to monitor the client Capture is a term used to denote that the appropriate complex is followed by the pacing spike. In this instance, the patient's temporary pacemaker is functioning appropriately; all Ps wave followed by an atrial pacing spike. The nurse should document the findings and continue to monitor the client. Repositioning the client, placing the client on the left side, checking the security of all connections, and increasing the milliamperage are nursing interventions used when the pacemaker has a loss of capture. Obtaining a 12-lead ECG and chest x-ray are indicated when there is a loss of pacing-total absence of pacing spikes or when there is a change in pacing QRS shape.

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?

"It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node." 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.

A client is unconscious on arrival to the emergency department. The nurse in the emergency department identifies that the client has a permanent pacemaker due to which characteristic?

"Spike" on the rhythm strip Confirmation that the client has a permanent pacemaker is the characteristic "spike" identified by a thin, straight stroke on the rhythm strip. The scar on the chest is suggestive of pacer implantation but not definitive. There should be no change in pulse quality, and no vibration under the skin.

Failure to capture A client receives a pacemaker to treat a recurring arrhythmia. When monitoring the cardiac rhythm strip, the nurse observes extra pacemaker spikes that don't precede a beat. Which condition should the nurse suspect?

Failure to capture Extra pacemaker spikes that don't precede a beat may indicate failure to capture, in which the pacemaker fires but the heart doesn't conduct the beat. In failure to pace, the pacemaker doesn't fire when it should; this causes hypotension and other signs of low cardiac output accompanied by bradycardia or a heart rate slower than the pacemaker's preset rate. In failure to sense, the pacemaker can't sense the client's intrinsic heartbeat; on the rhythm strip, spikes may fall on T waves, or they may fall regularly but at points at which they shouldn't appear. An absent heart rate or rhythm, reflected as a flat line on the rhythm strip, characterizes asystole.

A client presents to the emergency department via ambulance with a heart rate of 210 beats/minute and a sawtooth waveform pattern per cardiac monitor. The nurse is most correct to alert the medical team of the presence of a client with which disorder?

Atrial flutter Atrial flutter is a disorder in which a single atrial impulse outside the SA node causes the atria to contract at an exceedingly rapid rate. The atrioventricular (AV) node conducts only some impulses to the ventricle, resulting in a ventricular rate slower than the atrial rate, thus forming a sawtooth pattern on the heart monitor. Asystole is the absence of cardiac function and can indicate death. Premature ventricular contraction indicates an early electric impulse and does not necessarily produce an exceedingly rapid heart rate. Ventricular fibrillation is the inefficient quivering of the ventricles and indicative of a dying heart.

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 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

A client's electrocardiogram (ECG) tracing reveals a ventricular rate between 250 and 400, with saw-toothed P waves. The nurse correctly identifies this dysrhythmia as

Atrial flutter 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.

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?

Decreased cardiac output and decreased systolic and diastolic blood pressure 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 observing the monitor of a patient with a first-degree atrioventricular (AV) block. What is the nurse aware characterizes this block?

Delayed conduction, producing a prolonged PR interval First-degree AV block occurs when all the atrial impulses are conducted through the AV node into the ventricles at a rate slower than normal. Thus the PR interval is prolonged (>0.20 seconds).

Elective cardioversion is similar to defibrillation except that the electrical stimulation waits to discharge until an R wave appears. What does this prevent?

Disrupting the heart during the critical period of ventricular repolarization It is similar to defibrillation. One difference is that the machine that delivers the electrical stimulation waits to discharge until it senses the appearance of an R wave. By doing so, the machine prevents disrupting the heart during the critical period of ventricular repolarization. Therefore, the other options are incorrect.

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?

Question the client about alcohol and illicit drug use. 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.

The licensed practical nurse is co-assigned with a registered nurse in the care of a client admitted to the cardiac unit with chest pain. The licensed practical nurse is assessing the accuracy of the cardiac monitor, which notes a heart rate of 34 beats/minute. The client appears anxious and states not feeling well. The licensed practical nurse confirms the monitor reading. When consulting with the registered nurse, which of the following is anticipated?

The registered nurse administering atropine sulfate intravenously The licensed practical nurse and registered nurse both identify that client's bradycardia. Atropine sulfate, a cholinergic blocking agent, is given intravenously (IV) to increase a dangerously slow heart rate. Lanoxin is not administered when the pulse rate falls under 60 beats/minute. It is dangerous to wait until the pulse rate increases without nursing intervention or administering additional medications until the imminent concern is addressed.