1) Chapter 26: Management of Patients With Dysrhythmias and Conduction Problems

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) A client with atrial dysrhythmias b) A client with poor kidney perfusion c) A new myocardial infarction client d) A client with third-degree heart block

a) 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.

A patient has had an implantable cardioverter defibrillator inserted. What should the nurse be sure to include in the education of this patient prior to discharge? (Select all that apply.) a) Call for emergency assistance if feeling dizzy. b) The patient may have a throbbing pain that is normal c) The patient will have to schedule monthly chest x-rays to make sure the device is patent. d) Avoid magnetic fields such as metal detection booths. e) Record events that trigger a shock sensation.

a) Call for emergency assistance if feeling dizzy. d) Avoid magnetic fields such as metal detection booths. e) Record events that trigger a shock sensation. The nurse should instruct the patient to avoid large magnetic fields such as those created by magnetic resonance imaging, large motors, arc welding, electrical substations, and so forth. Magnetic fields may deactivate the device, negating its effect on a dysrhythmia. The patient should call 911 for emergency assistance if a feeling of dizziness occurs. The patient should maintain a log that records discharges of an implantable cardioverter defibrillator (ICD). Record events that precipitate the sensation of shock. This provides important data for the physician to use in readjusting the medical regimen. Throbbing pain is not normal and should be reported immediately. An initial x-ray is indicated prior to discharge, but monthly x-rays are unnecessary.

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? a) Lead wire dislodgement b) Faulty generator c) Sensitivity is too low d) Fracture of the lead wire

a) 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.

The nurse expects to see which of the following characteristics on an ECG strip for a patient who has third-degree AV block? a) More P waves than QRS complexes b) Atrial rate of 60 bpm or below c) Extended PR interval d) Shortened QRS duration.

a) 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.

A 26-year-old male patient, who has been diagnosed with paroxysmal supraventricular tachycardia (PSVT), is being treated in the emergency department. The patient is experiencing occasional runs of PSVT lasting up to several minutes at a time. During these episodes, the patient becomes lightheaded but does not lose consciousness. Which of the following maneuvers may be used to interrupt the patient's atrioventricular nodal reentry tachycardia (AVNRT)? Select all that apply. a) Stimulating the patient's gag reflex b) Performing carotid massage c) Instructing the patient to breathe deeply d) Placing the patient's face in cold water e) Instructing the patient to vigorously exercise

a) Stimulating the patient's gag reflex b) Performing carotid massage c) Instructing the patient to breathe deeply The following vagal maneuvers can be used to interrupt AVNRT: stimulating the patient's gag reflex, having the patient hold his breath, cough, bear down, placing his face in cold water, or performing carotid massage. These measures elicit a vagal response which will slow AV conduction time and help restore a regular rhythm. Because of the risk of a cerebral embolic event, carotid massage is contraindicated in patients with carotid bruits. If the vagal maneuvers are ineffective, the patient may receive a bolus of adenosine to correct the rhythm; this is nearly 100% effective in terminating AVNRT. Overexertion and deep inspirations are measures that could precipitate SVT.

Which of the following medications does the nurse anticipate administering to a client preparing for cardioversion? a) Valium b) Vasotec c) Atropine d) Lanoxin

a) Valium Prior to cardioversion, cardiac medications are held, and the client is sedated with a medication such as Valium.

The nurse is proving discharge instruction for a patient with a new arrhythmia. Which of the following should the nurse include? a) Your family and friends may want to take a CPR class. b) If you miss a dose of your antiarrhythmia medication, double up on the next dose. c) It is not necessary to learn how to take your own pulse. d) Do not be concerned if you experience symptoms of lightheadedness and dizziness.

a) Your family and friends may want to take a CPR class. Having friends and family learn to take a pulse and perform CPR will help patients to manage their condition. Antiarrhythmic medication should be taken on time. Lightheadedness and dizziness are symptoms which should be reported to the provider.

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 can still drink coffee and tea." c) "I should eat foods rich in protein." d) "I'll enroll in an aerobic exercise program."

b) "I can still drink coffee and tea." 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.

The nurse is caring for a client with a diagnosis of atrial fibrillation. The onset was approximately 2 to 3 days ago. The client is scheduled for a transesophageal echocardiogram this morning. The client's spouse asks what this test is for. The best response by the nurse is which of the following? a) "This test will show the specific area causing the atrial fibrillation and what can be done to stop it." b) "This test will show any blood clots in the heart and if it is safe to do a cardioversion." c) "This test will let the doctor know if the client is at risk for hypotension." d) "This test will show if the client needs a cardiac catheterzation."

b) "This test will show any blood clots in the heart and if it is safe to do a cardioversion." When contemplating cardioversion for the client with atrial fibrillation, the absence of a thrombus in the atria can be confirmed by transesophageal echocardiogram.

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? a) "Cancel your tennis tournament and wait until fall, then try hockey; skating is much easier on pacemakers." b) "You will need to cancel this activity; you must restrict arm movement above your head for 2 weeks." c) "You should avoid tennis; basketball or football would be a good substitute." d) "You may resume all normal activity in 1 week; if you are used to playing tennis, you may proceed with this activity."

b) "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).

You are overseeing a 62-year-old who has started to exhibit dangerous PVCs in the cardiac postoperative unit. He's been given a bolus of lidocaine and is under continuous IV infusion, but serious side effects, including hypotension during administration, could occur. What should you be ready to do? a) Prepare for defibrillation. b) Adjust the IV infusion. c) Administer additional lidocaine. d) Call for the doctor and just wait.

b) Adjust the IV infusion. Call for the physician while adjusting the IV infusion to the slowest possible rate until the physician can examine the patient. Call for the physician while adjusting the IV infusion to the slowest possible rate until the physician can examine the patient. Do not do anything else. Call for the physician while adjusting the IV infusion to the slowest possible rate until the physician can examine the patient. Stay focused on the IV. Call for the physician and while waiting, adjust the IV infusion to the slowest possible rate until the physician can examine the patient.

The nurse is analyzing the electrocardiogram (ECG) strip of a stable patient admitted to the telemetry unit. The patient's ECG strip demonstrates PR intervals that measure 0.24 seconds. Which of the following is the nurse's most appropriate action? a) Instruct the patient to bear down as if having a bowel movement. b) Document the findings and continue to monitor the patient. c) Notify the patient's primary care provider of the findings. d) Apply oxygen via nasal cannula and obtain a 12-lead ECG.

b) Document the findings and continue to monitor the patient. The patient's ECG tracing indicates a first-degree atrioventricular (AV) block. First-degree AV block rarely causes any hemodynamic effect; the other blocks may result in decreased heart rate, causing a decrease in perfusion to vital organs, such as the brain, heart, kidneys, lungs, and skin. The most appropriate action by the nurse is to document the findings and continue to monitor the patient.

Jack Johnson is a 58-year-old who's been living with an internal, fixed-rate pacemaker. You're checking his readings on a cardiac monitor and notice an absence of spikes. What should you do? a) Suggest the need for a new beta-blocker to the doctor. b) Double-check the monitoring equipment. c) Nothing, there's no cause for alarm. d) Take Jack's blood pressure.

b) Double-check the monitoring equipment. One of the reasons for lack of pacemaker spikes is faulty monitoring equipment. It's important to be careful. One of the reasons for lack of pacemaker spikes is faulty monitoring equipment. Focus on the monitor. One of the reasons for lack of pacemaker spikes is faulty monitoring equipment. Check the monitor. One of the reasons for lack of pacemaker spikes is faulty monitoring equipment.

The nurse is preparing a patient for upcoming electrophysiology (EP) studies and possible ablation for treatment of atrial tachycardia. Which of the following information should the nurse include? a) The procedure takes less time than a cardiac catheterization. b) During the procedure, the arrhythmia will be reproduced under controlled conditions. c) After the procedure, the arrhythmia will not recur. d) The procedure will occur in the operating room under general anesthesia.

b) During the procedure, the arrhythmia will be reproduced under controlled conditions. During EP studies, the patient is awake and may experience symptoms related to the arrhythmia. EP studies do not always include ablation of the arrhythmia.

Undersensing occurs as a pacemaker malfunctions as a result of which of the following events? a) Total absence of the pacing spike b) Pacing spike occurs at the preset level despite the patient's intrinsic rhythm c) Loss of pacing artifact d) The complex does not follow the pacing spike

b) Pacing spike occurs at the preset level despite the patient's intrinsic rhythm 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.

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? a) The registered nurse stating to administer all medications accept those which are cardiotonics b) The registered nurse administering atropine sulfate intravenously c) The registered nurse stating to hold all medication until the pulse rate returns to 60 beats/minute d) The registered nurse stating to administer Lanoxin (digoxin)

b) 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.

The nurse is caring for a 32-year-old client admitted with a medical diagnosis of atrial fibrillation, related to "holiday heart" syndrome. A nursing student working with the nurse asks for information about "holiday heart" syndrome. The best response by the nurse is which of the following? a) "This is the association of heart dysrhythmias, especially atrial fibrillation, with extramarital sex." b) "This is the association of heart dysrhythmias, especially atrial fibrillation, with very heavy meals." c) "This is the association of heart dysrhythmias, especially atrial fibrillation, with binge drinking." d) "This is the association of heart dysrhythmias, especially atrial fibrillation, with physical activity. the client is not used to"

c) "This is the association of heart dysrhythmias, especially atrial fibrillation, with binge drinking." Atrial fibrillation may be found in people with acute moderate to heavy ingestion of alcohol.

The nurse is caring for a client who had a permanent pacemaker surgically placed yesterday and is now ready for discharge. Which statement made by the client indicates the need for more education. a) "I will call the doctor if my incision becomes swollen and red." b) "I will check my pulse every day and report to the doctor if the rate is below the pacemaker setting." c) "We will be getting rid of our microwave oven so it will not affect my pacemaker." d) "I will avoid any large magnets that may affect my pacemaker."

c) "We will be getting rid of our microwave oven so it will not affect my pacemaker." Permanent pacemaker generators have filters that protect them from electrical interference from most household devices, motors, and appliances.

A patient with mitral valve stenosis and coronary artery disease (CAD) is in the telemetry unit with pneumonia. The nurse assesses a 6-second rhythm strip and determines that the ventricular rhythm is highly irregular at 88, with no discernible P waves. What does the nurse determine this rhythm to be? a) Sinus tachycardia b) Ventricular flutter c) Atrial flutter d) Nonparoxysmal junctional tachycardia

c) 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. Ventricular rhythm may be irregular, and P waves may be absent. Ventricular rate usually ranges between 75 and 150 bpm.

After having several Stokes-Adams attacks within 4 months, a client reluctantly agrees to implantation of a permanent pacemaker. Before discharge, the nurse reviews pacemaker care and safety guidelines with the client and his spouse. Which safety precaution is appropriate for a client who has a pacemaker? a) Stay at least 2' away from microwave ovens. b) Never engage in activities that require vigorous arm and shoulder movement. c) Avoid undergoing magnetic resonance imaging (MRI). d) Avoid going through airport metal detectors.

c) Avoid undergoing magnetic resonance imaging (MRI). A client with a pacemaker should avoid undergoing an MRI because the magnet could disrupt pacemaker function and cause injury to the client. Disruption is less likely to occur with newer microwave ovens; nonetheless, the client should stay at least 5' away from microwaves, not 2'. The client must avoid vigorous arm and shoulder movement only for the first 6 weeks after pacemaker implantation. Airport metal detectors don't harm pacemakers; however, the client should notify airport security guards that he has a pacemaker because its metal casing and programming magnet could trigger the metal detector.

After evaluating a client for hypertension, a physician orders atenolol (Tenormin), 50 mg P.O. daily. Which therapeutic effect should atenolol have? a) Increased cardiac output and increased systolic and diastolic blood pressure b) Decreased blood pressure with reflex tachycardia c) Decreased cardiac output and decreased systolic and diastolic blood pressure d) Decreased peripheral vascular resistance

c) 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.

Your client has been diagnosed with an atrial dysrhythmia. The client has come to the clinic for a follow-up appointment and to talk with the physician about options to stop this dysrhythmia. What would be a procedure used to treat this client? a) Elective electrical defibrillation b) Chemical cardioversion c) Elective electrical cardioversion d) Mace procedure

c) 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.

Which of the following is the treatment of choice for ventricular fibrillation? a) Implanted defibrillator b) Pacemaker c) Immediate bystander CPR d) Atropine

c) Immediate bystander CPR The treatment of choice for v-fib is immediate bystander cardiopulmonary resuscitation (CPR), defibrillation as soon as possible, and activation of emergency services.

A nurse should obtain serum levels of which electrolytes in a client with frequent episodes of ventricular tachycardia? a) Potassium and calcium b) Potassium and sodium c) Magnesium and potassium d) Calcium and magnesium

c) Magnesium and potassium Hypomagnesemia as well as hypokalemia and hyperkalemia are common causes of ventricular tachycardia. Calcium imbalances cause changes in the QT interval and ST segment. Alterations in sodium level don't cause rhythm disturbances.

Which of the following nursing interventions must a nurse perform when administering prescribed vasopressors to a patient with a cardiac dysrhythmia? a) Administer every five minutes during cardiac resuscitation b) Document heart rate before and after administration c) Monitor vital signs and cardiac rhythm d) Keep the patient flat for one hour after administration

c) Monitor vital signs and cardiac rhythm The nurse should monitor the patient'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 patient. The side effects of vasopressor drugs are hypertension, dysrhythmias, pallor, and oliguria. It is not necessary to place a patient flat during or after vasopressor administration. When administering cholinergic antagonists, documentation of the heart rate is necessary.

When the nurse observes an electrocardiogram (ECG) tracing on a cardiac monitor with a pattern in lead II and observes a bizarre, abnormal shape to the QRS complex, the nurse has likely observed which of the following ventricular dysrhythmias? a) Ventricular tachycardia b) Ventricular bigeminy c) Premature ventricular contraction (PVC) d) Ventricular fibrillation

c) Premature ventricular contraction (PVC) A 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.

When no atrial impulse is conducted through the AV node into the ventricles, the patient is said to be experiencing which type of AV block? a) First degree b) Second degree, type II c) Third degree d) Second degree, type I

c) 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.

Idioventricular rhythm occurs when the impulse starts in the conduction system below the AV node. The nurse would expect which of the following atrial rates to correlate with an idioventricular rhythm? a) Not measurable b) 100 to 250 c) 220 to 350 d) 20 to 40

d) 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.

An 83-year-old resident in the long-term care facility where you practice nursing has an irregular heart rate of around 100 beats/minute. He also has a significant pulse deficit. What component of his history would produce such symptoms? a) Bundle branch block b) Heart block c) Atrial flutter d) Atrial fibrillation

d) 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 fibrillation generally causes disorganized activity, irregular heart rates, and pulse deficits.

A 73-year-old client has returned to the postanesthesia care unit where you practice nursing. The client had a pacemaker implanted and it is your responsibility to begin client education upon his becoming alert. Which of the following postimplantation instructions must you provide to the client now that he has a permanent pacemaker? a) Delay for at least 3 weeks activities such as swimming and bowling. b) Keep the arm on the side of the pacemaker higher than the head. c) Keep moving the arm on the side where the pacemaker is inserted. d) Avoid sources of electrical interference.

d) Avoid sources of electrical interference. The nurse must instruct the client with a permanent pacemaker to avoid sources of electrical interference, such as MRI devices, large industrial motors, peripheral nerve stimulators, etc. The main warning to a client with a pacemaker is to avoid sources of electrical interference.

A patient has had several episodes of recurrent tachydysrhythmias over the last 5 months and medication therapy has not been effective. What procedure should the nurse prepare the patient for? a) Insertion of an ICD b) Maze procedure c) Insertion of a permanent pacemaker d) Catheter ablation therapy

d) Catheter ablation therapy Catheter ablation destroys specific cells that are the cause or central conduction route of a tachydysrhythmia. It is performed with or after an electrophysiology study. Usual indications for ablation are atrioventricular nodal reentry tachycardia, a recurrent atrial dysrhythmia (especially atrial fibrillation), or ventricular tachycardia unresponsive to previous therapy (or for which the therapy produced significant side effects).

You are caring for a client who has premature ventricular contractions. What sign or symptom is observed in this client? a) Nausea b) Hypotension c) Fever d) Fluttering

d) 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.

Sam, a retired professional NFL player, visits his cardiologist for his annual physical. The nurse takes an ECG and notices an abnormal finding. However, the nurse realizes that this result can be normal when present without symptoms. This finding is a: a) PR interval of 0.18 seconds. b) P-to-QRS ratio of 1:1. c) QT interval of 0.37 seconds. d) Heart rate of 42 beats per minute (bpm).

d) Heart rate of 42 beats per minute (bpm). All answers refer to a normal sinus rhythm (NSR) except for the heart rate. A rate of 42 bpm is slow but normal when it occurs in athletes without symptoms.

The nurse is analyzing the electrocardiogram (ECG) tracing of a client newly admitted to the cardiac step-down unit with a diagnosis of chest pain. Which of the following findings indicate the need for follow-up? a) ST segment that is isoelectric in appearance b) PR interval that is 0.18 seconds long c) QRS complex that is 0.10 seconds long d) QT interval that is 0. 46 seconds long

d) 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 patient may be at risk for a lethal ventricular dysrhythmia called torsades de pointes. The other findings are normal.

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. The correct response would be which of the following? a) SA node, AV node, bundle of His, the Purkinje fibers, and the right and left bundle branches b) SA node, AV node, right and left bundle branches, bundle of His, and the Purkinje fibers c) AV node, SA node, bundle of His, right and left bundle branches, and the Purkinje fibers d) Sinoatrial (SA) node, atrioventricular (AV) node, bundle of His, right and left bundle branches, and the Purkinje fibers

d) 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.

Which heart rhythm occurs when the atrial and ventricular rhythms are both regular, but independent of each other? a) Second-degree heart block b) Asystole c) First-degree AV block d) Third-degree atrioventricular (AV) heart block

d) 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.