Dysrhythmias

11. The nurse knows that discharge teaching about the management of a new permanent pacemaker has been most effective when the patient states "It will be several weeks before I can return to my usual activities." "I will avoid cooking with a microwave oven or being near one in use." "I will notify the airlines when I make a reservation that I have a pacemaker." "I won't lift the arm on the pacemaker side until I see the health care provider."

"I won't lift the arm on the pacemaker side until I see the health care provider."

3. A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of _____ beats/min. 15 to 20 20 to 40 40 to 60 60 to 100

40 to 60

22. The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first? A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due

A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due

14. A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Mid-sternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave

ANS: A Chest pain, possibly angina, indicates that tachycardia may be increasing the clients myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and should be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death.

13. A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge? a. Medication reconciliation b. Immunization history c. Religious beliefs d. Nutrition preferences

ANS: A The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a plan of care for the client.

17. A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure? a. Clean the skin and clip hairs if needed. b. Add gel to the electrodes prior to applying them. c. Place the electrodes on the posterior chest. d. Turn off oxygen prior to monitoring the client.

ANS: A To ensure the best signal transmission, the skin should be clean and hairs clipped. Electrodes should be placed on the anterior chest, and no additional gel is needed. Oxygen has no impact on electrocardiographic monitoring.

3. A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this clients teaching? (Select all that apply.) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium

ANS: A, B, D A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances.

2. A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this clients teaching? (Select all that apply.) a. Until your incision is healed, do not submerge your pacemaker. Only take showers. b. Report any pulse rates lower than your pacemaker settings. c. If you feel weak, apply pressure over your generator. d. Have your pacemaker turned off before having magnetic resonance imaging (MRI). e. Do not lift your left arm above the level of your shoulder for 8 weeks.

ANS: A, B, E The client should not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client should be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client should never apply pressure over the generator and should avoid tight clothing. The client should never have MRI because, whether turned on or off, the pacemaker contains metal. The client should be advised to inform all health care providers that he or she has a pacemaker.

1. A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output f. Increase in urine output

ANS: A, D, E Elevated heart rates in a healthy client initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall.

3. A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily b. A 50-year-old who is post coronary artery bypass graft surgery c. A 78-year-old who had a carotid endarterectomy d. An 80-year-old with chronic obstructive pulmonary disease

ANS: B Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these clients at higher risk for atrial fibrillation.

2. A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate? a. Make certain that your bath water is warm. b. Avoid straining while having a bowel movement. c. Limit your intake of caffeinated drinks to one a day. d. Avoid strenuous exercise such as running.

ANS: B Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition.

4. A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity

ANS: B Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.

12. Which intervention by a new nurse who is caring for a patient who has just had an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more teaching about the care of patients with ICDs? The nurse administers amiodarone (Cordarone) to the patient. The nurse helps the patient fill out the application for obtaining a Medic Alert device. The nurse encourages the patient to do active range of motion exercises for all extremities. The nurse teaches the patient that sexual activity can be resumed when the incision is healed.

The nurse encourages the patient to do active range of motion exercises for all extremities.

8. A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the clients electrocardiogram. Which action should the nurse take next? a. Administer intravenous diltiazem (Cardizem). b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.

ANS: B In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and contraction. The nurse should assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture.

10. After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. I should wear a snug-fitting shirt over the ICD. b. I will avoid sources of strong electromagnetic fields. c. I should participate in a strenuous exercise program. d. Now I can discontinue my antidysrhythmic medication.

ANS: B The client being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields. Clients should avoid tight clothing, which could cause irritation over the ICD generator. The client should be encouraged to exercise but should not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. The client should continue all prescribed medications.

7. A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability

ANS: C A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, light- headedness, confusion, syncope, and seizure activity. Although the other assessments should be completed, the clients level of consciousness is the priority.

6. A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response? a. Decreased intraocular pressure b. Increased heart rate c. Short period of asystole d. Hypertensive crisis

ANS: C Clients usually respond to adenosine with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain. Adenosine has no conclusive impact on intraocular pressure.

11. A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this clients concerns? a. Administer oxygen therapy at 2 liters per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask unlicensed assistive personnel to help bathe the client.

ANS: C Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with self-care activities.

16. The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, Why do you want to know if I use cocaine? How should the nurse respond? a. Substance abuse puts clients at risk for many health issues. b. The hospital requires that I ask you about cocaine use. c. Clients who use cocaine are at risk for fatal dysrhythmias. d. We can provide services for cessation of substance abuse.

ANS: C Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias. The other responses do not adequately address the clients question.

1. A nurse assesses a clients electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The clients chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.

ANS: D Normal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization. This finding on an electrocardiograph tracing is not an indication of hyperkalemia, ventricular tachycardia, or disconnection of leads.

9. A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a. Make sure the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 joules. d. Ensure that everyone is clear of contact with the client and the bed.

ANS: D To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation.

20. A patient develops sinus bradycardia at a rate of 32 beats/min, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which action should the nurse take next? Recheck the heart rhythm and BP in 5 minutes. Have the patient perform the Valsalva maneuver. Give the scheduled dose of diltiazem (Cardizem). Apply the transcutaneous pacemaker (TCP) pads.

Apply the transcutaneous pacemaker (TCP) pads.

19. A patient's heart monitor shows sinus rhythm, rate 64. The PR interval is 0.18 seconds at 1:00 AM, 0.22 seconds at 2:30 PM, and 0.28 seconds at 4:00 PM. Which action should the nurse take next? Place the transcutaneous pacemaker pads on the patient. Give atropine sulfate 1 mg IV per agency dysrhythmia protocol. Call the health care provider before giving scheduled metoprolol (Lopressor). Document the patient's rhythm and assess the patient's response to the rhythm.

Call the health care provider before giving scheduled metoprolol (Lopressor).

13. Which action should the nurse perform when preparing a patient with supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm Hg? Turn the synchronizer switch to the "off" position. Give a sedative before cardioversion is implemented. Set the defibrillator/cardioverter energy to 360 joules. Provide assisted ventilations with a bag-valve-mask device.

Give a sedative before cardioversion is implemented.

23. A patient who is on the telemetry unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first? Obtain a 12-lead electrocardiogram (ECG). Notify the health care provider of the change in rhythm. Give supplemental O2 at 2 to 3 L/min via nasal cannula. Assess the patient's vital signs including O2 saturation.

Give supplemental O2 at 2 to 3 L/min via nasal cannula.

8. After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the drug has been effective? Increase in the patient's heart rate Increase in strength of peripheral pulses Decrease in premature atrial contractions Decrease in premature ventricular contractions

Increase in the patient's heart rate

1. To determine whether there is a delay in impulse conduction through the ventricles, the nurse will measure the duration of the patient's P wave. Q wave. PR interval. QRS complex.

PR interval.

9. A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. Teaching for this patient would include information about anticoagulant therapy. permanent pacemakers. emergency cardioversion. IV adenosine (Adenocard).

anticoagulant therapy.

16. A patient has ST segment changes that suggest an acute inferior wall myocardial infarction. Which lead would be best for monitoring the patient? a. I b. II c. V2 d. V6

b. II

5. A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this clients medication administration record to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Sal-Tropine) d. Lidocaine (Xylocaine)

ANS: B Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication.

21. The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, which action should the nurse take next? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d. Ask the clients family about code status.

ANS: B The clients rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The clients code status should already be known by the nurse prior to this event.

20. A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The clients blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 liters per nasal cannula. The nurse assesses the clients rhythm on the cardiac monitor and observes the reading shown below: Which action should the nurse take first? a. Begin external temporary pacing .b. Assess peripheral pulse strength. c. Ask the client what medications he or she takes. d. Administer 1 mg of atropine.

ANS: CThis client is stable and therefore does not require any intervention except to determine the cause of the bradycardia. Bradycardia is often caused by medications. Clients who have multiple chronic diseases are often on multiple medications that can interact with each other. The nurse should assess the clients current medications first.

21. A 19-yr-old student comes to the student health center at the end of the semester complaining that, "My heart is skipping beats." An electrocardiogram (ECG) shows occasional unifocal premature ventricular contractions (PVCs). What action should the nurse take next? Insert an IV catheter for emergency use. Start supplemental O2 at 2 to 3 L/min via nasal cannula. Ask the patient about current stress level and caffeine use. Have the patient taken to the nearest emergency department (ED).

Ask the patient about current stress level and caffeine use.

27. Which action by a new registered nurse (RN) who is orienting to the telemetry unit indicates a good understanding of the treatment of heart dysrhythmias? Prepares defibrillator settings at 360 joules for a patient whose monitor shows asystole. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia Turns the synchronizer switch to the "on" position before defibrillating a patient with ventricular fibrillation Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second degree AV block

Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia

26. Which nursing action can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) working as telemetry technicians on the cardiac care unit? Decide whether a patient's heart rate of 116 requires urgent treatment. Observe heart rhythms for multiple patients who have telemetry monitoring. Monitor a patient's level of consciousness during synchronized cardioversion. Select the best lead for monitoring a patient admitted with acute coronary syndrome.

Observe heart rhythms for multiple patients who have telemetry monitoring.

18. A patient's heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious, apneic, and pulseless. Which action should the nurse take first? Give epinephrine (Adrenalin) IV. Perform immediate defibrillation. Prepare for endotracheal intubation. Ventilate with a bag-valve-mask device.

Perform immediate defibrillation.

7. A patient who was admitted with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/min. Which action should the nurse take next? Immediately notify the health care provider. Document the rhythm and continue to monitor the patient. Prepare to give IV amiodarone per agency dysrhythmia protocol. Perform synchronized cardioversion per agency dysrhythmia protocol.

Prepare to give IV amiodarone per agency dysrhythmia protocol.

15. When analyzing the rhythm of a patient's electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n) isoelectric ST segment. PR interval of 0.18 second. QT interval of 0.38 second. QRS interval of 0.14 second.

QRS interval of 0.14 second.

17. Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider? Blood glucose of 243 mg/dL Serum chloride of 92 mEq/L Serum sodium of 134 mEq/L Serum potassium of 2.9 mEq/L

Serum potassium of 2.9 mEq/L

24. A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic, and has no palpable pulses. What action should the nurse take next? Perform synchronized cardioversion. Start cardiopulmonary resuscitation (CPR). Give atropine per agency dysrhythmia protocol. Provide supplemental O2 via non-rebreather mask.

Start cardiopulmonary resuscitation (CPR).

10. Which information will the nurse include when teaching a patient who is scheduled for a radiofrequency catheter ablation for treatment of atrial flutter? The procedure prevents or minimizes the risk for sudden cardiac death. The procedure uses cold therapy to stop the formation of the flutter waves. The procedure uses electrical energy to destroy areas of the conduction system. The procedure stimulates the growth of new conduction pathways between the atria.

The procedure uses electrical energy to destroy areas of the conduction system.

2. The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use? Count the number of large squares in the R-R interval and divide by 300. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10. Calculate the number of small squares between one QRS complex and the next and divide into 1500.

Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.

5. The nurse notes that a patient's heart monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm? Ventricular couplets Ventricular bigeminy Ventricular R-on-T phenomenon Multifocal premature ventricular contractions

Ventricular bigeminy

6. A patient has a sinus rhythm and a heart rate of 72 beats/min. The nurse determines that the PR interval is 0.24 seconds. The most appropriate intervention by the nurse would be to notify the health care provider immediately. document the finding and monitor the patient. give atropine per agency dysrhythmia protocol. prepare the patient for temporary pacemaker insertion.

document the finding and monitor the patient.

15. A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this clients teaching? a. Minimize or abstain from caffeine. b. Lie on your side until the attack subsides. c. Use your oxygen when you experience PACs. d. Take amiodarone (Cordarone) daily to prevent PACs.

ANS: A PACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs, the nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the client first should try lifestyle changes to control them.

12. A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure a tongue blade is available. d. Position the client on the left side.

ANS: B For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client should be placed in a supine position.

14. A 20-yr-old patient has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. Blood pressure (BP) is 114/54 mm Hg, and the student denies any health problems. What action by the nurse is most appropriate? Allow the student to participate on the soccer team. Refer the student to a cardiologist for further testing. Tell the student to stop playing immediately if any dyspnea occurs. Obtain more detailed information about the student's family health history.

Allow the student to participate on the soccer team.

25. Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin? Explain the association between dysrhythmias and syncope. Instruct the patient to call for assistance before getting out of bed. Teach the patient about the need to avoid caffeine and other stimulants. Tell the patient about the benefits of implantable cardioverter-defibrillators.

Instruct the patient to call for assistance before getting out of bed.

28. A patient reports dizziness and shortness of breath for several days. During heart monitoring in the emergency department (ED), the nurse obtains the following electrocardiographic (ECG) tracing. The nurse interprets this heart rhythm as a. junctional escape rhythm. accelerated idioventricular rhythm. third-degree atrioventricular (AV) block. sinus rhythm with premature atrial contractions (PACs).

third-degree atrioventricular (AV) block.

4. The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, and QRS complex wide and distorted, and QRS duration of 0.18 second. The nurse interprets the patient's cardiac rhythm as atrial flutter. sinus tachycardia. ventricular fibrillation. ventricular tachycardia.

ventricular tachycardia.