Chapter 26: Management of Patients With Dysrhythmias and Conduction Problems

Your client has just been diagnosed with a dysrhythmia. The client asks you to explain normal sinus rhythm. What would you explain are the characteristics of normal sinus rhythm?

a) Impulse travels to the atrioventricular (AV) node in 0.15 to 0.5 seconds.
b) Heart rate between 60 and 150 beats per minute.
c) The sinoatrial (SA) node initiates the impulse.
d) The ventricles depolarize in 0.5 seconds or less.

c) The sinoatrial (SA) node initiates the impulse.
Explanation:
The characteristics of normal sinus rhythm are heart rate between 60 and 100 beats per minute; the SA node initiates the impulse; the impulse travels to the AV node in 0.12 to 0.2 seconds; the ventricles depolarize in 0.12 seconds or less; and each impulse occurs regularly. pg.698
A 65-year-old client has come to the emergency department reporting light-headedness, chest pain, and shortness of breath. As you finish your assessment, the physician enters and orders tests to ascertain what is causing the client’s problems. In your client education, you explain the tests. Which test is used to identify cardiac rhythms?

a) Electroencephalogram
b) Electrocardiogram
c) Electrocautery
d) Echocardiogram

b) Electrocardiogram
Explanation:
An electrocardiogram is used to identify normal and abnormal cardiac rhythms. An electrocardiogram is the device used to identify normal and abnormal cardiac rhythms. pg.694
A home care nurse is visiting a left-handed client who has an implantable cardioverter-defibrillator (ICD) implanted in his left chest. The client tells the nurse how excited he is because he’s planning to go rifle hunting with his grandson. How should the nurse respond?

a) “You’ll need to take an extra dose of your antiarrhythmic before you shoot.”
b) “Being that close to a rifle might make your ICD fire.”
c) “Enjoy your time with your grandson.”
d) “You can’t shoot a rifle left-handed because the rifle’s recoil will traumatize the ICD site.”

d) “You can’t shoot a rifle left-handed because the rifle’s recoil will traumatize the ICD site.”
Explanation:
The recoil from the rifle can damage the ICD, so the client should be warned against shooting a rifle with his left hand. Close proximity to a rifle won’t cause the ICD to fire inadvertently. The client shouldn’t take an extra dose of his antiarrhythmic. pg.724
A 66-year-old female client is having cardiac diagnostic tests to determine the cause of her symptoms. In her follow-up visit to the cardiologist, she is told that she has a dysrhythmia at a rate slower than 60 beats/minute. What type of dysrhythmia did the tests reveal?

a) Heart block
b) Atrial bradycardia
c) Sinus bradycardia
d) None

c) Sinus bradycardia
Explanation:
Sinus bradycardia is a dysrhythmia that proceeds normally through the conduction pathway but at a slower than usual (≤60 beats/minute) rate. Sinus bradycardia is a slower than usual (≤60 beats/minute) heart rate. pg.698
The nurse is in the mall and observes a client slump to the floor. The nurse assesses the client and notes no pulse. The nurse calls for assistance to others in the mall and requests which piece of equipment?

a) A cell phone to call 911
b) A stethoscope
c) An automatic external defibrillator
d) A blood pressure cuff

c) An automatic external defibrillator
Explanation:
Most malls in the United States now have automatic external defibrillators in common areas. These defibrillators can easily be applied and obtain electrical confirmation of no ventricular contraction or R wave. The machine allows an electrical stimulation when the discharge button is depressed. A blood pressure cuff and stethoscope will not provide the equipment needed to save the client’s life. The 911 can be called by a bystander, but the priority is to obtain the life-saving equipment. If defibrillation is performed within the first 3 minutes of cardiac arrest, the potential for survival is 74%. pg.717
A patient with hypertension has a newly diagnosed atrial fibrillation. What medication does the nurse anticipate administering to prevent the complication of atrial thrombi?

a) Adenosine (Adenocard)
b) Atropine
c) Warfarin (Coumadin)
d) Amiodarone (Pacerone)

c) Warfarin (Coumadin)
Explanation:
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 (Cordarone), flecainide (Tambocor), ibutilide (Corvert), propafenone (Rythmol), or sotalol (Betapace) prior to cardioversion to enhance the success of cardioversion and prevent relapse of the atrial fibrillation (Fuster, Rydén et al., 2011). pg.704
The staff educator is teaching a class in dysrhythmias. What statement is correct for defibrillation?

a) It uses less electrical energy than cardioversion.
b) It is used to eliminate ventricular dysrhythmias.
c) The client is sedated before the procedure.
d) It is a scheduled procedure 1 to 10 days in advance.

b) It is used to eliminate ventricular dysrhythmias.
Explanation:
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. pg.715
Which medication is the drug of choice for sinus bradycardia?

a) Pronestyl
b) Cardizem
c) Lidocaine
d) Atropine

d) Atropine
Explanation:
Atropine is the medication of choice in treating symptomatic sinus bradycardia. Lidocaine treats ventricular dysrhythmias. Pronestyl treats and prevents atrial and ventricular dysrhythmias. Cardizem is a calcium channel blocker and treats atrial dysrhythmias. pg.699
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) The patient will have to schedule monthly chest x-rays to make sure the device is patent.
b) The patient may have a throbbing pain that is normal
c) Record events that trigger a shock sensation.
d) Call for emergency assistance if feeling dizzy.
e) Avoid magnetic fields such as metal detection booths.

c) Record events that trigger a shock sensation.
d) Call for emergency assistance if feeling dizzy.
e) Avoid magnetic fields such as metal detection booths.
Correct
Explanation:
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. pg.725
The nurse is caring for clients on a telemetry unit. Which nursing consideration best represents concerns of altered rhythmic patterns of the heart?

a) Altered patterns frequently cause a variety of home safety issues.
b) Altered patterns frequently turn into life-threatening arrhythmias.
c) Altered patterns frequently affect the heart’s ability to pump blood effectively.
d) Altered patterns frequently produce neurological deficits.

c) Altered patterns frequently affect the heart’s ability to pump blood effectively.
Explanation:
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. pg.693
What nursing interventions could you institute with a client who has a suspected dysrhythmia that would help detect life-threatening dysrhythmias and would manage and minimize any that occur?

a) Palpate the client’s pulse and observe the client’s response.
b) Provide supplemental oxygen.
c) Monitor blood pressure continuously.
d) Monitor cardiac rhythm continuously.

d) Monitor cardiac rhythm continuously.
Explanation:
The nurse should monitor cardiac rhythm continuously. Cardiac monitors display real-time heart rate and rhythm and alert the nurse to potentially life-threatening dysrhythmias. Monitoring blood pressure continuously and palpating the client’s pulse do not help detect life-threatening dysrhythmias. Providing supplemental oxygen helps maintain adequate cardiac output and does not help detect life-threatening dysrhythmias. pg.692
The nurse is analyzing 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 which of the following?

a) Junctional tachycardia
b) Normal sinus rhythm
c) Sinus tachycardia
d) First-degree atrioventricular (AV) block

b) Normal sinus rhythm
Explanation:
The 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. pg.698
A nursing student is caring for one of the nurse’s assigned cardiac clients. The student asks, “How can I tell the difference between sinus rhythm and sinus bradycardia when I look at the EKG strip” The best reply by the nurse is which of the following?

a) “The QRS complex will be smaller in sinus bradycardia.”
b) “The P waves will be shaped differently.”
c) “The only difference is the rate, which will be below 60 bpm in sinus bradycardia.”
d) “The P-R interval will be prolonged in sinus bradycardia, and you will have to measure carefully to note the width.”

c) “The only difference is the rate, which will be below 60 bpm in sinus bradycardia.”
Explanation:
All characterestics of sinus bradycardia are the same as those of normal sinus rhythm, except for the rate, which will be below 60 in sinus bradycardia. pg.726
A patient is admitted to the emergency department (ED) with complaints of chest pain and shortness of breath. The nurse notes an irregular rhythm on the bedside electrocardiograph (ECG) monitor. The nurse counts 9 RR intervals on the patient’s 6-second rhythm tracing. The nurse correctly identifies the patient’s heart rate as which of the following?

a) 70 bpm
b) 100 bpm
c) 90 bpm
d) 80 bpm

c) 90 bpm
Explanation:
An alternative but less accurate method for estimating heart rate, which is usually used when the rhythm is irregular, is to count the number of RR intervals in 6 seconds and multiply that number by 10. The RR intervals are counted, rather than QRS complexes, because a computed heart rate based on the latter might be inaccurately high. The same methods may be used for determining atrial rate, using the PP interval instead of the RR interval. In this instance, 9 × 10 = 90. pg.697
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?

a) Ventricular tachycardia
b) Ventricular fibrillation
c) Atrial fibrillation
d) Third-degree heart block

b) Ventricular fibrillation
Explanation:
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. pg.709
A 26-year-old Air Force staff sergeant is returning for diagnostic follow-up to the cardiologist’s office where you practice nursing. Her 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?

a) All options are correct
b) Elevated temperature
c) Shock
d) Strenuous exercise

a) All options are correct
Explanation:
It occurs in clients with healthy hearts as a physiologic response to strenuous exercise, anxiety and fear, pain, fever, hyperthyroidism, hemorrhage, shock, or hypoxemia. There are a variety of causes that can create an elevated heart rate in an otherwise healthy heart. Fever is one cause. There are a variety of causes that can create an elevated heart rate in an otherwise healthy heart. Shock is one cause. There are a variety of causes that can create an elevated heart rate in an otherwise healthy heart. Strenuous exercise is one cause. pg.694
While assessing a client, the nurse finds a heart rate of 120 beats per minute. The nurse recalls that causes of sinus tachycardia include which of the following?

a) Hypothyroidism and athletic training
b) Vagal stimulation and sleep
c) Hypovolemia and fever
d) Digoxin and vagal stimulation

c) Hypovolemia and fever
Explanation:
Causes of sinus tachycardia include physiologic or psychological stress (acute blood loss, anemia, shock, hypovolemia, fever, and exercise). Vagal stimulation, sleep, hypothyroidism, athletic training, and Digoxin all will cause a slow heart rate. pg.698
The nurse is observing the monitor of a patient with a first-degree atrioventricular (AV) block. What is the nurse aware characterizes this block?

a) P waves hidden with the QRS complex
b) An irregular rhythm
c) A variable heart rate, usually fewer than 60 bpm
d) Delayed conduction, producing a prolonged PR interval

d) Delayed conduction, producing a prolonged PR interval
Explanation:
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). pg.711
Two days after discharge following a permanent pacemaker insertion, the client returns to the clinic for a follow-up appointment. He reports tenderness and throbbing around the incision. The nurse observes mild swelling, erythema, and warmth at the site and suspects which of the following:

a) Postoperative site hematoma
b) Normal postoperative healing
c) Internal bleeding at pacemaker site
d) Pacemaker site infection

d) Pacemaker site infection
Explanation:
Postoperative care for a pacemaker insertion includes observing for symptoms of infection. These include swelling, unusual tenderness, drainage, and increased warmth. pg.723
The nurse is working on a telemetry unit, caring for a client who has been in a sinus rhythm for the past 2 days with a heart rate of 88 to 96 beats per minute. The client puts on the call light in the bathroom and reports severe dizziness. The telemetry shows a heart rate of 46 beats per minute. What should the nurse be prepared to do?

a) Assist with a temporary pacemaker.
b) Prepare the client for maze surgery.
c) Send the client to the cardiac catheterization laboratory.
d) Give an IV bolus of atropine.

d) Give an IV bolus of atropine.
Explanation:
Atropine 0.5 mg given rapidly as an intravenous bolus every 3 to 5 minutes to a maximum total dose of 3.0 mg is the medication of choice in treating symptomatic sinus bradycardia. pg.699
The nurse caring for a patient with a dysrhythmia understands that the P wave on an electrocardiogram (ECG) represents what phase of the cardiac cycle?

a) Ventricular repolarization
b) Ventricular depolarization
c) Atrial depolarization
d) Early ventricular repolarization

c) Atrial depolarization
Explanation:
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. pg.696
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) Do not be concerned if you experience symptoms of lightheadedness and dizziness.
c) If you miss a dose of your antiarrhythmia medication, double up on the next dose.
d) It is not necessary to learn how to take your own pulse.

a) Your family and friends may want to take a CPR class.
Explanation:
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. pg.714
The nurse is caring for a client with atrial fibrillation. The client’s symptoms started about 1 week ago, but he is just now seeking medical attention. The client asks the nurse why he has to wait several weeks before the cardioversion takes place. The best answer by the nurse is which of the following?

a) “There is a long list of clients in line to be cardioverted.”
b) “We have to allow your heart to rest for a few weeks before it is stressed by the cardioversion.”
c) “The doctor wants to see if your heart will switch back to its normal rhythm by itself.”
d) “Your atrial chambers may contain blood clots now, so you must take an anticoagulant for a few weeks before the cardioversion.”

d) “Your atrial chambers may contain blood clots now, so you must take an anticoagulant for a few weeks before the cardioversion.”
Explanation:
Because of the high risk of embolization of atrial thrombi, cardioversion of atrial fibrillation that has lasted longer than 48 hours should be avoided unless the client has received warfarin for at least 3 to 4 weeks prior to cardioversion. pg.702
A client has a medical diagnosis of an advanced AV block and is symptomatic due to a slow heart rate. With what initial treatment(s) should the nurse be prepared to assist?

a) A maze procedure or IV bolus of furosemide
b) Cardiac catheterization
c) IV bolus of atropine or temporary pacing
d) Cardioversion or IV bolus of dopamine

c) IV bolus of atropine or temporary pacing
Explanation:
The initial treatment of choice is an IV bolus of atropine. If the client does not respond to atropine, has advanced AV block, or has had an acute MI, temporary pacing may be started. A permanent pacemaker my be necessary if the block persists. pg.713
Two nursing students are reading EKG strips. One of the students asks the instructor what the P-R interval represents. The correct response should be which of the following?

a) “It shows the time it takes the AV node impulse to depolarize the atria and travel through the SA node.”
b) “It shows the time it takes the AV node impulse to depolarize the ventricles and travel through the SA node.”
c) “It shows the time it takes the AV node impulse to depolarize the septum and travel through the Purkinje fibers.”
d) “It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node.”

d) “It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node.”
Explanation:
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. pg.696
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?

a) Asystole
b) Ventricular fibrillation
c) Atrial flutter
d) Premature ventricular contraction

c) Atrial flutter
Explanation:
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. pg.702
A patient with dilated cardiomyopathy is having frequent episodes of ventricular fibrillation. What choice would be best to sense and terminate these episodes?

a) Implantable cardioverter defibrillator
b) Epinephrine
c) Pacemaker
d) Atropine

a) Implantable cardioverter defibrillator
Explanation:
The implantable cardioverter defibrillator (ICD) is an electronic device that detects and terminates life-threatening episodes of tachycardia or fibrillation, especially those that are ventricular in origin. Patients at high risk of ventricular tachycardia (VT) or ventricular fibrillation and who would benefit from an ICD are those who have survived sudden cardiac death syndrome, which usually is caused by ventricular fibrillation, or have experienced spontaneous, symptomatic VT (syncope secondary to VT) not due to a reversible cause (called a secondary prevention intervention). pg.721
The nurse is assessing vital signs in a patient with a permanent pacemaker. What should the nurse document about the pacemaker?

a) Date and time of insertion
b) Pacer rate
c) Location of the generator
d) Model number

b) Pacer rate
Explanation:
After a permanent pacemaker is inserted, the patient’s heart rate and rhythm are monitored by ECG. pg.723
You enter your client’s room and find him pulseless and unresponsive. What would be the treatment of choice for this client?

a) Immediate defibrillation
b) Electric cardioversion
c) Chemical cardioversion
d) IV lidocaine

a) Immediate defibrillation
Explanation:
Defibrillation is used during pulseless ventricular tachycardia, ventricular fibrillation, and asystole (cardiac arrest) when no identifiable R wave is present. pg.716
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 can still drink coffee and tea.”
b) “I should increase my fluid intake.”
c) “I should eat foods rich in protein.”
d) “I’ll enroll in an aerobic exercise program.”

a) “I can still drink coffee and tea.”
Explanation:
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. pg.699
A patient tells the nurse “my heart is skipping beats again; I’m having palpitations.” After completing a physical assessment, the nurse concludes the patient is experiencing occasional premature atrial complexes (PACs). The nurse should instruct the patient to complete which of the following?

a) Apply supplemental oxygen.
b) Avoid caffeinated beverages.
c) Lie down and elevate the feet.
d) Request sublingual nitroglycerin.

b) Avoid caffeinated beverages.
Explanation:
If 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 patient to avoid caffeinated beverages. pg.700
A 26-year-old client is returning for diagnostic follow-up. Her Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minutes. What type of dysrhythmia would you expect the cardiologist to diagnose?

a) Supraventricular bradycardia
b) Sinus tachycardia
c) Supraventricular tachycardia
d) Sinus bradycardia

b) Sinus tachycardia
Explanation:
Sinus tachycardia is a dysrhythmia that proceeds normally through the conduction pathway but at a faster than usual rate (100 to 150 beats/minute). Sinus tachycardia is the dysrhythmia with a faster than usual heart rate (100 to 150 beats/minute). pg.699
Which PR interval presents a first-degree heart block?

a) 0.14 seconds
b) 0.18 seconds
c) 0.16 seconds
d) 0.24 seconds

d) 0.24 seconds
Explanation:
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. pg.711
A nurse is performing discharge teaching with a client who has an implantable cardioverter defibrillator (ICD) placed. Which client statement indicates effective teaching?

a) “I need to stay at least 10? away from the microwave.”
b) “I have an appointment for magnetic resonance imaging of my knee scheduled for next week.”
c) “I’ll keep a log of each time my ICD discharges.”
d) “I can’t wait to get back to my football league.”

c) “I’ll keep a log of each time my ICD discharges.”
Explanation:
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. pg.725
The nurse in the intensive care unit (ICU) hears an alarm sound in the patient’s room. Arriving in the room, the patient is unresponsive, without a pulse, and a flat line on the monitor. What is the first action by the nurse?

a) Defibrillate with 360 joules (monophasic defibrillator)
b) Administer atropine 0.5 mg
c) Begin cardiopulmonary resuscitation (CPR)
d) Administer epinephrine

c) Begin cardiopulmonary resuscitation (CPR)
Explanation:
Commonly called flatline, ventricular asystole (Fig. 26-19) is characterized by absent QRS complexes confirmed in two different leads, although P waves may be apparent for a short duration. There is no heartbeat, no palpable pulse, and no respiration. Without immediate treatment, ventricular asystole is fatal. Ventricular asystole is treated the same as PEA, focusing on high-quality CPR with minimal interruptions and identifying underlying and contributing factors. pg.710
A nurse is providing morning care for a patient in the ICU. Suddenly, the bedside monitor shows ventricular fibrillation and the patient becomes unresponsive. After calling for assistance, what action should the nurse take next?

a) Prepare for endotracheal intubation.
b) Begin cardiopulmonary resuscitation.
c) Provide electrical cardioversion.
d) Administer intravenous epinephrine.

b) Begin cardiopulmonary resuscitation.
Explanation:
In the acute care setting, when ventricular fibrillation is noted, the nurse should call for assistance and defibrillate the patient as soon as possible. If defibrillation is not readily available, CPR is begun until the patient can be defibrillated, followed by advanced cardiovascular life support (ACLS) intervention, which includes endotracheal intubation and administration of epinephrine. Electrical cardioversion is not indicated for a patient in ventricular fibrillation. pg.709
Premature ventricular contractions (PVCs) are considered precursors of ventricular tachycardia (VT) when they:

a) have the same shape
b) occur at a rate of more than six per minute
c) are paired with a normal beat
d) occur during the QRS complex

b) occur at a rate of more than six per minute
Explanation:
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. pg.708
Your patient is experiencing asymptomatic sinus tachycardia with a rate of 118. The nurse understands that the treatment of this condition includes:

a) Treating the underlying cause
b) Immediate defibrillation
c) Administration of amiodarone
d) Electrical cardioversion

a) Treating the underlying cause
Explanation:
Sinus tachycardia occurs in response to an underlying condition and will usually resolve once that condition is corrected. pg.699
A patient has a persistent third-degree heart block and has had several periods of syncope. What priority treatment should the nurse anticipate for this patient?

a) Administration of epinephrine
b) Insertion of a pacemaker
c) Insertion of an implantable cardioverter defibrillator (ICD)
d) Administration of atropine

b) Insertion of a pacemaker
Explanation:
Third-degree AV block, also known as a complete block, occurs when no atrial impulse is conducted through the AV node into the ventricles. A permanent pacemaker may be necessary if the block persists. pg.713
A 63-year-old client is in the cardiac step-down unit where you practice nursing. In your discussions about his condition, the client is puzzled as to what causes the heart to be an effective pump. Which of the following statements would you include in your response?

a) Sufficient blood pressure
b) Inherent rhythmicity of all muscle tissue
c) Inherent electrons in muscle tissue
d) Inherent rhythmicity of cardiac muscle tissue

d) Inherent rhythmicity of cardiac muscle tissue
Explanation:
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. pg.693
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) “You should avoid tennis; basketball or football would be a good substitute.”
b) “You may resume all normal activity in 1 week; if you are used to playing tennis, you may proceed with this activity.”
c) “Cancel your tennis tournament and wait until fall, then try hockey; skating is much easier on pacemakers.”
d) “You will need to cancel this activity; you must restrict arm movement above your head for 2 weeks.”

d) “You will need to cancel this activity; you must restrict arm movement above your head for 2 weeks.”
Explanation:
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). pg.725
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 hold all medication until the pulse rate returns to 60 beats/minute
b) The registered nurse stating to administer Lanoxin (digoxin)
c) The registered nurse administering atropine sulfate intravenously
d) The registered nurse stating to administer all medications accept those which are cardiotonics

c) The registered nurse administering atropine sulfate intravenously
Explanation:
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. pg.699
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 a permanent pacemaker
b) Catheter ablation therapy
c) Insertion of an ICD
d) Maze procedure

b) Catheter ablation therapy
Explanation:
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). pg.726
The nurse is monitoring a patient in the postanesthesia care unit (PACU) following a coronary artery bypass graft, observing a regular ventricular rate of 82 beats/min and “sawtooth” P waves with an atrial rate of approximately 300 beat/min. How does the nurse interpret this rhythm?

a) Ventricular fibrillation
b) Atrial fibrillation
c) Ventricular tachycardia
d) Atrial flutter

d) Atrial flutter
Explanation:
Atrial flutter occurs because of a conduction defect in the atrium and causes a rapid, regular atrial rate, usually between 250 and 400 bpm and results in P waves that are saw-toothed. Because the atrial rate is faster than the AV node can conduct, not all atrial impulses are conducted into the ventricle, causing a therapeutic block at the AV node. This is an important feature of this dysrhythmia. If all atrial impulses were conducted to the ventricle, the ventricular rate would also be 250 to 400 bpm, which would result in ventricular fibrillation, a life-threatening dysrhythmia. Atrial flutter often occurs in patients with chronic obstructive pulmonary disease, pulmonary hypertension, valvular disease, and thyrotoxicosis, as well as following open heart surgery and repair of congenital cardiac defects (Fuster, Walsh et al., 2011). pg.702
Which of the following is a potential cause of premature ventricular complexes (PVCs)?

a) Bradycardia
b) Alkalosis
c) Hypokalemia
d) Hypovolemia

c) Hypokalemia
Explanation:
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. pg.707
You are caring for a client who has been admitted to have a cardioverter defibrillator implanted. You would know that implanted cardioverter defibrillators are used in what clients?

a) Clients with recurrent life-threatening bradycardias
b) Clients with sinus tachycardia
c) Clients with ventricular bradycardia
d) Clients with recurrent life-threatening tachydysrhythmias

d) Clients with recurrent life-threatening tachydysrhythmias
Explanation:
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. pg.715
Which of the following nursing interventions must a nurse perform when administering prescribed vasopressors to a patient with a cardiac dysrhythmia?

a) Monitor vital signs and cardiac rhythm
b) Keep the patient flat for one hour after administration c) Document heart rate before and after administration
d) Administer every five minutes during cardiac resuscitation

a) Monitor vital signs and cardiac rhythm
Explanation:
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.
After evaluating a client for hypertension, a physician orders atenolol (Tenormin), 50 mg P.O. daily. Which therapeutic effect should atenolol have?

a) Decreased blood pressure with reflex tachycardia
b) Decreased peripheral vascular resistance
c) Decreased cardiac output and decreased systolic and diastolic blood pressure
d) Increased cardiac output and increased systolic and diastolic blood pressure

c) Decreased cardiac output and decreased systolic and diastolic blood pressure
Explanation:
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. pg.701
A client has had a pacemaker inserted and is ready for discharge. The nurse is providing education about pacemaker safety. Which of the following are items that the nurse will be sure to address? Choose all that apply.

a) Avoid large magnetic fields.
b) Sit at least 12 feet from television sets.
c) Carry a card identifying yourself as a pacemaker recipient.
d) Monitor your pulse once a month.
e) Do not spend time near a microwave oven.

c) Carry a card identifying yourself as a pacemaker recipient.
a) Avoid large magnetic fields.
Explanation:
Recent pacemaker technology allows clients to safely use most household electronic appliances and devices, including microwave ovens, electric tools, and televisions. The client with a pacemaker should monitor his or her pulse daily. He or she should always carry medical identification of pacemaker use. The client should avoid large magnetic fields (eg, large motors, magnetic resonance imaging, arc welding, electrical substations). pg.720
A patient comes to the emergency department with complaints 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?

a) Sinus tachycardia
b) Ventricular tachycardia
c) Normal sinus rhythm
d) Sinus bradycardia

a) Sinus tachycardia
Explanation:
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). pg.699
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 will occur in the operating room under general anesthesia.
b) After the procedure, the arrhythmia will not recur.
c) During the procedure, the arrhythmia will be reproduced under controlled conditions.
d) The procedure takes less time than a cardiac catheterization.

c) During the procedure, the arrhythmia will be reproduced under controlled conditions.
Explanation:
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. pg.724
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) QRS complex that is 0.10 seconds long
b) ST segment that is isoelectric in appearance
c) PR interval that is 0.18 seconds long
d) QT interval that is 0. 46 seconds long

d) QT interval that is 0. 46 seconds long
Explanation:
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. pg.696
The nurse is caring for a patient following the insertion of a permanent pacemaker. Which of the following discharge instructions are appropriate for the nurse to review with the patient? Select all that apply.

a) Wear a medical alert noting the presence of a pacemaker.
b) Avoid the usage of microwave ovens and electronic tools.
c) Avoid handheld screening devices in airports.
d) Refrain from walking through antitheft devices.
e) Check pulse daily, reporting sudden slowing or increase.

c) Avoid handheld screening devices in airports.
e) Check pulse daily, reporting sudden slowing or increase.
a) Wear a medical alert noting the presence of a pacemaker.
Explanation:
Handheld screening devices used in airports may interfere with the pacemaker. Patients should be advised to ask security personnel to perform a hand search instead of using the handheld screening device. With a permanent pacemaker, the patient should be instructed initially to restrict activity on the side of implantation. Patients also should be educated to perform a pulse check daily and to wear or carry medical identification to alert personnel to the presence of the pacemaker. Patients should walk through antitheft devices quickly and avoid standing in or near these devices. Patients can safely use microwave ovens and electronic tools. pg.720
Which of the following medication classifications is more likely to be expected when the nurse is caring for a client with atrial fibrillation?

a) Potassium supplement
b) Diuretic
c) Antihypertensive
d) Anticoagulant

d) Anticoagulant
Explanation:
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. pg.704
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) Take Jack’s blood pressure.
b) Double-check the monitoring equipment.
c) Nothing, there’s no cause for alarm.
d) Suggest the need for a new beta-blocker to the doctor.

b) Double-check the monitoring equipment.
Explanation:
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. pg.721
You are an operating room nurse caring for a client who is having a pacemaker implanted. The physician has requested a demand mode pacemaker for this client. What is this type of pacemaker?

a) Self-activated
b) A fixed-rate pacemaker
c) A temporary pacemaker
d) Asynchronous

a) Self-activated
Explanation:
Demand (synchronous) mode pacemakers self-activate when the client’s pulse falls below a certain level. A fixed-rate pacemaker is asynchronous and permanent. Temporary pacemakers are used until a permanent pacemaker can be implanted. pg.718
After observing a code blue situation, a nursing student asks a member of the code team what the treatment of choice is for witnessed ventricular fibrillation. The best response by the nurse is which of the following?

a) IV bolus of dobutamine
b) Cardiac catheterization
c) IV bolus of lidocaine
d) Defibrillation

d) Defibrillation
Explanation:
Because there is no coordinated cardiac activity, cardiac arrest and death are imminent if the dysrhythmia is not corrected. Early defibrillation is critical to survival. pg.717
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 cardioversion
b) Elective electrical defibrillation
c) Chemical cardioversion
d) Mace procedure

a) Elective electrical cardioversion
Explanation:
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. pg.715
A nursing instructor is reviewing the parts of an EKG strip with a group of students. One student asks about the names of all the EKG cardiac complex parts. Which of the following items are considered a part of the cardiac complex on an EKG strip? Choose all that apply.

a) T wave
b) P-R interval
c) QRT wave
d) P wave
e) S-Q segment

d) P wave
b) P-R interval
a) T wave
Explanation:
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. pg.696
Treatment of symptomatic bradycardia includes which of the following?

a) Cardioversion
b) Adenocard
c) Lidocaine
d) Atropine

d) Atropine
Explanation:
Treatment of symptomatic bradycardia includes transcutaneous pacing and atropine. Lidocaine may be used in the treatment of ventricular fibrillation. Cardioversion and Adenocard may be used in patients diagnosed with atrial flutter. pg.699
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, right and left bundle branches, bundle of His, and the Purkinje fibers
b) Sinoatrial (SA) node, atrioventricular (AV) node, bundle of His, right and left bundle branches, and the Purkinje fibers
c) SA node, AV node, bundle of His, the Purkinje fibers, and the right and left bundle branches
d) AV node, SA node, bundle of His, right and left bundle branches, and the Purkinje fibers

b) Sinoatrial (SA) node, atrioventricular (AV) node, bundle of His, right and left bundle branches, and the Purkinje fibers
Explanation:
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. pg.693
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) Call for the doctor and just wait.
b) Administer additional lidocaine.
c) Prepare for defibrillation.
d) Adjust the IV infusion.

d) Adjust the IV infusion.
Explanation:
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. pg.701
Which medication is indicated for the patient with atrial fibrillation who is at high risk for stroke?

a) Plavix
b) Lovenox
c) Aspirin
d) Coumadin

d) Coumadin
Explanation:
Warfarin (Coumadin) is indicated if the patient with atrial fibrillation is at high risk for stroke. Aspirin, Lovenox, and Plavix are not indicated. If immediate anticoagulation is necessary, the patient may be placed on heparin until the warfarin level is therapeutic. pg.705
Which of the following postimplantation instructions must a nurse provide a patient with a permanent pacemaker?

a) Avoid sources of electrical interference
b) Keep moving the arm on the side where the pacemaker is inserted
c) Keep the arm on the side of the pacemaker higher than the head
d) Delay for at least 3 weeks activities such as swimming and bowling

a) Avoid sources of electrical interference
Explanation:
The nurse must instruct the patient with a permanent pacemaker to avoid sources of electrical interference. The nurse should also instruct the patient 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. pg.717
Which of the following nursing interventions is required to prepare a patient with cardiac dysrhythmia for an elective electrical cardioversion?

a) Administer digitalis and diuretics 24 hours before cardioversion
b) Facilitate CPR until the patient is prepared for cardioversion
c) Instruct the patient to restrict food and oral intake
d) Monitor blood pressure every 4 hours

c) Instruct the patient to restrict food and oral intake
Explanation:
The nurse should instruct the patient 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 patient is in cardiopulmonary arrest, the nurse should facilitate CPR until the patient is prepared for defibrillation and not for cardioversion. Monitoring blood pressure every 4 hours is not required to prepare a patient with cardiac dysrhythmia. pg.715
A nurse is evaluating a client with a temporary pacemaker. The patient’s ECG tracing shows each P wave followed by the pacing spike. The nurse’s best response is which of the following?

a) Reposition the extremity and turn the patient to left side.
b) Obtain a 12-lead ECG and a portable chest x-ray.
c) Check the security of all connections and increase the milliamperage.
d) Document the findings and continue to monitor the patient.

d) Document the findings and continue to monitor the patient
Explanation:
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 patient. Repositioning the patient, placing the patient 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. pg.718
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) Fluttering
d) Fever

c) Fluttering
Explanation:
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. pg.702
Which of the following tends to be prolonged on the electrocardiogram (ECG) during a first-degree atrioventricular (AV) block?

a) PR interval
b) T wave
c) P wave
d) QRS

a) PR interval
Explanation:
First-degree AV block occurs when atrial conduction is delayed through AV node resulting in a prolonged PR interval. The QRS complex, T wave, and P wave are not prolonged in first-degree AV block. pg.711
The nurse is caring for a client who has just been diagnosed with sinus bradycardia. The client asks the nurse to explain what sinus bradycardia is. What would be the nurse’s best explanation?

a) In many clients a heart rate slower than 60 beats per minute is considered to slow to maintain an adequate cardiac output.
b) Sinus bradycardia means your heart is not beating fast enough to keep you alive.
c) Sinus bradycardia is nothing to worry about.
d) In many clients a heart rate slower than 70 beats per minute is considered to slow to maintain an adequate cardiac output.

a) In many clients a heart rate slower than 60 beats per minute is considered to slow to maintain an adequate cardiac output.
Explanation:
A heart rate slower than 60 beats per minute is pathologic in clients with heart disorders, increased intracranial pressure, hypothyroidism, or digitalis toxicity. The danger in sinus bradycardia is that the slow rate may be insufficient to maintain cardiac output. Option B is incorrect as it is an incomplete answer to the client’s question. Option C minimizes the client’s concern so it is incorrect. Option D is incorrect as it gives the client incorrect information. pg.698
You are caring for a client who has been admitted to have a cardioverter defibrillator implanted. You would know that implanted cardioverter defibrillators are used in what clients?

a) Clients with recurrent life-threatening bradycardias
b) Clients with sinus tachycardia
c) Clients with ventricular bradycardia
d) Clients with recurrent life-threatening tachydysrhythmias

d) Clients with recurrent life-threatening tachydysrhythmias
Explanation:
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. pg.715
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?

a) “Spike” on the rhythm strip
b) Quality of the pulse
c) Scar on the chest
d) Vibration under the skin

a) “Spike” on the rhythm strip
Explanation:
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. pg.718
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 poor kidney perfusion
b) A new myocardial infarction client
c) A client with atrial dysrhythmias
d) A client with third-degree heart block

A client with atrial dysrhythmias
Explanation:
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. pg.716
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) Keep moving the arm on the side where the pacemaker is inserted.
b) Keep the arm on the side of the pacemaker higher than the head.
c) Avoid sources of electrical interference.
d) Delay for at least 3 weeks activities such as swimming and bowling.

c) Avoid sources of electrical interference.
Explanation:
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. pg.720
The nurse is working on a monitored unit assessing the cardiac monitor rhythms. Which waveform pattern needs attention first?

a) Sustained asystole
b) Supraventricular tachycardia
c) Ventricular fibrillation
d) Atrial fibrillation

c) Ventricular fibrillation
Explanation:
Ventricular fibrillation is called the rhythm of a dying heart. It is the rhythm that needs attention first because there is no cardiac output, and it is an indication for CPR and immediate defibrillation. Sustained asystole either is from death, or the client is off of the cardiac monitor. Supraventricular tachycardia and atrial fibrillation is monitored and reported to the physician but is not addressed first. pg.709
The nurse is caring for a client who is being discharged after insertion of a permanent pacemaker. Which question by the client indicates a need for clarification?

a) “I should ask for a handheld device search when I go through airport security.”
b) “I should avoid contact sports.”
c) “I’ll watch the incision for swelling or redness and will report if either occurs.”
d) “I should avoid large magnetic fields, such as an MRI machine or large motors.”

a) “I should ask for a handheld device search when I go through airport security.”
Explanation:
At security gates at airports, government buildings, or other secured areas, the client with a permanent pacemaker should show a pacemaker ID card and request a hand (not handheld device) search. The client should obtain and carry a physician’s letter about this requirement. pg.720
A patient admitted to the telemetry unit has a serum potassium level of 6.6 mEq/L. Which of the following electrocardiographic (ECG) characteristics is commonly associated with this laboratory finding?

a) Peaked T waves
b) Flattened P waves
c) Prolonged QT interval
d) Occasional U waves

a) Peaked T waves
Explanation:
The patient’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 patient’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 patient’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 patient’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 patient’s serum potassium level. pg.696
Electrocardiogram (ECG) waveforms are printed on graph paper that is divided by light and dark vertical and horizontal lines at standard intervals. When the nurse is interpreting the heart rhythm, he or she understands that each large block equals how many seconds?

a) 0.3
b) 0.2
c) 0.1
d) 0.4

b) 0.2
Explanation:
Each small block on the graph paper equals 0.04 second, and five small blocks form a large block, which equals 0.2 second. pg.696
Electrocardiogram (ECG) characteristics of atrial fibrillation include which of the following?

a) P wave resent before each QRS
b) Normal PR interval
c) Atrial rate of 300 to 400
d) Regular rhythm

c) Atrial rate of 300 to 400
Explanation:
ECG characteristics of atrial fibrillation include an atrial rate of 300 to 400, a nonmeasurable PR interval, irregular rhythm, and no discernible P waves. pg.703
The licensed practical nurse is setting up the room for a client arriving at the emergency department with ventricular arrhythmias. The nurse is most correct to place which of the following in the room for treatment?

a) A suction machine
b) Cardioversion equipment
c) An ECG machine
d) A defibrillator

d) A defibrillator
Explanation:
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. pg.716
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
Explanation:
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. It is not atrial flutter. Atrial fibrillation generally causes disorganized activity, irregular heart rates, and pulse deficits. It is not heart block. Atrial fibrillation generally causes disorganized activity, irregular heart rates, and pulse deficits. It is not bundle branch block. pg.704
John, an 82-year-old retired librarian is brought into the ED where you practice nursing. The client’s heart rate is greater than 155 beats/minute. As you connect him to the ECG, you notice that his rhythm is regular, rate is 162 beats/minute, and diastole is shortened. He is intermittently alert and reports chest pain. P waves cannot be identified. What condition would you expect the physician to diagnose?

a) Atrial flutter
b) Sinus tachycardia
c) Heart block
d) Supraventricular tachycardia

d) Supraventricular tachycardia
Explanation:
Supraventricular tachycardia (SVT) is a dysrhythmia in which the heart rate has a consistent rhythm but beats at a dangerously high rate (≥150 beats/minute). P waves cannot be identified on the ECG. Diastole is shortened and the heart does not have sufficient time to fill. Supraventricular tachycardia (SVT) is a dysrhythmia in which the heart rate has a consistent rhythm but a dangerously high heartbeat (≥150 beats/minute). It is not sinus tachycardia. Supraventricular tachycardia (SVT) is a dysrhythmia in which the heart rate has a consistent rhythm but a dangerously high heartbeat (≥150 beats/minute). It is not heart block. Supraventricular tachycardia (SVT) is a dysrhythmia in which the heart rate has a consistent rhythm but a dangerously high heartbeat (≥150 beats/minute). It is not atrial flutter. pg. 707
The nurse receives a telephone call from a client with an implanted pacemaker who reports that his pulse is 68 beats per minute, but his pacemaker rate is set at 72 beats per minute. The best response by the nurse is which of the following?

a) “This is okay as long as you are not having any symptoms.”
b) “Try walking briskly for about 5 minutes to see if that gets your heart rate to increase.”
c) “Don’t worry. The pacemaker’s rate is often higher than the client’s actual heart rate.”
d) “Please come to the clinic right away so that we may interrogate the pacemaker to see if it is malfunctioning.”

d) “Please come to the clinic right away so that we may interrogate the pacemaker to see if it is malfunctioning.”
Explanation:
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. pg.720
The nurse is participating in the care of a client requiring emergent defibrillation. The nurse will complete the following steps in which order?

a) Turn on the defibrillator and place it in “not sync” mode.
b) Call “clear” three times ensuring patient and environmental safety.
c) Deliver the prescribed electrical charge.
d) Charge the defibrillator to the prescribed voltage.
e) Apply the multifunction conductor pads to the patient’s chest.

a) Turn on the defibrillator and place it in “not sync” mode.
d) Charge the defibrillator to the prescribed voltage.
e) Apply the multifunction conductor pads to the patient’s chest.
b) Call “clear” three times ensuring patient and environmental safety.
c) Deliver the prescribed electrical charge.
Explanation:
This is the sequence of events the nurse should implement when delivering emergent defibrillation. If not followed correctly, the patient and health care team may be placed in danger. pg.716
The nursing instructor is discussing pacemakers with her clinical group. One of the students is caring for a client with a transvenous pacemaker. One of the students asks why this client has a transvenous pacemaker. What would be the instructor’s best response?

a) “A transvenous pacemaker is used in place of a transarterial pacemaker.”
b) “A transvenous pacemaker is used to manage transient bradydysrhythmias like those that occur during acute MIs.”
c) “A transvenous pacemaker is used for a ventricular tachyarrhythmia.”
d) “A transvenous pacemaker is a permanent pacemaker that is asynchronous.”

b) “A transvenous pacemaker is used to manage transient bradydysrhythmias like those that occur during acute MIs.”
Explanation:
A transvenous pacemaker is a temporary pulse-generating device that sometimes is necessary to manage transient bradydysrhythmias such as those that occur during acute MIs or after coronary artery bypass graft surgery, or to override tachydysrhythmias. pg.717
When the nurse observes that the patient’s heart rate increases during inspiration and decreases during expiration, the nurse reports that the patient is demonstrating

a) sinus bradycardia.
b) normal sinus rhythm.
c) sinus tachycardia.
d) sinus dysrhythmia.

d) sinus dysrhythmia.
Explanation:
Sinus dysrhythmia occurs when the sinus node creates an impulse at an irregular rhythm. Normal sinus rhythm occurs when the electrical impulse starts at a regular rate and rhythm in the SA node and travels through the normal conduction pathway. Sinus bradycardia occurs when the sinus node regularly creates an impulse at a slower-than-normal rate. Sinus tachycardia occurs when the sinus node regularly creates an impulse at a faster-than-normal rate. pg.700
A physician orders esmolol (Brevibloc) for a client with supraventricular tachycardia. During esmolol therapy, the nurse should monitor the client’s:

a) heart rate and blood pressure.
b) ocular pressure.
c) cerebral perfusion pressure.
d) body temperature.

a) heart rate and blood pressure.
Explanation:
Because class II antiarrhythmics such as esmolol inhibit sinus node stimulation, they may produce bradycardia. Hypotension with peripheral vascular insufficiency also may occur, especially with esmolol. Class II antiarrhythmics don’t alter body temperature, ocular pressure, or cerebral perfusion pressure. pg.701
The treatment for symptomatic junctional rhythm is the same as for which of the following other heart rhythms?

a) Atrial flutter
b) Tachycardia
c) Atrial fibrillation
d) Bradycardia

d) Bradycardia
Explanation:
If symptomatic, the treatment is the same as for bradycardia: the patient may be treated with pacing (temporary or permanent), IV atropine, or epinephrine. pg.706
Two clients in cardiac rehabilitation are discussing the differences between scheduled cardioversion and unexpected defibrillation. Which difference will the nurse confirm?

a) Both procedures sedate the clients.
b) Cardioversion uses less electrical energy.
c) Both used to eliminate ventricular dysrhythmias.
d) Machine determines when electrical energy is delivered.

b) Cardioversion uses less electrical energy.
Explanation:
Cardioversion uses less electrical energy (50 to 100 joules) than defibrillation (200 to 360 joules). All of the other statements are correct. pg.716
In looking at the ECG of a new patient, 43-year-old Mrs. Smith, you see what appears to be a P wave slightly different than normal. You’re considering the possibility of premature atrial contractions (PAC). Which of the following questions will you ask her when taking her history?

a) Caffeine
b) Nicotine
c) Hyperthyroidism or other metabolic disorders
d) All options are correct

d) All options are correct
Explanation:
There are a number of causes of premature atrial contractions (PAC), which it is why it’s so important to know and review a patient’s complete history when examining for dysrhythmias. There are a number of causes of premature atrial contractions (PAC). pg.700
The nurse is caring for a client who is displaying a third-degree AV block on the EKG monitor. The client is symptomatic due to the slow heart rate. The most appropriate nursing diagnosis for this client would be which of the following?

a) Decreased cardiac output
b) Ineffective health maintenance
c) Ineffective breathing pattern
d) Risk for vascular trauma

a) Decreased cardiac output
Explanation:
Based on assessment data for this client, the most logical nursing diagnosis will be decreased cardiac output. Third-degree AV block that is causing symptoms will be a slow rhythm that will produce a decreased cardiac output. pg.712
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) Fracture of the lead wire
d) Sensitivity is too low

a) Lead wire dislodgement
Explanation:
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. pg.720
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) Premature ventricular contraction (PVC)
b) Ventricular fibrillation
c) Ventricular bigeminy
d) Ventricular tachycardia

a) Premature ventricular contraction (PVC)
Explanation:
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. pg.707
A patient’s ECG tracing reveals a ventricular rate between 250 and 400, with saw-toothed P waves. The nurse correctly identifies this dysrhythmia as which of the following?

a) Atrial flutter
b) Atrial fibrillation
c) Ventricular tachycardia
d) Ventricular fibrillation

a) Atrial flutter
Explanation:
The nurse correctly identifies the 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. pg.703
The nurse is preparing to defibrillate a client with no breathing or pulse. Which nursing action precedes the nurse pressing the discharge button?

a) Shouts, “All clear”
b) States, “Charging”
c) Placing gel on the chest
d) Checking the ECG rhythm

a) Shouts, “All clear”
Explanation:
Preceding pressing the discharge button, the nurse shouts “All clear” to ensure that no one is in contact with the client. The other options are correct but not the nursing action immediately preceding. pg.716
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) “I will avoid any large magnets that may affect my pacemaker.”
d) “We will be getting rid of our microwave oven so it will not affect my pacemaker.”

d) “We will be getting rid of our microwave oven so it will not affect my pacemaker.”
Explanation:
Permanent pacemaker generators have filters that protect them from electrical interference from most household devices, motors, and appliances. pg.717
A 78-year-old client was just admitted to the cardiac step-down unit where you practice nursing. Upon stabilizing his condition, you begin a conversation about his symptoms and you answer his questions to the best of your ability. In your discussion of cardiac dysrhythmias, which of the following would you rule out as a likely origination point for cardiac dysrhythmias?

a) Ventricles
b) Bundle of His
c) Atria
d) Atrioventricular node

b) Bundle of His
Explanation:
Cardiac dysrhythmias may originate in the atria, atrioventricular node, or ventricles. They do not originate in the Bundle of His. Cardiac dysrhythmias do not originate in the Bundle of His. pg.693
A 28-year-old female patient presents to the emergency department (ED) stating severe restlessness and anxiety. Upon assessment, the patient’s heart rate is 118 bpm and regular, the patient’s pupils are dilated, and the patient appears excitable. Which action should the nurse take next?

a) Place the patient on supplemental oxygen.
b) Prepare to administer a calcium channel blocker.
c) Question the patient about alcohol and illicit drug use.
d) Instruct the patient to hold her breath and bear down.

c) Question the patient about alcohol and illicit drug use.
Explanation:
The patient is experiencing sinus tachycardia. Since the patient’s findings of tachycardia, dilated pupils, restlessness, anxiety, and excitability can indicate illicit drug use (cocaine), the nurse should question the patient about alcohol and illicit drug use. This information will direct the patient’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. pg.700
You are caring for a client with atrial fibrillation. What procedure would be recommended if drug therapies did not control the dysrhythmia?

a) Pacemaker implantation
b) Elective cardioversion
c) Mace procedure
d) Defibrillation

b) Elective cardioversion
Explanation:
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 Mace procedure is only a distractor for this question. Pacemakers are implanted for bradycardia. pg.704
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) Apply oxygen via nasal cannula and obtain a 12-lead ECG.
b) Document the findings and continue to monitor the patient.
c) Instruct the patient to bear down as if having a bowel movement.
d) Notify the patient’s primary care provider of the findings.

b) Document the findings and continue to monitor the patient.
Explanation:
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. pg.711
Elective cardioversion is similar to defibrillation except that the electrical stimulation waits to discharge until an R wave appears. What does this prevent?

a) Disrupting the heart during the critical period of atrial repolarization.
b) Disrupting the heart during the critical period of ventricular repolarization.
c) Disrupting the heart during the critical period of ventricular depolarization.
d) Disrupting the heart during the critical period of atrial depolarization.

b) Disrupting the heart during the critical period of ventricular repolarization.
Explanation:
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, options A, C, and D are incorrect. pg.716