Chapter 36: Nursing Management: Dysrhythmias

Question 1

1. To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the duration of the patients

a.

P wave.

b.

Q wave.

c.

P-R interval.

d.

QRS complex.

Answer 1

ANS: A

The P wave represents the depolarization of the atria. The P-R interval represents depolarization of the atria, atrioventricular (AV) node, bundle of His, bundle branches, and the Purkinje fibers. The QRS represents ventricular depolarization. The Q wave is the first negative deflection following the P wave and should be narrow and short.

Question 2

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?

a.

Count the number of large squares in the R-R interval and divide by 300.

b.

Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes.

c.

Calculate the number of small squares between one QRS complex and the next and divide into 1500.

d.

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

Answer 2

ANS: D

This is the quickest way to determine the ventricular rate for a patient with a regular rhythm. All the other methods are accurate, but take longer.

Question 3

3. A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of _____ beats/minute.

a.

15 to 20

b.

20 to 40

c.

40 to 60

d.

60 to 100

Answer 3

ANS: C

If the sinoatrial (SA) node fails to discharge, the atrioventricular (AV) node will automatically discharge at the normal rate of 40 to 60 beats/minute. The slower rates are typical of the bundle of His and the Purkinje system and may be seen with failure of both the SA and AV node to discharge. The normal SA node rate is 60 to 100 beats/minute.

Question 4

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, P-R interval not measurable, ventricular rate 162, R-R interval regular, and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patients cardiac rhythm as

a.

atrial flutter.

b.

sinus tachycardia.

c.

ventricular fibrillation.

d.

ventricular tachycardia.

Answer 4

ANS: D

The absence of P waves, wide QRS, rate >150 beats/minute, and the regularity of the rhythm indicate ventricular tachycardia. Atrial flutter is usually regular, has a narrow QRS configuration, and has flutter waves present representing atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration.

Question 5

5. The nurse notes that a patients cardiac 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?

a.

Ventricular couplets

b.

Ventricular bigeminy

c.

Ventricular R-on-T phenomenon

d.

Multifocal premature ventricular contractions

Answer 5

ANS: B

Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking. Pairs of wide QRS complexes are described as ventricular couplets. There is no indication that the premature ventricular contractions (PVCs) are multifocal or that the R-on-T phenomenon is occurring.

Question 6

6. A patient has a normal cardiac rhythm and a heart rate of 72 beats/minute. The nurse determines that the P-R interval is 0.24 seconds. The most appropriate intervention by the nurse would be to

a.

notify the health care provider immediately.

b.

give atropine per agency dysrhythmia protocol.

c.

prepare the patient for temporary pacemaker insertion.

d.

document the finding and continue to monitor the patient.

Answer 6

ANS: D

First-degree atrioventricular (AV) block is asymptomatic and requires ongoing monitoring because it may progress to more serious forms of heart block. The rate is normal, so there is no indication that atropine is needed. Immediate notification of the health care provider about an asymptomatic rhythm is not necessary.

Question 7

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/minute. Which of the following actions should the nurse take next?

a.

Immediately notify the health care provider.

b.

Document the rhythm and continue to monitor the patient.

c.

Perform synchronized cardioversion per agency dysrhythmia protocol.

d.

Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol.

Answer 7

ANS: D

The burst of sustained ventricular tachycardia indicates that the patient has significant ventricular irritability, and antidysrhythmic medication administration is needed to prevent further episodes. The nurse should notify the health care provider after the medication is started. Defibrillation is not indicated given that the patient is currently in a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation.

Question 8

8. After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective?

a.

Increase in the patients heart rate

b.

Increase in strength of peripheral pulses

c.

Decrease in premature atrial contractions

d.

Decrease in premature ventricular contractions

Answer 8

ANS: A

Atropine will increase the heart rate and conduction through the AV node. Because the medication increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have premature atrial or ventricular contractions.

Question 9

9. A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. The priority teaching needed for this patient would include information about

a.

anticoagulant therapy.

b.

permanent pacemakers.

c.

electrical cardioversion.

d.

IV adenosine (Adenocard).

Answer 9

ANS: A

Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant treatment for 3 weeks before attempting cardioversion. This is done to prevent embolization of clots from the atria. Cardioversion may be done after several weeks of anticoagulation therapy. Adenosine is not used to treat atrial fibrillation. Pacemakers are routinely used for patients with bradydysrhythmias. Information does not indicate that the patient has a slow heart rate.

Question 10

10. Which information will the nurse include when teaching a patient who is scheduled for a radiofrequency catheter ablation for treatment of atrial flutter?

a.

The procedure will prevent or minimize the risk for sudden cardiac death.

b.

The procedure will use cold therapy to stop the formation of the flutter waves.

c.

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

d.

The procedure will stimulate the growth of new conduction pathways between the atria.

Answer 10

ANS: C

Radiofrequency catheter ablation therapy uses electrical energy to burn or ablate areas of the conduction system as definitive treatment of atrial flutter (i.e., restore normal sinus rhythm) and tachydysrhythmias. All other statements regarding the procedure are incorrect.

Question 11

11. After providing a patient with discharge instructions on the management of a new permanent pacemaker, the nurse knows that teaching has been effective when the patient states

a.

I will avoid cooking with a microwave oven or being near one in use.

b.

It will be 1 month before I can take a bath or return to my usual activities.

c.

I will notify the airlines when I make a reservation that I have a pacemaker.

d.

I wont lift the arm on the pacemaker side up very high until I see the doctor.

Answer 11

ANS: D

The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The patient should notify airport security about the presence of a pacemaker before going through the metal detector, but there is no need to notify the airlines when making a reservation. Microwave oven use does not affect the pacemaker. The insertion procedure involves minor surgery that will have a short recovery period.

Question 12

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 education about care of patients with ICDs?

a.

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

b.

The nurse assists the patient to fill out the application for obtaining a Medic Alert ID.

c.

The nurse gives amiodarone (Cordarone) to the patient without first consulting with the health care provider.

d.

The nurse teaches the patient that sexual activity usually can be resumed once the surgical incision is healed.

Answer 12

ANS: A

The patient should avoid moving the arm on the ICD insertion site until healing has occurred in order to prevent displacement of the ICD leads. The other actions by the new nurse are appropriate for this patient.

Question 13

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?

a.

Turn the synchronizer switch to the off position.

b.

Give a sedative before cardioversion is implemented.

c.

Set the defibrillator/cardioverter energy to 360 joules.

d.

Provide assisted ventilations with a bag-valve-mask device.

Answer 13

ANS: B

When a patient has a nonemergency cardioversion, sedation is used just before the procedure. The synchronizer switch is turned on for cardioversion. The initial level of joules for cardioversion is low (e.g., 50). Assisted ventilations are not indicated for this patient.

Question 14

14. A 20-year-old 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, and the student denies any health problems. What action by the nurse is most appropriate?

a.

Allow the student to participate on the soccer team.

b.

Refer the student to a cardiologist for further diagnostic testing.

c.

Tell the student to stop playing immediately if any dyspnea occurs.

d.

Obtain more detailed information about the students family health history.

Answer 14

ANS: A

In an aerobically trained individual, sinus bradycardia is normal. The students normal BP and negative health history indicate that there is no need for a cardiology referral or for more detailed information about the familys health history. Dyspnea during an aerobic activity such as soccer is normal.

Question 15

15. When analyzing the rhythm of a patients electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n)

a.

isoelectric ST segment.

b.

P-R interval of 0.18 second.

c.

Q-T interval of 0.38 second.

d.

QRS interval of 0.14 second.

Answer 15

ANS: D

Because the normal QRS interval is 0.04 to 0.10 seconds, the patients QRS interval of 0.14 seconds indicates that the conduction through the ventricular conduction system is prolonged. The P-R interval and Q-T interval are within normal range, and ST segment should be isoelectric (flat).

Question 16

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

Answer 16

ANS: B

Leads II, III, and AVF reflect the inferior area of the heart and the ST segment changes. Lead II will best capture any electrocardiographic (ECG) changes that indicate further damage to the myocardium. The other leads do not reflect the inferior part of the myocardial wall and will not provide data about further ischemic changes in that area.

Question 17

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?

a.

Blood glucose 243 mg/dL

b.

Serum chloride 92 mEq/L

c.

Serum sodium 134 mEq/L

d.

Serum potassium 2.9 mEq/L

Answer 17

ANS: D

Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation. The health care provider will need to prescribe a potassium infusion to correct this abnormality. Although the other laboratory values also are abnormal, they are not likely to be the etiology of the patients PVCs and do not require immediate correction.

Question 18

18. A patients cardiac monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious and pulseless. Which action should the nurse take first?

a.

Perform immediate defibrillation.

b.

Give epinephrine (Adrenalin) IV.

c.

Prepare for endotracheal intubation.

d.

Give ventilations with a bag-valve-mask device.

Answer 18

ANS: A

The patients rhythm and assessment indicate ventricular fibrillation and cardiac arrest; the initial action should be to defibrillate. If a defibrillator is not immediately available or is unsuccessful in converting the patient to a better rhythm, the other actions may be appropriate.

Question 19

19. A patients cardiac monitor shows sinus rhythm, rate 64. The P-R 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?

a.

Place the transcutaneous pacemaker pads on the patient.

b.

Administer atropine sulfate 1 mg IV per agency dysrhythmia protocol.

c.

Document the patients rhythm and assess the patients response to the rhythm.

d.

Call the health care provider before giving the next dose of metoprolol (Lopressor).

Answer 19

ANS: D

The patient has progressive first-degree atrioventricular (AV) block, and the b-blocker should be held until discussing the medication with the health care provider. Documentation and assessment are appropriate but not fully adequate responses. The patient with first-degree AV block usually is asymptomatic, and a pacemaker is not indicated. Atropine is sometimes used for symptomatic bradycardia, but there is no indication that this patient is symptomatic.

Question 20

20. A patient develops sinus bradycardia at a rate of 32 beats/minute, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which actions should the nurse take next?

a.

Recheck the heart rhythm and BP in 5 minutes.

b.

Have the patient perform the Valsalva maneuver.

c.

Give the scheduled dose of diltiazem (Cardizem).

d.

Apply the transcutaneous pacemaker (TCP) pads.

Answer 20

ANS: D

The patient is experiencing symptomatic bradycardia, and treatment with TCP is appropriate. Continued monitoring of the rhythm and BP is an inadequate response. Calcium channel blockers will further decrease the heart rate, and the diltiazem should be held. The Valsalva maneuver will further decrease the rate.

Question 21

21. A 19-year-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 premature ventricular contractions (PVCs). What action should the nurse take next?

a.

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

b.

Ask the patient about current stress level and caffeine use.

c.

Ask the patient about any history of coronary artery disease.

d.

Have the patient taken to the hospital emergency department (ED).

Answer 21

ANS: B

In a patient with a normal heart, occasional PVCs are a benign finding. The timing of the PVCs suggests stress or caffeine as possible etiologic factors. It is unlikely that the patient has coronary artery disease, and this should not be the first question the nurse asks. The patient is hemodynamically stable, so there is no indication that the patient needs to be seen in the ED or that oxygen needs to be administered.

Question 22

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.

A patient who is in a sinus rhythm, rate 98, after having electrical cardioversion 2 hours ago

b.

A patient with new onset atrial fibrillation, rate 88, who has a first dose of warfarin (Coumadin) due

c.

A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating

d.

A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due

Answer 22

ANS: D

The frequent firing of the ICD indicates that the patients ventricles are very irritable, and the priority is to assess the patient and administer the amiodarone. The other patients may be seen after the amiodarone is administered.

Question 23

23. A patient who is on the progressive care 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?

a.

Obtain a 12-lead electrocardiogram (ECG).

b.

Notify the health care provider of the change in rhythm.

c.

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

d.

Assess the patients vital signs including oxygen saturation.

Answer 23

ANS: C

Because this patient has dyspnea and chest pain in association with the new rhythm, the nurses initial actions should be to address the patients airway, breathing, and circulation (ABC) by starting with oxygen administration. The other actions also are important and should be implemented rapidly.

Question 24

24. A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic and has no palpable pulses. What is the first action that the nurse should take?

a.

Perform synchronized cardioversion.

b.

Start cardiopulmonary resuscitation (CPR).

c.

Administer atropine per agency dysrhythmia protocol.

d.

Provide supplemental oxygen via non-rebreather mask.

Answer 24

ANS: B

The patients clinical manifestations indicate pulseless electrical activity and the nurse should immediately start CPR. The other actions would not be of benefit to this patient.

Question 25

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

Answer 25

ANS: A A patient with fainting episodes is at risk for falls. The nurse will plan to minimize the risk by having assistance whenever the patient up. The other actions may be needed if dysrhythmias are found to be the cause of the patients syncope, but are not appropriate for syncope of unknown origin.

Question 26

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

Answer 26

ANS: C UAP serving as telemetry technicians can monitor cardiac rhythms for individuals or groups of patients. Nursing actions such as assessment and choice of the most appropriate lead based on ST segment elevation location require RN-level education and scope of practice.

Question 27

27. Which action by a new registered nurse (RN) who is orienting to the progressive care unit indicates a good understanding of the treatment of cardiac dysrhythmias? a. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia b. Obtains the defibrillator and quickly brings it to the bedside of a patient whose monitor shows asystole c. Turns the synchronizer switch to the on position before defibrillating a patient with ventricular fibrillation d. Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second degree AV block

Answer 27

ANS: A Adenosine must be given over 1 to 2 seconds to be effective. The other actions indicate a need for more education about treatment of cardiac dysrhythmias. The RN should hold the diltiazem until talking to the health care provider. The treatment for asystole is immediate CPR. The synchronizer switch should be off when defibrillating.

Question 28

28. A patient reports dizziness and shortness of breath for several days. During cardiac 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. b. accelerated idioventricular rhythm. c. third-degree atrioventricular (AV) block. d. sinus rhythm with premature atrial contractions (PACs).

Answer 28

ANS: C The inconsistency between the atrial and ventricular rates and the variable P-R interval indicate that the rhythm is third-degree AV block. Sinus rhythm with PACs will have a normal rate and consistent P-R intervals with occasional PACs. An accelerated idioventricular rhythm will not have visible P waves.

Question 29

29. A patient who is complaining of a racing heart and feeling anxious comes to the emergency department. The nurse places the patient on a heart monitor and obtains the following electrocardiographic (ECG) tracing. Which action should the nurse take next? a. Prepare to perform electrical cardioversion. b. Have the patient perform the Valsalva maneuver. c. Obtain the patients vital signs including oxygen saturation. d. Prepare to give a b-blocker medication to slow the heart rate.

Answer 29

ANS: C The patient has sinus tachycardia, which may have multiple etiologies such as pain, dehydration, anxiety, and myocardial ischemia. Further assessment is needed before determining the treatment. Vagal stimulation or b-blockade may be used after further assessment of the patient. Electrical cardioversion is used for some tachydysrhythmias, but would not be used for sinus tachycardia.

Question 30

1. When preparing to defibrillate a patient. In which order will the nurse perform the following steps? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Turn the defibrillator on. b. Deliver the electrical charge. c. Select the appropriate energy level. d. Place the paddles on the patients chest. e. Check the location of other staff and call out all clear.

Answer 30

ANS: A, C, D, E, B This order will result in rapid defibrillation without endangering hospital staff.