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NOTES

Chapter 36

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1. Which action will the nurse take to improve the quality of the electrocardiographic rhythm transmission to the monitoring system?

a.

Apply lotion to the client's chest before attaching the chest leads.

b.

Remove the hair from the chest area before attaching the chest leads.

c.

Instruct the client not to wear any clothing made from synthetic fabrics during the test.

d.

Apply skin protectant to area prior to placing electrode.

Electrocardiographic transmission quality is directly related to the degree of skin contact with the leads. Impedance is decreased by shaving contact areas, cleansing them with soap and water, and drying them thoroughly before attaching the leads.

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2. What will the nurse do to ensure the validity of comparison of electrocardiograms (ECGs) taken at different times?

a.

Remove electrodes after each ECG is completed.

b.

Place new ECG chest leads on the client before each ECG is completed.

c.

Position the client supine prior to each ECG.

d.

Ensure that electrode placement is identical for each ECG.

Positioning electrodes is crucial in obtaining an accurate ECG. To ensure validity of comparison of ECGs taken at different times, electrode placement must be accurate and identical at each test.

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3. A client's cardiac status is being observed by telemetry monitoring. A nurse observes a P wave that changes shape in lead II. What conclusion will the nurse make from this?

a.

The P wave is originating from an ectopic focus.

b.

The P wave is firing twice from the sinoatrial (SA) node.

c.

There is no real P wave.

d.

The P wave is normal.

If the P wave is firing consistently from the SA node, the P wave will have a consistent shape in a given lead. If the impulse is from an ectopic focus, then the P wave will vary in shape in that lead.

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4. What does the P wave on an ECG tracing represent?

a.

Contraction of the atria

b.

Contraction of the ventricles

c.

Depolarization of the atria

d.

Depolarization of the ventricles

The ECG tracing of a P wave represents electrical changes caused by atrial depolarization.

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DIF:

Cognitive Level: Knowledge REF: p. 734

OBJ:

Learning Outcome 6

TOP:

Client Needs Category: Physiological Integrity (Basic Care and Comfort)

MSC:

Integrated Process: Nursing Process (Assessment)

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5. A nurse notes that the PR interval on a client's ECG tracing is 0.14 second. What action will the nurse take?

a.

Call the health care provider.

b.

Administer epinephrine.

c.

Administer oxygen via nasal cannula.

d.

Document the finding as the only action.

The PR interval normally ranges from 0.12 to 0.20 second. This is a normal finding, so the nurse simply documents this. No further action is required.

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6. The client has exactly 8.0 R-R intervals in 150 small blocks on the ECG paper. Based on this information, the nurse calculates the client's ventricular heart rate to be which of the following?

a.

40 beats/min

b.

80 beats/min

c.

160 beats/min

d.

Cannot be calculated from the information provided

Precisely 6 seconds is represented by 150 small blocks on ECG paper. The number of R-R intervals, representing ventricular depolarization episodes present in 6 seconds, can be multiplied by 10 to calculate the ventricular heart rate.

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7. In analyzing a client's ECG tracing, the nurse observes that not all QRS complexes are preceded by a P wave. What is the nurse's interpretation of this observation?

a.

The client has hyperkalemia.

b.

The client is in ventricular tachycardia.

c.

One of the chest leads is not making sufficient contact with the skin.

d.

Ventricular depolarization is being initiated at a site different from atrial depolarization.

Normal rhythm shows one P wave preceding each QRS, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization.

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8. The nurse observes a prominent U wave on the client's ECG tracing. What is the nurse's interpretation of this finding?

a.

This is a normal finding.

b.

The client may have a potassium imbalance.

c.

The client is at risk for R-on-T phenomenon.

d.

The client has an evolving myocardial infarction.

Prominent U waves may be the result of hypokalemia.

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9. The client has a consistent and regular heart rate of 128 beats/min. Which physiologic alterations would be consistent with this finding?

a.

A decrease in cardiac output and blood pressure

b.

An increase in cardiac output and blood pressure

c.

An increase in blood pressure and decrease in cardiac output

d.

A decrease in blood pressure and increase in cardiac output

Consistently elevated heart rates initially cause blood pressure and cardiac output to increase. However, ventricular filling time, cardiac output, and blood pressure eventually decrease.

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10. The client's heart rate increases slightly during inspiration and decreases slightly during expiration. What action will the nurse take?

a.

Notify the physician.

b.

Assess the client for chest pain.

c.

Document the finding as the only action.

d.

Prepare to administer antidysrhythmic drugs.

Sinus dysrhythmia is noted when the heart rate increases slightly during inspiration and decreases slightly during expiration. Sinus dysrhythmia is a variant of normal sinus rhythm that is frequently observed in healthy children and adults.

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11. The client with tachycardia is experiencing clinical manifestations. Which one alerts the nurse to the need for immediate intervention?

a.

Chest pain

b.

Increased urine output

c.

Mild orthostatic hypotension

d.

P wave touching the T wave

Chest pain, possibly angina, indicates that the tachycardia may be increasing the client's myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain.

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12. The client is experiencing sinus bradycardia with hypotension and dizziness. Which will the nurse administer?

a.

Atropine (Atropine)

b.

Digoxin (Lanoxin)

c.

Lidocaine (Xylocaine)

d.

Metoprolol (Lopressor)

Atropine is a cholinergic antagonist that inhibits parasympathetic-induced hyperpolarization of the sinoatrial node. This inhibition results in an increased heart rate.

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13. The client is experiencing occasional premature atrial contractions (PACs) accompanied by palpitations. These episodes resolve spontaneously without treatment. What instructions will be included in a teaching plan for this client?

a.

Limit or abstain from caffeine.

b.

Lie on your left side until the attack subsides.

c.

Use your oxygen whenever you experience PACs.

d.

Take your quinidine twice daily on the days that you experience palpitations.

PACs usually have no hemodynamic consequences. For a client experiencing infrequent bouts of PACs, the nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress.

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14. The client's ECG reveals tachycardia with a heart rate of 170 beats/min that was initiated after a premature atrial contraction. This rhythm resolved spontaneously without treatment. What is the nurse's interpretation of this finding?

a.

Paroxysmal supraventricular tachycardia (PSVT)

b.

Ventricular tachycardia

c.

Ventricular fibrillation

d.

Rapid atrial flutter

PSVT is the term applied when the tachycardia is intermittent, initiated suddenly by a premature complex, such as a PAC. This dysrhythmia resolves without intervention.

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15. The nurse notes absent P waves and a heart rate of 200 beats/min on the client's telemetry. How does the nurse interpret these findings?

a.

Ventricular tachycardia

b.

Second-degree heart block

c.

Supraventricular tachycardia

d.

Premature ventricular contraction

Supraventricular tachycardia involves the rapid stimulation of atrial tissue. Thus, depolarization is stimulated above the ventricular conduction system and is using normal conduction pathways. P waves are obscured by the preceding T waves.

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16. What will the nurse administer to a client with sustained supraventricular tachycardia?

a.

Atropine (Atropine)

b.

Epinephrine (Adrenalin)

c.

Lidocaine (Xylocaine)

d.

Diltiazem (Cardizem)

Diltiazem, a calcium channel blocker, slows depolarization through the conduction system and is commonly used as an agent to terminate a sustained episode of supraventricular tachycardia.

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17. The client has a heart rate averaging 56 beats/min. The client has no adverse symptoms associated with this bradycardia and is not being treated for it. Which of the following activity modifications should the nurse suggest to avoid further slowing of the heart rate?

a.

"Make certain that your bath water is warm (100° F)."

b.

"Avoid bearing down or straining while having a bowel movement."

c.

"Avoid strenuous exercise, such as running, during the late afternoon."

d.

"Limit your intake of caffeinated drinks to no more than two cups per day."

Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in a slowing of the heart rate. Such a response is not desirable in a person who has bradycardia.

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18. Which client is most at risk for atrial fibrillation?

a.

A middle-aged client who takes an aspirin daily

b.

A client 3 days postcoronary artery bypass surgery

c.

An older adult client post-carotid endarterectomy

d.

An older adult with diabetes mellitus and hypertension

Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after CABG (coronary artery bypass graft) surgery.

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19. What physical assessment findings are expected in a client with atrial flutter and a rapid ventricular response?

a.

The presence of a split S1 and wheezing

b.

Anorexia and gastric distress

c.

Shortness of breath and anxiety

d.

Hypertension and mental status changes

Rapid atrial flutter may be manifested as palpitations, shortness of breath, and anxiety. Syncope, angina, and evidence of heart failure also may be present.

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20. Which is a priority intervention for the client experiencing atrial fibrillation?

a.

Measuring urinary output

b.

Assessing for shortness of breath

c.

Assessing pulse oximetry every hour

d.

Measuring blood pressure in the lying and sitting positions

A serious and frequent complication of atrial fibrillation is systemic emboli, particularly pulmonary emboli. The nurse should assess for shortness of breath, chest pain, and hemoptysis because they are symptoms of pulmonary emboli.

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21. Which alteration, when manifested in a client with atrial fibrillation, should alert the nurse to the possibility of an embolic stroke?

a.

A pulse deficit

b.

Speech alterations

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