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ch 35 Dysrhythmias

Terms in this set (55)

A patient reports a new onset of jaw pain. The nurse obtains the following electrocardiogram (ECG) tracing. What action should the nurse take?
1
Contact the primary health care provider
2
Administer hydrocodone
3
Place the patient in a Trendelenburg position
4
Recognize the ECG changes as indicative of digitalis toxicity
1
Contact the primary health care provider

The ECG tracing is showing ST elevation indicative of myocardial infarction (MI). The primary health care provider should be notified immediately so appropriate interventions can be prescribed. Morphine sulfate is the drug of choice for a patient experiencing an acute MI. Whenever possible, the patient experiencing an MI should be placed in a position promoting respirations. The Trendelenburg position inhibits respirations. Digoxin toxicity is characterized by ST segment depression, not elevation.
The nurse reviews the following electrocardiogram (ECG) tracing. The nurse recognizes that the abnormal ECG finding is usually caused by what?
1
Medications
2
Myocardial ischemia
3
Fluid overload
4
dehydration
2
Myocardial ischemia

Typical ECG changes that are seen in myocardial ischemia include ST segment depression and/or T wave inversion. Medications, fluid overload, and dehydration do not often affect the ST segment position on the ECG tracing.
A patient's electrocardiogram (ECG) tracing has changed from sinus tachycardia (ST) to the following rhythm. What should the nurse conclude from the ECG finding?
1
The patient is at risk for a pulmonary embolism
2
The patient is at risk for ventricular tachycardia
3
The patient is experiencing a myocardial infarction
4
The patient is showing signs of an elevated potassium level
3
The patient is experiencing a myocardial infarction

ST elevation is a manifestation of a myocardial infarction (MI). ST elevation does not increase a patient's risk of a pulmonary embolism. A patient can go into ventricular tachycardia because of an MI, but it is not the main reason the nurse would notify the primary health care provider in this situation. Hyperkalemia is evidenced by a peaked T wave, not ST elevation.
What does the T wave in an electrocardiogram (ECG) represent?
1
Time for ventricular repolarization
2
Time for depolarization of both ventricles
3
Time between ventricular depolarization and repolarization
4
Time for the passage of the electrical impulse through the atrium
1
Time for ventricular repolarization

The electrocardiogram is commonly used to detect abnormal heart rhythms and to investigate the cause of chest pains. The T wave in the electrocardiogram should be upright; it represents time for ventricular repolarization. Time taken for depolarization of both ventricles is represented by QRS interval. Time between ventricular depolarization and repolarization is represented by ST segment. Time for the passage of the electrical impulse through the atrium is represented by P wave.
The nurse analyzes a patient's electrocardiogram (ECG) and determines that there are 8 R-R intervals in a span of six seconds. What should the nurse document as the patient's heart rate? Record the answer using a whole number. __ beats/minute.
The heart rate can be calculated from an ECG by counting the number of R-R intervals in six seconds and multiplying that number by 10. In this case, the patient's ECG has eight R-R intervals. Therefore, 8 multiplied by 10 is 80.
Which property of the cardiac cell aids in responding mechanically to an impulse?
1
Excitability
2
Contractility
3
Automaticity
4
Conductivity
2
Contractility


Cardiac cells have different properties that are associated with the stimulation and formation of impulse. The property of the cardiac cell to respond mechanically to an impulse is called contractility. The property of the cardiac cell to be electrically stimulated is called excitability. The property of the cardiac cell to initiate an impulse spontaneously and continuously is called automaticity. The property of the cardiac cell to transmit an impulse along a membrane in an orderly manner is called conductivity.
The nurse has obtained a rhythm strip from a patient's telemetry monitor. Which description of the electrocardiogram (ECG) is correct?
1
Sinus tachycardia
2
Sinus bradycardia
3
Ventricular fibrillation
4
Ventricular tachycardia
1 Sinus tachycardia

This rhythm strip shows sinus tachycardia because the rate on this strip is above 101, and it displays normal P wave, PR interval, and QRS complex. Sinus bradycardia would look similar to sinus tachycardia but with a rate less than 60 beats/minute. Ventricular fibrillation does not have a measurable heart rate, PR interval, or QRS, and the P wave is not visible and the rhythm is irregular and chaotic. Ventricular tachycardia has a rate of 150 to 250 beats/minute, with a regular or irregular rhythm and P waves occurring independently of the QRS complex.
What is a disadvantage of a centralized monitoring system?
1
It cannot diagnose dysrhythmias.
2
It measures the patients' heart rate remotely.
3
It cannot rapidly detect myocardial ischemia.
4
It requires continuous observation of patients' ECGs
4
It requires continuous observation of patients' ECGs


A centralized monitoring system is a type of telemetry monitoring system. It requires continuous observation of a group of patients' electrocardiograms at a central location. Centralized monitoring systems observe heart rate and rhythm remotely, at a site distant from the patient. A centralized monitoring system helps to detect dysrhythmias, ischemia, or infarction in patients.
A patient is hospitalized following a 3-day history of heart palpitations and dizziness. The patient's electrocardiogram (ECG) shows the following rhythm. The nurse identifies that the patient is at risk for what?
1
Stroke
2
Type 2 diabetes
3
Myocardial infarction
4
Sudden cardiac death
1
Stroke

A risk of atrial fibrillation is clot formation in the atria caused by altered blood flow through the heart. If the clot forms on the right side of the heart, it can travel to the lungs, causing a pulmonary embolism. If the clot forms on the left side of the heart, the risk is of it traveling to the brain, causing a stroke or an embolism to other arteries in the body. The risk of an embolus is particularly high when the patient converts back to a normal sinus rhythm. To reduce the risk of clot formation in the heart, most patients with chronic atrial fibrillation are on some type of anticoagulation. Coumadin (Warfarin) often is prescribed.
Which action does flecainide have on the heart?
1
Decreases automaticity
2
Accelerates repolarization
3
Decreases impulse conduction
4
Reduces myocardial contractility
3
Decreases impulse conduction


Flecainide is a class IC sodium channel blocker; it decreases impulse conduction in patients. Mexiletine is a class IB sodium channel blocker that accelerates repolarization. β-adrenergic blockers like esmolol decrease the automaticity of the sinoatrial node. Myocardial contractility is reduced with diltiazem, a calcium channel blocker.
The nurse assesses a patient and notes a temperature of 101.6° F. Which type of dysrhythmia is associated with a fever?
1
Fibrillation
2
Sinus tachycardia
3
Sinus bradycardia
4
Junctional tachycardia
2
Sinus tachycardia

A fever may cause tachycardia with a decrease in cardiac output and hypotension. Fibrillation can cause significant problems for a patient with complex disease processes, but it is not related to fever. Bradycardia and junctional tachycardia are not typical results of fever.
The nurse that is monitoring the electrocardiogram (ECG) of a patient with hyperthyroidism observes regular, sawtooth-shaped flutter waves with an atrial rate 250 beats/minute. How should the nurse document this pattern?
1
Sinus bradycardia
2
Sinus tachycardia
3
Atrial flutter
4
Atrial fibrillation
3
Atrial flutter

Atrial flutter is an atrial tachydysrhythmia identified by flutter (F) waves, a sawtoothed pattern, with a 200-350 beats/minute atrial rate. In sinus bradycardia, the heart rate is less than 60 beats/minute, with regular rhythm and normal P waves. Sinus tachycardia is identified by 101 to 200 beats/minute, with regular rhythm and normal P waves. In atrial fibrillation, atrial rate is 350 to 600 beats/minute, with irregular rhythm, and fibrillatory (f) waves.
The nurse notes artifact on a patient's telemetry monitor. Which factors contribute to artifact?
1
Disabled automaticity
2
Stimulation of the vagus nerve fibers
3
Electrodes placed in the incorrect lead
4
Excessive hair under the electrode pads
4
Excessive hair under the electrode pads

One reason that artifact is seen on the monitor is when leads and electrodes are not secure. Electrode pads may not be secure if there is excessive hair under the pads, the skin is oily, or if diaphoresis is present. Disabled automaticity would cause an atrial dysrhythmia. Electrodes placed in the incorrect place will measure electricity in a different plane of the heart and may have a different wave form than expected. Stimulation of the vagus nerve fibers causes a decrease in heart rate, not artifact.
The nurse reviews a patient's electrocardiogram (ECG) tracing and notes a heart rate of 82 and an irregular rhythm. How should the nurse interpret the findings?
1
Sinus tachycardia
2
Junctional dysrhythmia
3
Premature atrial contractions
4
Paroxysmal supraventricular tachycardia
3
Premature atrial contractions

When premature atrial contractions are present, the result is an irregular rhythm. In sinus tachycardia, the patient's heart rate is 101 to 200 beats per minute, and the cardiac rhythm is regular. A heart rate of 40 to 180 beats per minute with regular cardiac rhythm is observed in patients with junctional dysrhythmias. A heart rate of 150 to 220 beats per minute with regular cardiac rhythm is observed in patients with paroxysmal supraventricular tachycardia.
A patient reports a sudden onset of dizziness. The nurse records the following electrocardiogram (ECG) tracing. The nurse suspects that the dizziness is most likely a result of what?
1
Inner ear infection
2
Myocardial infarction
3
Decreased cardiac output
4
Rapid metoprolol administration
3
Decreased cardiac output

The patient's rhythm is paroxysmal supraventricular tachycardia (PSVT). Depending on the rate and duration of PSVT, the patient often experiences symptoms related to decreased cardiac output. The cardiac output drops because of decreased ventricular filling time. Although an inner ear infection can cause dizziness, the ECG tracing is more likely to be the source of the dizziness. The ECG tracing is not indicative of a myocardial infarction. Metoprolol is given to treat hypertension and to decrease the heart rate.
The nurse is monitoring a patient on a wireless electrocardiogram (ECG) monitor. Which observation is a cause for concern?
1
Upright P wave
2
Flat ST segment
3
Prolonged QT interval
4
Upright T wave
3
Prolonged QT interval

Prolonged QT interval is a cause for concern. QT disturbance may be caused by drugs, electrolyte imbalances, and changes in heart rate. Upright P wave, flat ST segment, and upright T wave are normal findings.
A patient's electrocardiogram (ECG) shows a heart rate of 150 beats/minute and a normal P wave preceding each QRS complex. How should the nurse interpret the finding?
1
Atrial fibrillation
2
Sinus tachycardia
3
Ventricular fibrillation
4
Premature atrial contractions
2
Sinus tachycardia

Sinus tachycardia inhibits the vagus nerve or stimulates the sympathetic nervous system. This causes an increase in the heart rate to about 101 beats to 200 beats per minute. The electrocardiographic study of sinus tachycardia shows a normal P wave preceding each QRS complex with normal time and duration. In atrial fibrillation, the P waves are chaotic and fibrillatory and the QRS complex is normal. The electrocardiographic study of ventricular fibrillation elicits the absence of P waves and the PR interval and QRS interval cannot be measured. In premature atrial contraction, there are distorted P waves in the ECG.
A patient arrives in the emergency room with indigestion, shortness of breath, and back pain. The nurse reviews the results of the patient's 12-lead electrocardiogram (ECG) and notes ST elevation in leads II, III, and AVF. How should the nurse interpret the findings?
1
The patient has acute injury to the circumflex artery.
2
The patient has acute injury to the right coronary artery.
3
The patient has acute infarction of the left anterior descending artery.
4
The patient is not having a heart attack and most likely has gastric reflux.
2
The patient has acute injury to the right coronary artery.

An ST elevation in leads II, III, and AVF indicates an acute injury to the inferior wall of the left ventricle involving the right coronary artery. An ST elevation in leads V1-V4 indicates acute infarction of the septal or anterior wall of the left ventricle involving the circumflex and left anterior descending arteries. An ST elevation with T wave inversion and a pathologic Q wave indicate acute infarction with cardiac cell death. A patient with symptoms of indigestion, shortness of breath, and back pains should have an immediate 12-lead ECG to rule out cardiac involvement; these symptoms indicate something more severe than reflux.
The nurse observes the rhythm strip of a patient sitting up in bed and talking. The strip shows ventricular tachycardia (VT). What action should the nurse take?
1
Perform rapid defibrillation.
2
Palpate the patient for a pulse.
3
Take the patient's blood pressure.
4
Start cardiopulmonary resuscitation (CPR).
2
Palpate the patient for a pulse

The rhythm strip characterizes ventricular tachycardia (VT). Therefore the first step is to palpate the pulse. The treatment for VT with a pulse differs greatly than for VT without a pulse. If the VT is monomorphic and the patient has a pulse and has preserved left ventricular function, IV drugs are used. VT without a pulse is a life-threatening situation; rapid defibrillation and CPR are the first lines of treatment in this scenario. The nurse can take the patient's blood pressure after the presence of a pulse has been determined.
A patient with acute coronary syndrome has continuous ECG monitoring in place. The nurse analyzes the patient's rhythm strip and notes a normal atrial rate, regular atrial rhythm, normal-shaped P waves, widened QRS complexes, and 2 P waves preceding every QRS complex. There is no progressive lengthening of PR intervals. What is an appropriate priority intervention?
1
Perform synchronized cardioversion.
2
Administer amiodarone intravenous infusion.
3
Observe for symptoms of decreased cardiac output (CO).
4
Apply a transcutaneous pacemaker.
2
Administer amiodarone intravenous infusion.

The rhythm is a type II second-degree atrioventricular (AV) block (i.e., Mobitz II). The rhythm is identified by noting P waves that are nonconducted without progressive PR lengthening. This usually occurs when a block in one of the bundle branches is present. On conducted beats, the PR interval is constant. Type II second-degree AV block is a more serious type of block in which a certain number of impulses from the sinoatrial (SA) node are not conducted to the ventricles. This occurs in ratios of 2:1, 3:1, and so on (i.e., two P waves to one QRS complex, three P waves to one QRS complex). The nurse should assess for bradycardia, hypotension, and angina. If the patient becomes symptomatic, atropine or a temporary pacemaker may be needed.
A patient in asystole is likely to receive which drug treatment?
1
Epinephrine and vasopressin
2
Lidocaine and amiodarone
3
Digoxin and procainamide
4
β-adrenergic blockers and dopamine
1
Epinephrine and vasopressin

Treatment of asystole consists of CPR with initiation of ACLS measures. These include definitive drug therapy with epinephrine and/or vasopressin, and intubation.

Lidocaine and amiodarone are used for premature ventricular contractions (PVCs).
Digoxin and procainamide are used for ventricular rate control.

β-adrenergic blockers are used to slow heart rate and dopamine is used to increase heart rate.
A patient experiencing syncope is prescribed the head-up tilt-test. The nurse should perform the steps of the procedure in what order?
1.
Tilt the table 60 to 80 degrees.
2.
Keep the patient in the upright position for 20 to 60 minutes.
3.
Place the patient on a table supported by a belt across the torso and feet.
4.
Record the electrocardiogram and heart rate continuously and measure the blood pressure every three minutes.
5.
Obtain a baseline electrocardiogram, blood pressure, and heart rate in the horizontal position.
00:00:39
Question Answer Confidence ButtonsJust a guessPretty sureNailed it
Correct1.Place the patient on a table supported by a belt across the torso and feet.
Correct2.Obtain a baseline electrocardiogram, blood pressure, and heart rate in the horizontal position.
Correct3.Tilt the table 60 to 80 degrees.
Correct4.Keep the patient in the upright position for 20 to 60 minutes.
Correct5.Record the electrocardiogram and heart rate continuously and measure the blood pressure every three minutes.


The head-up tilt-test is a procedure used to determine the cause of fainting spells in a patient. It is a simple, noninvasive, and informative test. The first step is to place the patient on a table supported by a belt across the torso and feet. Next, a baseline electrocardiogram, blood pressure, and heart rate are obtained in the horizontal position. Next, the table is tilted 60 to 80 degrees, and the patient is kept in this upright position for 20 to 60 minutes. The electrocardiogram and heart rate are recorded continuously and blood pressure is measured every three minutes.
The nurse is caring for a patient with monomorphic ventricular tachycardia that is clinically stable. What is appropriate to be included on the patient's treatment plan?
1
Perform defibrillation
2
Administer amiodarone
3
Administer a vasopressor
4
Initiate cardiopulmonary resuscitation
2
Administer amiodarone

Amiodarone is an antiarrhythmic agent that corrects various atrial and ventricular dysrhythmias. Since the patient is clinically stable, amiodarone can be used. Defibrillation is not indicated for a patient that is clinically stable. There is no need to administer a vasopressor to a clinically stable patient. Cardiopulmonary resuscitation is not needed for a patient with a pulse and that is breathing.
What should a nurse advise a group of caregivers with regards to a patient with an implantable cardioverter-defibrillator (ICD)? Select all that apply.
1
Restrict air travel.
2
If the ICD fires more than once, contact the emergency response system (ERS).
3
Report any signs of infection at incision site.
4
Restrict magnetic resonance imaging (MRI) scan.
5
Restrict the lifting of the arm on the ICD side above the shoulder until approved.
2
If the ICD fires more than once, contact the emergency response system (ERS).
3
Report any signs of infection at incision site.
4
Restrict magnetic resonance imaging (MRI) scan.
5
Restrict the lifting of the arm on the ICD side above the shoulder until approved.

The patient should be instructed to contact ERS if the ICD fires more than once. The patient with an ICD should immediately report any signs of infection such as redness, swelling, drainage, or fever. The patient should not undergo MRI scan unless the ICD is approved as MRI-safe. Also, the arm on the ICD side should not be lifted above the shoulder unless approved by the cardiologist. Air travel is not restricted. However, while traveling, the patient should inform the airport security personnel about the presence of ICD because it may set off the metal detector.
A patient undergoing treatment for dysrhythmia is provided with a Holter monitor. What information should the nurse include in the patient teaching about the test? Select all that apply.
1
The patient should activate the monitor when experiencing symptoms.
2
The monitor records the electrocardiogram (ECG) when the patient is ambulatory.
3
The patient should record activities and any symptoms in a diary.
4
New technology using smart phone apps can obtain and save electrocardiogram (ECG) recordings.
5
The monitor records the electrocardiogram (ECG) when the patient performs daily activities.
2
The monitor records the electrocardiogram (ECG) when the patient is ambulatory.
3
The patient should record activities and any symptoms in a diary.
4
New technology using smart phone apps can obtain and save electrocardiogram (ECG) recordings.
5
The monitor records the electrocardiogram (ECG) when the patient performs daily activities.


The Holter monitor continuously records the ECG while the patient is ambulatory and performing daily activities. The patient should keep a diary and record activities and any symptoms. New technology using smart phone apps can obtain and save electrocardiogram (ECG) recordings and even detect some dysrhythmias. Exercise treadmill testing evaluates the patient's heart rhythm during exercise.
Assessment findings of a patient on a cardiac unit include decreased heart rate (HR), decreased cardiac output (CO), and type I second-degree atrioventricular (AV) block. The nurse identifies that what ECG findings are characteristic of this rhythm and may be responsible for the patient's symptoms? Select all that apply.
1
Regular rhythm
2
Slower ventricular rate
3
Consistent R-R intervals
4
Progressive lengthening of PR intervals
5
Blocked QRS complexes
2
Slower ventricular rate
4
Progressive lengthening of PR intervals
5
Blocked QRS complexes

Type I second-degree AV block is also called Mobitz I or Wenckebach phenomenon. It is depicted by the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. Once a ventricular beat is blocked, the cycle repeats itself with progressive lengthening of the PR intervals until another QRS complex is blocked. The atrial rate remains normal, but ventricular rate may be slower, due to blocked QRS complex. This results in bradycardia. The cardiac rhythm is irregular. The R-R intervals are not consistent
A patient is scheduled to receive IV adenosine. What action should the nurse take while administering the medication?
1
Observe the patient for pallor and hypotension.
2
Give the dose over 1 to 2 minutes and follow with a 20 mL normal saline flush.
3
Monitor the patient carefully for 10 minutes, the length of the drug's half-life.
4
Use an injection site as close to the heart as possible.
4
Use an injection site as close to the heart as possible.

Adenosine has a very short half-life (less than 10 seconds). Therefore, it is imperative that it be given rapidly, within one to two seconds, followed immediately by 20 mL of normal saline bolus flush, and be given via an IV site as close as possible to the heart. The nurse should monitor the patient for flushing, dizziness, chest pain, or palpitations. The drug is to be given rapidly. The drug's half-life is very short.
While explaining temporary pacemakers to a group of nursing students, what should the nurse include? Select all that apply.
1
All temporary pacemakers are transvenous.
2
Epicardial pacing involves attaching leads to the epicardium during heart surgery.
3
A transvenous pacemaker consists of leads that are threaded into the left ventricle.
4
Epicardial pacemakers are inserted in emergency departments and critical care units in emergency situations.
5
A transvenous pacemaker is attached to an external power source.
6
The placement of a transcutaneous pacemaker is noninvasive; it is a temporary procedure.
2
Epicardial pacing involves attaching leads to the epicardium during heart surgery.

5
A transvenous pacemaker is attached to an external power source.
6
The placement of a transcutaneous pacemaker is noninvasive; it is a temporary procedure.


Epicardial pacing wires are inserted into the epicardial wall of the heart during cardiac surgery. The wires are brought through the chest wall and can be connected to a pulse generator if needed. Four wires are placed through the chest wall of the patient, two wires from the atrium and two wires from the ventricles. These four wires are connected to the temporary pacemaker, and pacing thresholds are set for each patient. With transvenous pacemakers, a pacing catheter is inserted percutaneously into the right ventricle, where it gets connected to the endocardium near the ventricular septum. It is connected to a small external pulse generator by electrode wires. Placement of the transcutaneous pacemaker is noninvasive and a temporary method until a more permanent treatment is sought. Transcutaneous pacemakers use electrical stimulation that is delivered through the skin via external electrode pads connected to an external pacemaker (a defibrillator with pacemaker functions). Temporary pacemakers include transcutaneous pacemakers, transvenous pacemakers, and epicardial pacemakers.
A patient's electrocardiogram (ECG) has changed from a normal sinus rhythm to the following rhythm. The nurse assesses the patient who was sleeping. The patient's respirations are 16 and unlabored, and the blood pressure has dropped from 110/70 to 104/68. What action should the nurse take?
1
Continue monitoring the patient
2
Notify the primary health care provider
3
Check the medical record for hyperkalemia
4
Perform an in-depth assessment
1
Continue monitoring the patient


Sinus bradycardia can be a normal finding for athletes or patients when they sleep. Sinus bradycardia becomes clinically significant if the patient is symptomatic (hypotensive, chest pain, shortness of breath, change of level of consciousness). Because the respiratory status of the patient is stable and the blood pressure is only slightly lower because the patient is sleeping, the nurse should continue monitoring the patient. Hyperkalemia is characterized by a peaked T wave, and in advanced stages a widened QRS complex, neither of which are demonstrated on this ECG tracing.
What should the nurse include in discharge instruction for a patient with an implantable cardioverter-defibrillator (ICD)? Select all that apply.
1
Avoid or limit air travel.
2
Avoid large magnets and strong electromagnetic fields.
3
Obtain and wear a Medic Alert ID device at all times.
4
Avoid lifting arm on ICD side above the shoulder until approved.
5
Do not walk through antitheft devices in doorways of stores and public buildings
2
Avoid large magnets and strong electromagnetic fields.
3
Obtain and wear a Medic Alert ID device at all times.
4
Avoid lifting arm on ICD side above the shoulder until approved.

Patients with ICDs need to avoid large magnets and strong electromagnetic fields, because they may interfere with ICD function. These patients need to obtain and wear a Medic Alert ID device at all times, and avoid lifting their arms on the ICD side above their shoulders until approved. These patients do not need to avoid air travel; they can walk through antitheft devices at a normal pace but should not stand next to them.
The nurse is monitoring a patient in the intensive care unit. Which are the most common leads selected for continuous monitoring? Select all that apply.
1
Lead II
2
Lead III
3
Lead V 1
4
Lead V 6
5
Lead aVR
1
Lead II
3
Lead V 1

An electrocardiogram is a graphical representation of the electrical impulses produced in the heart. It involves the use of 12 leads. Lead II and lead V1 are commonly used for continuous monitoring of the cardiac impulses. The use of lead III, lead V6, and lead aVR are also a part of the normal 12-lead electrocardiogram, but are not usually used for continuous monitoring.
A patient with a newly inserted pacemaker receives discharge instructions from the nurse. Which patient statement indicates that further teaching is required?
1
"I should avoid using microwave ovens."
2
"I should avoid standing near antitheft devices."
3
"I should avoid direct blows to the pacemaker site."
4
"I should avoid close proximity to high-output electric generators."
1
"I should avoid using microwave ovens."

Microwaves do not interfere with a pacemaker's function and can be used safely. Electric signals from antitheft devices can affect pacemaker functioning. The patient should avoid direct blows to the pacemaker site to reduce pressure at the site. Electric signals from high-output electric generators can move the pacemaker from its position and affect its functioning.
A patient is hospitalized with an acute myocardial infarction. The patient's cardiac rhythm suddenly changes from sinus tachycardia to the following rhythm. What is the priority nursing action?
1
Check for a pulse.
2
Administer vasopressin.
3
Defibrillate.
4
Perform synchronized cardioversion.
3
Defibrillate

The ECG tracing is ventricular fibrillation, a lethal rhythm requiring a team of health care providers to provide interventions. VF results in an unresponsive, pulseless, and apneic patient. There should be no delay in starting compressions and using a defibrillator once available. It is not necessary for the nurse to check for a pulse; with VF, there will not be a pulse. Defibrillation and CPR take priority over medications. Synchronized cardioversion is a treatment for patients with a pulse; with VF, there will be no pulse.
The ECG monitor of a patient in the cardiac care unit after myocardial infarction (MI) indicates ventricular fibrillation. What should be the nurse's immediate action?
1
Perform cardiopulmonary resuscitation (CPR)
2
Administer intravenous (IV) amiodarone
3
Perform synchronized cardioversion
4
Prepare for insertion of a temporary transvenous pacemaker
1
Perform cardiopulmonary resuscitation (CPR)

Treatment consists of immediate initiation of CPR and advanced cardiac life support (ACLS), with the use of defibrillation and definitive drug therapy (e.g., epinephrine, vasopressin). There should be no delay in using a defibrillator once available. Amiodarone, cardioversion, and temporary pacemakers are not used to treat ventricular fibrillation.
Which type of arrhythmia is associated with the absence of P waves on an electrocardiogram (ECG)?
1
Sinus tachycardia
2
Sinus bradycardia
3
Ventricular fibrillation
4
Type II second-degree AV block
3
Ventricular fibrillation

Ventricular fibrillation is associated with the absence of P waves on an electrocardiogram (ECG) because of a decrease in cardiac output. P waves are visible with sinus tachycardia, sinus bradycardia, and type II second-degree AV block rhythms.
The nurse understands that a pacemaker is used for which type of dysrhythmia?
1
Atrial fibrillation
2
Ventricular fibrillation
3
Ventricular tachycardia
4
Third-degree AV block
4
Third-degree AV block

The use of a pacemaker (temporary or permanent) is considered a lifesaving measure for patients who have experienced heart block, particularly third-degree or complete heart block. A temporary pacemaker may be used until the block is resolved through medical interventions or a permanent pacemaker is inserted. In special situations, a pacemaker may be used for ventricular fibrillation or ventricular tachycardia; however, this is more an exception rather than routine. Atrial fibrillation is treated with medication such as diltiazem or synchronized electrical cardioversion. In special situations a ventricular pacemaker may be used for ventricular fibrillation or ventricular tachycardia; however, this is more an exception rather than routine.
The nurse teaches a group of nursing students about telemetry monitoring. The nurse should provide information that the steps for applying electrodes should be performed in what order?
1.
Gently rub the skin with dry gauze.
2.
Clip excessive hair with scissors.
3.
Monitor for artifact.
4.
Affix the electrodes.
1.
Clip excessive hair with scissors.
Correct2.Gently rub the skin with dry gauze.
Correct3.Affix the electrodes.
Correct4.Monitor for artifact.


The first step during the measurement of an ECG is to remove excess hair on the skin. The presence of hair may not facilitate the proper adherence of electrodes to the skin. This could interfere with the recording of the cardiac impulses. It is followed by wiping the skin with alcohol to remove dirt and oil, and gently rubbing with gauze until the skin becomes pale pink. Wiping of the skin is followed by attaching the electrodes to the patient at the designated areas. Artifact may occur for various reasons. This indicates deformity of baseline and waveforms on electrocardiograph.
While ambulating, a patient's ECG tracing changes from normal sinus rhythm with a heart rate of 90/beats per minute to the following tracing. Which action should the nurse take?
1
Notify the primary health care provider.
2
Administer digoxin.
3
Continue ambulating the patient.
4
Place the patient back into bed.
3
Continue ambulating the patient.


It is a normal phenomenon for the heart rate to increase slightly during ambulation because of an increased demand for oxygen. Therefore, the correct answer is to continue ambulating the patient. There is no need to notify the primary health care provider unless other symptoms occur. Digoxin does decrease the heart rate, but is not given if the heart rate only increases with exertion. Ambulation is to be encouraged to promote health. Placing the patient back into bed would not be appropriate in this situation.
The nurse provides education to a group of nursing students about cardiac conditions that are common causes of dysrhythmias. What should the nurse include in the teaching? Select all that apply.
1
Valve disease
2
Emotional crisis
3
Conduction defects
4
Accessory pathways
5
Electrolyte imbalances
1
Valve disease
3
Conduction defects
4
Accessory pathways

Dysrhythmia is a condition of abnormal heart rhythm caused by either abnormal conduction or abnormal formation of heart impulses. Several conditions are responsible for the development of dysrhythmia. The cardiac disorders that may lead to dysrhythmia involve valve disease, conduction defects, and accessory pathways. Emotional crisis and electrolyte imbalances are noncardiac conditions that may cause a dysrhythmia.
The nurse analyzes a patient's telemetry monitor strip and documents a heart rate of 86, regular rhythm, PR interval of 0.24 second, and a QRS interval of 0.10 second. How should the nurse interpret the findings?
1
First-degree atrioventricular (AV) block
2
Type I second-degree AV block
3
Type II second-degree AV block
4
Premature ventricular contraction (PVC)
1
First-degree atrioventricular (AV) block

In first-degree AV block, there is prolonged duration of AV conduction that lengthens the PR interval > 0.20 seconds. In type I second-degree AV block, the PR interval continues to lengthen until a QRS complex is blocked. In type II second-degree AV block, the PR interval may be normal or prolonged, but the ventricular rhythm may be irregular, and the QRS usually is usually greater than 0.12 second. PVCs cause an irregular rhythm and the QRS complex is wide and distorted in shape.
The nurse provides education to a group of nursing students about nonemergent synchronized cardioversion. Which statement made by a student indicates effective learning?
1
"The shock is delivered on the P wave."
2
"Cardioversion is designed to stop the heart very briefly."
3
"Adenosine is given before the procedure for sedation."
4
"After cardioversion, medications to regulate the heart rhythm are no longer needed."
2
"Cardioversion is designed to stop the heart very briefly."

Synchronized cardioversion is designed to send an electrical shock through the heart on the R wave. This stops the heart momentarily, allowing it to convert back to a normal sinus rhythm. In a nonemergent situation, sedation medicine is given before the procedure because of the pain of the electrical current passing through the chest wall. Postcardioversion, the patient will receive a prescription for cardiac medication to prevent recurrence of the tachyarrhythmia. In nonemergent cases, sedation (e.g., IV midazolam) is given for the patient's comfort. Adenosine is an intravenous medication designed to treat paroxysmal supraventricular tachycardia (PSVT) by slowing the conduction through the AV node, allowing the heart to return to a normal rhythm, but it has no sedative effects.
The nurse is teaching a group of newly hired nurses about temporary pacemakers. Which conditions would the nurse include when discussing the indications for a temporary pacemaker? Select all that apply.
1
Heart failure
2
Post-open heart surgery
3
Atrial fibrillation with slow ventricular response
4
Acute anterior myocardial infarction (MI) with second- or third-degree AV block
5
Acute inferior MI with symptomatic bradycardia and AV block
2
Post-open heart surgery
4
Acute anterior myocardial infarction (MI) with second- or third-degree AV block
5
Acute inferior MI with symptomatic bradycardia and AV block

A temporary pacemaker helps to maintain a normal heart pace when its electrical pathways are damaged. The power source of this device is placed outside the body. Temporary pacemakers are used after open heart surgery as prophylaxis. They are also indicated for use in patients with acute anterior MI with second- or third-degree heart block or bundle branch block. They are also indicated for patients with acute inferior MI with symptomatic bradycardia and AV block. Heart failure and atrial fibrillation are not indications for a temporary pacemaker.
A patient is diagnosed with pulseless ventricular tachycardia. The nurse should perform the steps of defibrillation in what order?
1.
Check to see that the synchronizer switch is turned off.
2.
Apply conductive materials to the chest.
3.
Turn the defibrillator on and select the proper energy level.
4.
Deliver the charge by depressing buttons on both paddles simultaneously.
5.
Charge the defibrillator using the button on the defibrillator or the paddles.
6.
Position the paddles firmly on the chest wall over the conductive material.
7.
Call and look to see that everyone is "all clear".
3.
Turn the defibrillator on and select the proper energy level.
1.
Check to see that the synchronizer switch is turned off.
2.
Apply conductive materials to the chest.
5.
Charge the defibrillator using the button on the defibrillator or the paddles
6.
Position the paddles firmly on the chest wall over the conductive material.
.
Call and look to see that everyone is "all clear".
4.
Deliver the charge by depressing buttons on both paddles simultaneousl
The nurse is reviewing prescriptions of four patients. What does the nurse infer from this review?

Patient A has atrial fibrillation.
2
Patient B has sinus tachycardia.
3
Patient C has junctional escape rhythm.
4
Patient D has sinus bradycardia.
3
Patient C has junctional escape rhythm.

A patient with junctional escape rhythm shows a heart rate in the range of 40 to 60 beats/minute. Atropine increases the ventricular rate and can effectively improve the junctional escape rhythm in patient C. Atrial fibrillation in patient A is treated with diltiazem. Sinus tachycardia can be effectively treated by synchronized cardioversion in patient B. Sinus bradycardia in patient D can be treated by amiodarone.
If the patient becomes hemodynamically unstable and symptomatic, emergent cardioversion is considered.
A patient reports a fluttering feeling in the chest. The nurse assesses a rhythm of supraventricular tachycardia (PSVT), a heart rate of 150 beats per minute, and a blood pressure of 120/60 mm Hg. The nurse anticipates that the patient's plan of care will include what treatments? Select all that apply.
1
Intravenous adenosine
2
Intravenous β-blockers
3
Intravenous calcium channel blockers
4
Vagal stimulation
5
Emergent cardioversion
1
Intravenous adenosine
2
Intravenous β-blockers
3
Intravenous calcium channel blockers
4
Vagal stimulation

Medications that may be used include adenosine, β-blockers, calcium channel blockers, and amiodarone. These drugs have impact on various phases of action potential.
Adenosine decreases conduction through the AV nodes. β-blockers decrease automaticity of the SA node. Treatment for PSVT also includes vagal stimulation. Common vagal maneuvers include Valsalva, carotid massage, and coughing.
If the patient becomes hemodynamically unstable and symptomatic, emergent cardioversion is considered.
The nurse is caring for a patient 24 hours after the patient underwent pacemaker insertion surgery. What will be included on the postoperative plan of care?
1
Changing the surgical dressing as needed
2
Encouraging full range-of-motion exercises of the involved arm
3
Assessing the incision for any redness, swelling, or discharge
4
Applying wet-to-dry dressings every four hours to the insertion site
3
Assessing the incision for any redness, swelling, or discharge

After pacemaker insertion, it is important for the nurse to observe signs of infection by assessing for any redness, swelling, or discharge from the incision site. The dressing is kept dry until removed, usually 24 hours postoperatively. It is important for the patient to limit activity of the involved arm to minimize pacemaker lead displacement.
The nurse reviews the electrocardiogram of four patients. What should the nurse conclude from these findings?
1
Patient B: There is organized electrical activity of the atria.
2
Patient D: There are recurring regular, sawtooth-shaped flutter waves.
3
Patient C: The discharge rate from the sinoatrial (SA) node is decreased.
4
Patient A: The sinoatrial (SA) node is functioning as the pacemaker of the heart
2
Patient D: There are recurring regular, sawtooth-shaped flutter waves

Variable and not measurable PR intervals with an atrial rate of 200 to 350 beats/minute are characteristics of atrial flutter in Patient D. The inverted P wave and PR interval of less than 0.12 second indicates a junctional dysrhythmia in Patient A. Replacement of P waves with chaotic, fibrillatory waves in the ECG and the atrial rate of 500 beats/minute indicates atrial fibrillation in Patient B. The normal P wave and the heart rate of 150 beats/min indicate sinus tachycardia in Patient C.
After synchronized cardioversion, a patient's electrocardiogram (ECG) tracing reveals the following. How should the nurse interpret the findings?
1
The cardioversion was successful.
2
The cardioversion will need to be repeated.
3
The patient is in an accelerated junctional rhythm.
4
The ECG tracing indicates hyperkalemia.
1
The cardioversion was successful.

The patient has converted to a normal sinus rhythm (NSR). The cardioversion was successful. Accelerated junctional rhythm is characterized by an absent P wave and inverted P wave before or following the QRS complex. Hyperkalemia is characterized by a peaked T wave. The T wave in this tracing is normal.
The nurse is analyzing patients' ECG tracings. Which patient is at greatest risk for a stroke?
1
2
3
4
1

ECG tracing #1 is atrial flutter, which places the patient at risk for stroke. Thrombus formation because of stasis of ventricular blood is less likely in rhythms such as sinus rhythm with first-degree atrioventricular (AV) block (#2), junctional rhythm (#3), and paroxysmal supraventricular tachycardia (#4).
The nurse assesses an unresponsive patient and reviews the patient's ECG tracing. The nurse determines that the patient is experiencing pulseless electrical activity (PEA). In addition to identifying the cause, what is the priority nursing action?
1
Defibrillate
2
Apply warm blankets
3
Assist with intubation
4
Initiate cardiopulmonary resuscitation (CPR)
4
Initiate cardiopulmonary resuscitation (CPR)

PEA is a situation in which organized electrical activity is seen on the ECG, but there is no mechanical heart activity and the patient has no pulse. Treatment begins with CPR followed by drug therapy and intubation. Correcting the underlying cause is critical to prognosis. Applying warm blankets would help with hypothermia but can be completed later. Intubation depends upon the patient's response to cardiopulmonary resuscitation. It is not appropriate to defibrillate; the activity on the ECG is organized.
The nurse observing a telemetry monitor notes that a patient that was in sinus rhythm is now in a different rhythm. The electrocardiogram (ECG) now shows no P waves, fine and wavy lines between the QRS complexes, QRS complexes that measure 0.08 sec, and QRS complexes that occur irregularly with a rate of 120 beats/minute. The nurse correctly interprets this rhythm as what?
1
Sinus tachycardia
2
Atrial fibrillation
3
Ventricular fibrillation
4
Ventricular tachycardia
2
Atrial fibrillation

Atrial fibrillation is represented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atria are not contracting truly, just fibrillating. Sinus tachycardia is a sinus rate above 100 beats/minute with normal P waves. Ventricular fibrillation is seen on the ECG without a visible P wave, an unmeasurable heart rate, PR, or QRS, and the rhythm is irregular and chaotic. Ventricular tachycardia is seen as three or more premature ventricular contractions (PVCs) that have distorted QRS complexes with regular or irregular rhythm; the P wave usually is buried in the QRS complex without a measureable PR interval.
The nurse is preparing to perform an electrocardiogram (ECG) on a patient. The nurse observes artifact on the monitor. What are possible causes of the artifact? Select all that apply.
1
The patient has dry skin.
2
The patient is shivering.
3
The conductive gel is moist.
4
Electrical interference is present.
5
The leads and electrodes are not secure.
2
The patient is shivering.
4
Electrical interference is present.
5
The leads and electrodes are not secure.

Muscle activity caused by shivering of the patient, electrical interference, or loose leads and electrodes can cause distorted baseline and waveforms called artifact on the electrocardiogram (ECG). Oily skin is wiped dry with alcohol to prepare the patient for ECG. Electrodes may have to be replaced if conductive gel has dried out.
A patient is in ventricular fibrillation, and cardiopulmonary resuscitation (CPR) is in progress. What is the first step the nurse should take?
1
Turn on the device.
2
Analyze the rhythm.
3
Apply conductive gel pads.
4
Select proper energy setting.
1
Turn on the device.

The healthcare team will have to perform defibrillation, and the first step is to turn on the defibrillator or AED. Applying conductive gel pads is always completed after the device has been turned on. Proper energy level selection and rhythm analysis is only completed using a defibrillator; they cannot be done with the AED.
The nurse suspects that a patient is experiencing myocardial infarction (MI). Which component of the patient's electrocardiogram (ECG) is most important for the nurse to analyze to make this determination?
1
P wave
2
PR interval
3
ST segment
4
Heart rate
3
ST segment

The typical ECG change seen during myocardial injury is ST segment elevation. The P wave represents time for the passage of the electrical impulse through the atrium; there are no specific changes that occur with MI. A prolonged PR interval is indicative of a heart block and is usually not associated with MI. A specific change is heart rate is not associated with MI.
The nurse reviews a patient's electrocardiogram (ECG) tracing. How should the nurse interpret the finding?
1
Sinus tachycardia
2
Sinus bradycardia
3
Premature atrial contraction
4
Premature ventricular contraction
2
Sinus bradycardia

Sinus bradycardia is a heart rhythm that originates from the sinus node. With this rhythm, the P wave precedes each QRS complex has a normal shape and duration, normal PR interval, and QRS complex. The patient with sinus bradycardia generally has a heart rate of less than 60 beats/minute. Patients with sinus tachycardia have a heart rate in the range of 101 to 200 beats/minute. Patients with premature atrial contraction generally have an irregular rhythm and a different shaped P wave. Patients with premature ventricular contraction have wide and distorted QRS complexes.
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