Ch.

35

1. The nurse observes no P waves on the patients monitor strip. There are fine, wavy lines between
the QRS complexes. The QRS complexes measure 0.08 sec (narrow), but they occur irregularly with a
rate of 120 beats/min. What does the nurse determine the rhythm to be?

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 truly contracting, just
fibrillating. Sinus tachycardia is a sinus rate above 100 beats/min 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 that have distorted QRS complexes with regular or irregular rhythm, and the
P wave is usually buried in the QRS complex without a measurable PR interval

2.The nurse performs discharge teaching for a patient with an implantable cardioverter-defibrillator
(ICD). Which statement by the patient indicates to the nurse that further teaching is needed?

“I can expect redness and swelling of the incision site for a few days.”

Patients should be taught to report any signs of infection at incision site (e.g., redness, swelling,
drainage) or fever to their primary care providers immediately. Teach patients to inform TSA airport
security of presence of ICD because it may set off metal detectors. If a handheld screening wand is
used, it should not be placed directly over the ICD. Teach patients to avoid standing near antitheft
devices in doorways of stores and public buildings and to walk through them at a normal pace.
Caregivers should learn cardiopulmonary resuscitation.

3. When computing a heart rate from the electrocardiography (ECG) tracing, the nurse counts 15 of
the small blocks between the R waves of a patient whose rhythm is regular. What does the nurse
calculate the patient’s heart rate to be?

100 beats/min

Because each small block on the ECG paper represents 0.04 seconds, 1500 of these blocks represents 1
minute. By dividing the number of small blocks (15, in this case) into 1500, the nurse can calculate the
heart rate in a patient whose rhythm is regular (in this case, 100)

4. The nurse prepares to defibrillate a patient. For which dysrhythmia has the nurse observed in this
patient?

Ventricular fibrillation

Defibrillation is always indicated in the treatment of ventricular fibrillation. Drug treatments are
normally used in the treatment of uncontrolled atrial fibrillation and for ventricular tachycardia with a
pulse (if the patient is stable). Otherwise, synchronized cardioversion is used (as long as the patient
has a pulse). Pacemakers are the treatment of choice for third-degree heart block

5. The patient has a potassium level of 2.9 mEq/L, and the nurse obtains the following measurements
on the rhythm strip: Heart rate of 86 with a regular rhythm, the P wave is 0.06 seconds (sec) and
normal shape, the PR interval is 0.24 sec, and the QRS is 0.09 sec. How should the nurse document
this rhythm?

First-degree AV block

In first-degree atrioventricular (AV) block, there is prolonged duration of AV conduction that

lengthens the PR interval above 0.20 sec. In type I second-degree AV block, the PR interval continues
to increase in duration until a QRS complex is blocked. In type II, the PR interval may be normal or
prolonged, the ventricular rhythm may be irregular, and the QRS is usually greater than 0.12 sec. PACs
cause an irregular rhythm with a different-shaped P wave than the rest of the beats, and the PR
interval may be shorter or longer. PVCs cause an irregular rhythm, and the QRS complex is wide and
distorted in shape.

6. The nurse observes ventricular tachycardia (VT) on the patient’s monitor. What evaluation made
by the nurse led to this interpretation?

Rate 200 beats/min; P wave not visible

VT is associated with a rate of 150 to 250 beats/min; the P wave is not normally visible. Rate and
rhythm are not measurable in ventricular fibrillation. P wave inversion and a normal QRS complex are
not associated with VT

7. Which statement best describes the electrical activity of the heart represented by measuring the
PR interval on the electrocardiogram (ECG)?

The length of time for the electrical impulse to travel from the sinoatrial (SA) node to the
Purkinje fibers

The electrical impulse in the heart must travel from the SA node through the AV node and into the
Purkinje fibers in order for synchronous atrial and ventricular contraction to occur. When measuring
the PR interval (the time from the beginning of the P wave to the beginning of the QRS), the nurse is
identifying the length of time it takes for the electrical impulse to travel from the SA node to the
Purkinje fibers. The P wave represents the length of time it takes for the impulse to travel from the SA
node through the atrium, causing depolarization of the atria (atrial contraction). Atrial repolarization
occurs during ventricular depolarization and is hidden by the QRS complex. The length of time it takes
for the electrical impulse to travel from the SA node to the AV node is the flat line between the end of
the P wave and the beginning of the Q wave on the ECG and is not usually measured

8. A patient develops third-degree heart block and reports feeling chest pressure and shortness of
breath. Which instructions should the nurse provide to the patient before initiating emergency
transcutaneous pacing?

“The device delivers a current through your skin that can be uncomfortable.”

Before initiating transcutaneous pacing therapy, it is important to tell the patient what to expect. The
nurse should explain that the muscle contractions created by the pacemaker when the current passes
through the chest wall are uncomfortable. Pacing for complete heart block will not convert the heart
rhythm to normal. Overdrive pacing is used for very fast heart rates. Transcutaneous pacing is
delivered through pacing pads adhered to the skin.
9. The nurse observes a flat line on the patient’s monitor and the patient is unresponsive without
pulse. What medications does the nurse prepare to administer?

Epinephrine and/or vasopressin

Normally, the patient in asystole cannot be successfully resuscitated. However, administration of

epinephrine or vasopressin may prompt the return of depolarization and ventricular contraction.
Lidocaine and amiodarone are used for ventricular tachycardia or ventricular fibrillation. 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

10. Cardioversion is attempted for a patient with atrial flutter and a rapid ventricular response. After
the delivering 50 joules by synchronized cardioversion, the patient develops ventricular fibrillation.
Which action should the nurse take immediately?

Turn the synchronizer switch to the “off” position and recharge the device.

Ventricular fibrillation produces no effective cardiac contractions or cardiac output. If during

synchronized cardioversion the patient becomes pulseless or the rhythm deteriorates to ventricular
fibrillation, the nurse should turn the synchronizer switch off and initiate defibrillation. Fluids,
additional assessment, or treatment of pain alone will not restore an effective heart rhythm

11. The patient has atrial fibrillation with a rapid ventricular response. What electrical treatment
option does the nurse prepare the patient for

Synchronized cardioversion

Synchronized cardioversion is planned for a patient with supraventricular tachydysrhythmias (atrial

fibrillation with a rapid ventricular response). Defibrillation or AEDs are the treatment of choice to
end ventricular fibrillation and pulseless ventricular tachycardia (VT). An ICD is used with patients who
have survived sudden cardiac death, have spontaneous sustained VT, and are at high risk for future
life-threatening dysrhythmias.

12. The nurse is caring for a patient who is 24 hours postpacemaker insertion. Which nursing
intervention is most appropriate at this time?

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 nonpressure 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.

13. The nurse determines there is artifact on the patient’s telemetry monitor. Which factor should
the nurse assess for that could correct this issue?

Too much hair under the electrodes

Artifact is caused by muscle activity, electrical interference, or insecure leads and electrodes that
could be caused by excessive chest wall hair. Disabled automaticity would cause an atrial
dysrhythmia. Electrodes in the wrong lead 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

14. A patient informs the nurse of experiencing syncope. Which nursing action should the nurse
prioritize in the patient’s subsequent diagnostic workup?

Preparing to assist with a head-up tilt-test

In patients without structural heart disease, the head-up tilt-test is a common component of the
diagnostic workup after episodes of syncope. IV β-blockers are not indicated, although an IV infusion
of low-dose isoproterenol may be started in an attempt to provoke a response if the head-up tilt-test
did not have a response. Addressing pacemakers is premature and inappropriate at this stage of
diagnosis. Patient teaching surrounding antiplatelet aggregators is not directly relevant to the
patient’s syncope at this time

15. A patient reports dizziness and shortness of breath and is admitted with a dysrhythmia. Which
medication, if ordered, requires the nurse to carefully monitor the patient for asystole?

Adenosine

IV adenosine is the first drug of choice to convert supraventricular tachycardia to a normal sinus
rhythm. Adenosine is administered IV rapidly (over 1 or 2 seconds) followed by a rapid, normal saline
flush. The nurse should monitor the patient’s electrocardiogram continuously because a brief period
of asystole after adenosine administration is common and expected. Atropine sulfate increases heart
rate, whereas lanoxin and metoprolol slow the heart rate

16. The patient is admitted with acute coronary syndrome (ACS). The ECG shows ST-segment
depression and T-wave inversion. What should the nurse know that this indicates?

Myocardial ischemia

The ST depression and T wave inversion on the ECG of a patient diagnosed with ACS indicate
myocardial ischemia from inadequate supply of blood and oxygen to the heart. Myocardial injury is
identified with ST-segment elevation. Myocardial infarction is identified with ST-segment elevation
and a widened and deep Q wave. A pacemaker’s presence is evident on the ECG by a spike leading to
depolarization and contraction

17. The nurse obtains a 6-second rhythm strip and charts the following analysis:Tab 1Tab 2Tab 3Atrial
dataVentricular dataAdditional dataRate: 70, regularVariable PR interval Independent beatsRate: 40,
regularIsolated escape beatsQRS: 0.04 secP wave and QRS complexes unrelatedWhat is the correct
interpretation of this rhythm strip?

Third-degree heart block

Third-degree heart block represents a loss of communication between the atrium and ventricles from
atrioventricular node dissociation. This is depicted on the rhythm strip as no relationship between the
P waves (representing atrial contraction) and QRS complexes (representing ventricular contraction).
Whereas the atria are beating totally on their own at 70 beats/min, the ventricles are pacing
themselves at 40 beats/min. Sinus dysrhythmia is seen with a slower heart rate with exhalation and
an increased heart rate with inhalation. In Wenckebach heart block, there is a gradual lengthening of
the PR interval until an atrial impulse is nonconducted and a QRS complex is blocked or missing.
Premature ventricular contractions are the early occurrence of a wide, distorted QRS complex

18. The nurse is doing discharge teaching with the patient who received an implantable cardioverter-
defibrillator (ICD) in the left side. Which statement by the patient indicates to the nurse that further
teaching is required?

“I cannot fly because it will damage the ICD.”

The patient statement that flying will damage the ICD indicates misunderstanding about flying. The
patient should be taught that informing TSA security screening agents at the airport about the ICD
should be done because it may set off the metal detector and if a hand-held screening wand is used, it
should not be placed directly over the ICD. The other options indicate the patient understands the
teaching

19. The nurse is monitoring the electrocardiograms of several patients on a cardiac telemetry unit.
The patients are directly visible to the nurse, and all of the patients are observed to be sitting up and
talking with visitors. Which patient’s rhythm would require the nurse to take immediate action?

A 52-yr-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute

Frequent premature ventricular contractions (PVCs) (>1 every 10 beats) may reduce the cardiac
output and precipitate angina and heart failure, depending on their frequency. Because PVCs in CAD
or acute myocardial infarction indicate ventricular irritability, the patient’s physiologic response to
PVCs must be monitored. Frequent PVCs most likely must be treated with oxygen therapy, electrolyte
replacement, or antidysrhythmic agents