Chapter 36: Care of Patients with Dysrhythmias Nursing School Test Banks

Chapter 36: Care of Patients with Dysrhythmias

Test Bank

MULTIPLE CHOICE

1. A clients cardiac status is being observed by telemetry monitoring. The nurse observes a P wave that changes shape in lead II. What conclusion does the nurse make about the P wave?

a. It originates from an ectopic focus.
b. The P wave was replaced by U waves.
c. It is from the sinoatrial (SA) node.
d. Multiple P waves are present.

 

ANS: A

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.

 

DIF: Cognitive Level: Comprehension/Understanding REF: p. 715

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

2. The nurse is assessing the clients electrocardiography (ECG). What does the P wave on the ECG tracing represent?

a. Contraction of the atria
b. Contraction of the ventricles
c. Depolarization of the atria
d. Depolarization of the ventricles

 

ANS: C

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

 

DIF: Cognitive Level: Knowledge/Remembering REF: p. 715

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

3. A nurse notes that the PR interval on a clients electrocardiograph (ECG) tracing is 0.14 second. What action does the nurse take?

a. Assess serum cardiac enzymes.
b. Administer 1 mg epinephrine IV.
c. Administer oxygen via nasal cannula.
d. Document the finding in the clients chart.

 

ANS: D

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.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Analysis)

4. When analyzing a clients electrocardiograph (ECG) tracing, the nurse observes that not all QRS complexes are preceded by a P wave. What is the nurses interpretation of this observation?

a. The client has hyperkalemia causing irregular QRS complexes.
b. Ventricular tachycardia is overriding the normal atrial rhythm.
c. The clients chest leads are not making sufficient contact with the skin.
d. Ventricular and atrial depolarizations are initiated from different sites.

 

ANS: D

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.

 

DIF: Cognitive Level: Comprehension/Understanding REF: p. 718

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

5. The nurse observes a prominent U wave on the clients electrocardiograph (ECG) tracing. What is the most appropriate action for the nurse to take?

a. Document the finding as a normal variant.
b. Review the clients daily electrolyte results.
c. Move the crash cart closer to the clients room.
d. Call for an immediate electrocardiogram.

 

ANS: B

Prominent U waves may be the result of hypokalemia. The nurse should review the clients daily electrolyte results. Although documentation is important, this is not a normal variant. Moving the crash cart closer to the room may or may not be warranted. The client does not need an immediate ECG.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

6. The clients heart rate increases slightly during inspiration and decreases slightly during expiration. What action does the nurse take?

a. Evaluate for a respirator disorder.
b. Assess the client for chest pain.
c. Document the finding in the chart.
d. Administer antidysrhythmic drugs.

 

ANS: C

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. No other actions are needed.

 

DIF: Cognitive Level: Comprehension/Understanding REF: p. 718

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

7. A client with tachycardia is experiencing clinical manifestations. Which manifestation requires immediate intervention by the nurse?

a. Mid-sternal chest pain
b. Increased urine output
c. Mild orthostatic hypotension
d. P wave touching the T wave

 

ANS: A

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

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

8. A client is experiencing sinus bradycardia with hypotension and dizziness. What medication does the nurse administer?

a. Atropine (Atropine)
b. Digoxin (Lanoxin)
c. Lidocaine (Xylocaine)
d. Metoprolol (Lopressor)

 

ANS: A

Atropine is a cholinergic antagonist that inhibits parasympathetically-induced hyperpolarization of the sinoatrial node. This inhibition results in an increased heart rate. The other medications are not appropriate.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes)

MSC: Integrated Process: Nursing Process (Implementation)

9. A client experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. What instruction does the nurse include in the clients teaching plan?

a. Minimize or abstain from caffeine.
b. Lie on your side until the attack subsides.
c. Use your oxygen when you experience PACs.
d. Take quinidine (Cardioquin) daily to prevent PACs.

 

ANS: A

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. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the client first should try lifestyle changes to control them.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

10. The nurse identifies a clients rhythm to be a sustained supraventricular tachycardia. What medication does the nurse administer?

a. Atropine (Atropine)
b. Epinephrine (Adrenalin)
c. Lidocaine (Xylocaine)
d. Diltiazem (Cardizem)

 

ANS: D

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.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes)

MSC: Integrated Process: Nursing Process (Implementation)

11. A client has a heart rate averaging 56 beats/min with no adverse symptoms. What activity modifications does 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 2 cups per day.

 

ANS: B

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

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Implementation)

12. The nurse is assessing clients at a community clinic. Which client does the nurse assess most carefully for atrial fibrillation?

a. Middle-aged client who takes an aspirin daily
b. Client who is dismissed after coronary artery bypass surgery
c. Older adult client after a carotid endarterectomy
d. Client with chronic obstructive pulmonary disease

 

ANS: B

Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft (CABG) surgery. The other conditions do not place a client at higher risk for atrial fibrillation.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

13. The nurse is caring for a client on a cardiac monitor. The monitor shows a rapid rhythm with a saw tooth configuration. What physical assessment findings does the nurse expect?

a. Presence of a split S1 and wheezing
b. Anorexia and gastric distress
c. Shortness of breath and anxiety
d. Hypertension and mental status changes

 

ANS: C

The rhythm described is atrial flutter with a rapid ventricular response. Rapid atrial flutter may manifest with palpitations, shortness of breath, and anxiety. Syncope, angina, and evidence of heart failure also may be present.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

14. The nurse is caring for a client with atrial fibrillation. What manifestation most alerts the nurse to the possibility of a serious complication from this condition?

a. Sinus tachycardia
b. Speech alterations
c. Fatigue
d. Dyspnea with activity

 

ANS: B

Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

15. The nurse is caring for a client with chronic atrial fibrillation. Which drug does the nurse expect to administer to prevent a common complication of this condition?

a. Sotalol (Betapace)
b. Warfarin (Coumadin)
c. Atropine (Atropine)
d. Lidocaine (Xylocaine)

 

ANS: B

Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. The other drugs are not appropriate for this complication.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes)

MSC: Integrated Process: Nursing Process (Implementation)

16. The nurse is caring for a client admitted for myocardial infarction. The clients monitor shows frequent premature ventricular contractions (PVCs). What dysrhythmia does the nurse remain alert for?

a. Sinus tachycardia
b. Rapid atrial flutter
c. Ventricular tachycardia
d. Atrioventricular junctional rhythm

 

ANS: C

With an acute myocardial infarction (MI), the onset of PVCs may be considered as a warning that could herald the onset of ventricular tachycardia or ventricular fibrillation.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

17. A client with myocardial ischemia is having frequent early, wide ventricular complexes seen on the cardiac monitor. Which medication does the nurse administer?

a. Lanoxin (Digoxin)
b. Amiodarone (Cordarone)
c. Dobutamine (Dobutamine)
d. Atropine sulfate (Atropisol)

 

ANS: B

Early, wide ventricular complexes are premature ventricular contractions (PVCs). Amiodarone, an antidysrhythmic, is the treatment of choice for frequent PVCs. The other medications are not appropriate for this condition.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Analysis)

18. The nurse has administered adenosine (Adenocard). What is the expected therapeutic response?

a. Increased intraocular pressure
b. A brief tonic-clonic seizure
c. A short period of asystole
d. Hypertensive crisis

 

ANS: C

Clients usually respond to this medication with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain.

 

DIF: Cognitive Level: Comprehension/Understanding REF: p. 733

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Analysis)

19. A clients electrocardiograph (ECG) tracing shows a run of sustained ventricular tachycardia. What is the nurses first action?

a. Assess airway, breathing, and level of consciousness.
b. Administer an amiodarone bolus followed by a drip.
c. Cardiovert the client with a biphasic defibrillator.
d. Begin cardiopulmonary resuscitation (CPR).

 

ANS: A

The first action that the nurse should take when ventricular tachycardia is observed is to assess the clients airway, breathing, and level of consciousness. If the client is unconscious or has experienced respiratory arrest, defibrillation and CPR are begun.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

20. A client with unstable ventricular tachycardia is receiving amiodarone by intravenous infusion. The nurse notes that the clients heart rate has decreased from 68 to 50 beats/min. The client is asymptomatic. What is the nurses priority intervention?

a. Stop the infusion and flush the IV.
b. Slow the amiodarone infusion rate.
c. Administer a precordial thump.
d. Place the client in a side-lying position.

 

ANS: B

IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly ceasing the medication could allow fatal dysrhythmias to occur. A precordial thump is not required at this time because the client still has a heart rate. A side-lying position will not increase the clients heart rate.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Implementation)

21. A client with ischemic heart disease has an electrocardiograph (ECG) tracing that shows a PR interval of 0.24 second. What is the nurses best action?

a. Document the finding in the chart.
b. Measure blood pressure.
c. Notify the health care provider.
d. Administer oxygen.

 

ANS: A

This prolonged PR interval indicates a first-degree heart block. First-degree heart block in a stable client requires no intervention.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Implementation)

22. The physician is about to perform carotid sinus massage on a client with supraventricular tachycardia. What equipment is most important for the nurse to have ready?

a. Emesis basin
b. Magnesium sulfate
c. Resuscitation cart
d. Padded tongue blade

 

ANS: C

Complications of this procedure include bradydysrhythmias, asystole, ventricular fibrillation, and cerebral damage. The resuscitation cart, complete with defibrillator, should be available whenever this procedure is initiated. The other equipment is not needed.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Planning)

23. The nurse is caring for a client with a complete heart block (third-degree atrioventricular [AV] block). What is the nurses priority intervention?

a. Perform a cardioversion.
b. Assist with carotid massage.
c. Begin external pacing.
d. Administer adenosine (Adenocard) IV.

 

ANS: C

The nurse would expect the client with complete heart block or third-degree AV block to be paced externally until the client can be scheduled for a permanent pacemaker.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Planning)

24. A client with third-degree heart block is admitted to the telemetry unit. The nurse observes wide QRS complexes on the monitor with a heart rate of 35 beats/min. What priority assessment does the nurse perform?

a. Pulmonary auscultation
b. Pulse strength and amplitude
c. Level of consciousness
d. Mobility and gait stability

 

ANS: C

A heart rate of 40 beats/min or less, with widened QRS complexes, could have hemodynamic consequences, and the client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, lightheadedness, confusion, syncope, and seizure activity.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

25. The nurse is caring for a client with a temporary pacemaker. The clients bedside monitor shows a spike followed by a QRS complex. What is the nurses best action?

a. Remove the pacemaker; it is not needed.
b. Decrease the threshold of the pacemaker.
c. Document the finding in the clients chart.
d. Set the pacemaker to the synchronous mode.

 

ANS: C

A spike followed by a QRS complex indicates capture, meaning that the pacemaker has successfully depolarized or captured the ventricle. No action other than documentation of this finding is necessary.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation)

26. A client with ventricular tachycardia (VT) is unresponsive and has no pulse. The nurse calls for assistance and a defibrillator. What is the nurses priority intervention while waiting for the defibrillator to arrive?

a. Perform a pericardial thump.
b. Initiate cardiopulmonary resuscitation.
c. Start an 18-gauge IV in the antecubital.
d. Ask the clients family about code status.

 

ANS: B

A client with pulseless VT should be defibrillated immediately. If the defibrillator is not available, the nurse should initiate cardiopulmonary resuscitation (CPR) and then should defibrillate as soon as possible. Basic life support (BLS) is the basis of emergency cardiac care; if the client does not have an IV already, this can wait until others have arrived to help. Providing good quality CPR is vital. The client should have already been assessed for code status.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

27. A client has an epicardial pacemaker. The nurse observes the presence of a pacing spike but no QRS complex on the clients electrocardiograph (ECG) tracing. How does the nurse interpret this event?

a. Loss of capture
b. Ventricular fibrillation
c. Failure to sense
d. A normal tracing

 

ANS: A

In epicardial pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Assessment)

28. The nurse is assisting with resuscitation of a client. What priority intervention does the nurse perform before defibrillating a client?

a. Make sure the defibrillator is set to the synchronous mode.
b. Deliver a precordial thump to the upper portion of the sternum.
c. Test the equipment by delivering a smaller shock at 100 J.
d. Ensure that all personnel are clear of contact with the client and the bed.

 

ANS: D

To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thumb can be delivered when no defibrillator is available. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Defibrillation is done in asynchronous mode.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlSafe Use of Equipment)

MSC: Integrated Process: Nursing Process (Implementation)

29. The nurse is recovering a client after insertion of an implantable cardioverter-defibrillator (ICD). What complication must the nurse intervene for immediately?

a. 2/4 bilateral peripheral edema
b. Heart rate of 56 beats/min
c. Temperature of 96 F (35.5 C)
d. Muffled heart sounds

 

ANS: D

In the postimplantation period, the nurse should be alert for complications of cardiac tamponade, bleeding, and dysrhythmias. Muffled heart sounds are a manifestation of cardiac tamponade. Edema and a lower temperature would not be indicative of a complication of this procedure. Bradycardia might need intervention, but this clients heart rate is not critically low.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Evaluation)

30. A client was admitted for a permanent pacemaker insertion. What priority instruction does the nurse include in the clients discharge teaching?

a. Do not submerge your pacemaker, take only showers.
b. Report pulse rates lower than your pacemaker setting.
c. If you feel weak, apply pressure over your generator.
d. Have your pacemaker turned off before having an MRI.

 

ANS: B

The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

31. The nurse is providing discharge instructions for a client with an implantable cardioverter-defibrillator (ICD). What statement by the client indicates a good understanding of the instructions?

a. I should wear a snug-fitting shirt over the ICD.
b. I will avoid sources of strong electromagnetic fields.
c. I cant perform activities that increase my heart rate.
d. Now I can discontinue my antidysrhythmic medication.

 

ANS: B

The client being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields. Clients should avoid tight clothing, which could cause irritation over the ICD generator. The client should not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. The client should continue all prescribed medications.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

32. A nurse assesses the following electrocardiography (ECG) strip from a clients telemetry monitor. What does the nurse chart as the clients ventricular heart rate?

a. 40 beats/min
b. 80 beats/min
c. 120 beats/min
d. 160 beats/min

 

ANS: B

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.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Pathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

33. The nurse is assessing a clients ECG. What is the nurses interpretation of the following ECG strip?

a. Sinus rhythm with premature ventricular contractions (PVCs)
b. Ventricular tachycardia
c. Ventricular fibrillation
d. Sinus rhythm with premature atrial contractions (PACs)

 

ANS: A

Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometime precedes atrial depolarization.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Pathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

34. The nurse notes the following rhythm on a clients telemetry monitor. How does the nurse interpret these findings?

a. Ventricular tachycardia
b. Second-degree heart block
c. Supraventricular tachycardia
d. Premature ventricular contractions

 

ANS: A

Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Pathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

35. A nurse assesses the following ECG strip from a clients telemetry monitor. What does the nurse do next?

a. Measure hourly urine output.
b. Assess the clients vital signs.
c. Administer 0.5 mg atropine IV.
d. Prepare for external pacing.

 

ANS: B

Assessing the clients vital signs allows the nurse to determine if he or she is stable or unstable and symptomatic with the bradycardia. The clients stability with the bradycardia will determine the need for specific interventions.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

36. The nurse is alerted to a clients telemetry monitor. After assessing the following ECG, what is the nurses priority intervention?

a. Start a large-bore IV.
b. Administer atropine.
c. Prepare for intubation.
d. Perform defibrillation.

 

ANS: D

The clients rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. If the client does not already have an IV , other members of the team can insert one after defibrillation. Likewise, intubation can occur later if necessary. Atropine is not given for ventricular fibrillation.

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Pathophysiology)

MSC: Integrated Process: Nursing Process (Intervention)

MULTIPLE RESPONSE

1. A client has a consistently regular heart rate of 128 beats/min. Which related physiologic alterations does the nurse assess for? (Select all that apply.)

a. Decrease in cardiac output
b. Increase in cardiac output
c. Increase in blood pressure
d. Decrease in blood pressure
e. Increase in urine output

 

ANS: A, D

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

 

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

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