Nursing Care of Patients With Cardiac Dysrhythmias

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. A patient is diagnosed with a disorder affecting the P wave within the cardiac cycle. The nurse should plan care to address which cardiac action?
a. Atrial repolarization
b. Atrial depolarization
c. Ventricular repolarization
d. Ventricular depolarization
____ 2. The nurse is reviewing a patient’s electrocardiogram. Which wave should the nurse recognize as being the first positive wave in a normal cardiac cycle?
a. P wave
b. Q wave
c. R wave
d. S wave
____ 3. A patient is having an electrocardiogram. Which wave should the nurse identify as being the first negative wave after a P wave in a normal cardiac cycle?
a. Q wave
b. R wave
c. S wave
d. T wave
____ 4. The nurse is reviewing a patient’s electrocardiogram. Which wave should the nurse identify as being the second positive wave in a normal cardiac cycle?
a. Q wave
b. R wave
c. S wave
d. T wave
____ 5. A patient is experiencing electrocardiogram changes. Which wave should the nurse recognize as representing ventricular repolarization?
a. Q wave
b. R wave
c. S wave
d. T wave
____ 6. A patient is admitted for diagnosis of an electrocardiogram abnormality. Which wave should the nurse plan care based upon changes in the patient’s ventricular depolarization?
a. P wave
b. QRS complex
c. U wave
d. T wave
____ 7. After reviewing an electrocardiogram the nurse determines that an electrical impulse originated in a patient’s the sinoatrial node. What did the nurse see on this tracing?
a. An upright T wave
b. An inverted T wave
c. A positive P wave before a QRS complex
d. A negative P wave before a QRS complex
____ 8. The nurse is reinforcing teaching for a patient who has a pacemaker. Which measure should the nurse include when explaining how the pulse should be monitored?
a. Take radial pulse for 1 minute.
b. Take apical pulse for 1 minute.
c. Take jugular pulse for 30 seconds.
d. Take brachial pulse for 30 seconds.
____ 9. The nurse is teaching a patient what complications to report with a pacemaker rate set at 72 beats/minute. Which patient response indicates that further teaching is necessary?
a. “A pulse of 74 is still considered safe.”
b. “Any pulse rate over 60 is considered adequate.”
c. “If my pulse is 90, then I should notify the doctor.”
d. “My pulse rate will most likely be 72 when I take it.”
____ 10. A patient has a pacemaker set at 72 beats/min. The nurse obtains a heart rate of 62 beats/min. What action should the nurse take?
a. Review pacemaker documentation.
b. Palpate and observe the generator site.
c. Administer the patient’s scheduled digoxin dose.
d. Notify the registered nurse (RN) to inform the physician.
____ 11. The nurse is participating in the emergency care for a patient who is in ventricular fibrillation. Which manifestation should the nurse expect to find and document during data collection?
a. Dyspnea
b. Pinpoint pupils
c. Absent peripheral pulses
d. Capillary refill less than 3 seconds
____ 12. A patient is diagnosed with ventricular fibrillation. For which emergency intervention should the nurse anticipate preparing?
a. Defibrillation
b. Endotracheal Intubation
c. Synchronized cardioversion
d. Cardiopulmonary resuscitation (CPR)
____ 13. A patient scheduled for magnetic resonance imaging (MRI) has an implanted pacemaker. What should the nurse anticipate being done for this patient?
a. MRI will take longer than usual.
b. MRI is contraindicated for this patient.
c. The pacemaker settings will be adjusted.
d. The patient will be given sedation before MRI.
____ 14. A patient on cardiac telemetry has F waves present. Which entry should the nurse include in the documentation?
a. “Atrial fibrillation noted”
b. “Ventricular fibrillation present”
c. “Atrial flutter present on telemetry”
d. “Premature ventricular contractions noted”
____ 15. The nurse is reinforcing teaching for a patient with premature ventricular contractions (PVCs) and is being discharged. Which lifestyle recommendation should be the most important for the nurse to include?
a. “It is important for you to drink decaffeinated beverages.”
b. “You should increase the amount of exercise you do each day.”
c. “It is important for you to reduce the amount of fat in your diet.”
d. “Weight gain and fluid retention are likely causing your abnormal heart rhythm.”
____ 16. A patient is in sustained ventricular tachycardia. Which dysrhythmia should the nurse realize can occur if the ventricular tachycardia is not treated?
a. Atrial flutter
b. Atrial fibrillation
c. Complete heart block
d. Ventricular fibrillation
____ 17. The nurse is caring for a patient who develops sinus tachycardia. What action should the nurse take?
a. Inform the RN promptly.
b. Turn the patient onto the left side.
c. Recheck vital signs in 15 minutes.
d. Have the patient cough forcefully.
____ 18. The nurse is assessing a patient’s apical heart rate. Which heart rate should the nurse document as tachycardia?
a. 80 beats/min
b. 90 beats/min
c. 100 beats/min
d. 110 beats/min
____ 19. The nurse is reinforcing teaching for a patient who has had a pacemaker implanted in the right side of the chest. Which patient statement indicates correct understanding of the discharge teaching?
a. “I may lift 20 pounds safely.”
b. “I may move my arm freely.”
c. “I may resume normal activity in 1 week.”
d. “Grounded microwave ovens may be safely used.”
____ 20. The nurse is reviewing cardiac anatomy with a patient scheduled for pacemaker insertion. Where should the nurse identify the location of the sinus node for the patient?
a. Left atrium
b. Right atrium
c. Left ventricle
d. Right ventricle
____ 21. The nurse is reviewing the electrical activity of the heart with a patient scheduled for synchronized pacing. In which area of the heart should the nurse teach that an electrical impulse travels that originates in the sinus node?
a. Ventricle
b. Bundle of His
c. Purkinje’s fibers
d. Atrioventricular node
____ 22. The nurse is analyzing a patient’s electrocardiogram. What should the nurse consider as normal for the P-R interval?
a. 0.02 to 0.04 second
b. 0.05 to 0.l0 second
c. 0.12 to 0.20 second
d. 0.21 to 0.30 second
____ 23. A patient is experiencing palpitations that are found to be PVCs. Which manifestation should the nurse expect to observe in this patient?
a. Headache
b. Confusion
c. Lightheadedness
d. Tingling of extremities
____ 24. A patient is diagnosed with premature atrial contractions. On which area of the heart should the nurse focus when explaining this disorder to the patient?
a. Atrium
b. Ventricle
c. Bundle of His
d. Atrioventricular node
____ 25. The nurse observes two PACs in 1 minute on a patient’s cardiac monitor. The patient is asymptomatic. What action is required by the nurse?
a. Administer digoxin.
b. Notify the physician.
c. Continue monitoring the patient.
d. Take vital signs every 15 minutes.
____ 26. The nurse is seeking assistance for a patient having continuous cardiac monitoring. Which type of PVCs did the nurse most likely observe in this patient?
a. A PVC couplet
b. A unifocal PVC
c. R-on-T phenomenon
d. Less than six PVCs per minute
____ 27. While assessing vital signs the nurse determines the regularity of a patient’s cardiac rhythm. Which cardiac cycle measurement will the nurse use regularity to calculate?
a. Heart rate
b. ST segment
c. P-R interval
d. QRS interval
____ 28. A patient has a normal heartbeat of 72 beats per minute. What area of the conduction system should the nurse consider as functioning normally in this patient?
a. Bundle of His
b. Sinoatrial node
c. Purkinje’s fibers
d. Atrioventricular node
____ 29. The nurse notices that the ST segment is depressed on a patient reporting chest pain. What action should the nurse take?
a. Review the ECG recordings in the patient’s chart.
b. Auscultate chest sounds, and continue physical assessment.
c. Alert the supervising RN and patient’s physician immediately.
d. Continue to monitor the electrocardiogram (ECG) to determine if ST segment depression continues.
____ 30. While assisting in a code, the nurse recognizes a pattern of ventricular fibrillation on the cardiac monitor. Which should the nurse expect to be ordered next?
a. Defibrillation
b. Hyperoxygenation
c. Intravenous (IV) digoxin
d. IV atropine
____ 31. The nurse is conducting a community health screening. Which individual should the nurse recognize as being the highest risk for atrial fibrillation?
a. A 44-year-old obese male with asthma
b. A 62-year-old male smoker with a history of rheumatic heart disease
c. A 56-year-old female with diabetes who has elevated cholesterol levels
d. A 68-year-old female with Parkinson’s disease who takes carbidopa-levodopa (Sinemet)
____ 32. A patient is prescribed to have a 12-lead ECG completed. How many views of the patient’s heart will this ECG provide?
a. 6
b. 12
c. 18
d. 24
____ 33. The nurse is determining the functioning of a patient’s sinoatrial node. How many times per minute should the nurse expect the node to normally fire?
a. 20 to 40
b. 25 to 55
c. 40 to 85
d. 60 to 100
____ 34. The nurse is instructing a patient with an implantable cardioverter defibrillator (ICD) on cell phone use. How many inches should the nurse instruct the patient to keep the cell phone from the ICD?
a. 2
b. 4
c. 6
d. 8
____ 35. A patient recovering from an acute myocardial infarction has a heart rate of 30 beats per minute. Which area of the heart should the nurse consider as pacing this patient’s heart rate?
a. Sinoatrial node
b. Ventricular rate
c. Aortic valve rate
d. Atrioventricular node
____ 36. The nurse calculates a patient’s QRS interval as being 0.08 seconds. What should the nurse do for this patient?
a. Consider starting CPR.
b. Notify the RN immediately.
c. Prepare to defibrillate the patient.
d. Nothing since this is a normal finding.
____ 37. After analyzing a patient’s heart rhythm the nurse determines that the heart rate is 48 beats per minute. How should the nurse document this finding?
a. Sinus tachycardia
b. Sinus bradycardia
c. Ventricular fibrillation
d. Ventricular tachycardia
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 38. The nurse is contributing to a patient’s teaching plan after a pacemaker implantation. Which potential complications should be included in the patient’s teaching plan? (Select all that apply.)
a. Fainting
b. Embolism
c. Palpitations
d. Hemorrhage
e. Pulmonary edema
f. Infection at the site
____ 39. The nurse is reinforcing discharge teaching for a patient who has had a permanent pacemaker inserted. What is important for the nurse to include? (Select all that apply.)
a. Patient should avoid all grounded appliances.
b. Patient should wear medical alert identification.
c. Patient should avoid magnetic fields and high voltage.
d. Patient should avoid lifting anything more than 10 pounds.
e. Patient may return to normal activities, including sports, in 3 weeks.
f. Patient should report dizziness, irregular heartbeats, and palpitations.
____ 40. A patient is diagnosed with atrial fibrillation. Which characteristics of this rhythm should the nurse expect to observe on this patient’s cardiac monitor? (Select all that apply.)
a. Smooth P waves
b. Irregular rhythm
c. F waves with sawtooth pattern
d. PR interval 0.12 to 0.20 second
e. QRS complex not more than 0.10 second
f. Abnormal beat alternates with normal beat in a 1:1 ratio
____ 41. The nurse is caring for a patient recovering from cardioversion. For what should the nurse monitor in this patient? (Select all that apply.)
a. Skin burns
b. Blood pressure
c. Sensory disturbances
d. Respiratory problems
e. Rhythm disturbances
f. Changes in ST segment
____ 42. The nurse identifies the diagnosis of decreased cardiac output as being appropriate for a patient with an acute dysrhythmia. Which interventions should the nurse include in this patient’s plan of care? (Select all that apply.)
a. Monitor radial pulse.
b. Monitor apical pulse.
c. Monitor lung sounds.
d. Monitor level of consciousness.
e. Encourage patient to increase activity level.
f. Observe for adverse reactions to medications.
____ 43. The nurse is analyzing the P waves on a patient’s electrocardiogram tracing. For what should the nurse analyze this type of wave? (Select all that apply.)
a. The P waves all look alike.
b. The P waves all have different shapes.
c. The P waves are consistently occurring.
d. A P wave is present in front of every QRS.
e. A P wave is present at the end of every QRS.
____ 44. The nurse determines that a patient’s electrocardiogram is demonstrating normal sinus rhythm. What did the nurse observe to come to this conclusion? (Select all that apply.)
a. Regular rhythm
b. PR interval 0.16 seconds
c. QRS interval 0.20 seconds
d. Heart rate 88 beats per minute
e. P wave before each QRS complex

Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias
Answer Section

MULTIPLE CHOICE

1. ANS: B
P waves represent atrial depolarization. A. C. D. The P wave does not represent atrial repolarization, ventricular repolarization, or ventricular depolarization.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

2. ANS: A
P waves are the first positive wave in a normal cardiac cycle. B. C. D. These are not the first positive waves in the cardiac cycle.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

3. ANS: A
Q waves are the first negative wave after a P wave in a normal cardiac cycle. B. C. D. These waves are not the first negative waves in the cardiac cycle.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

4. ANS: B
R waves are the second positive wave in a normal cardiac cycle. A. The Q wave is the first negative wave. C. D. These waves are not the second positive wave in the cardiac cycle.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

5. ANS: D
T waves represent ventricular repolarization. A. B. C. These waves represent other actions within the cardiac cycle.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

6. ANS: B
QRS complex represents ventricular depolarization. A. C. D. These waves do not represent vascular depolarization.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

7. ANS: C
A positive P wave before a QRS complex indicates that an electrical impulse originated in the sinoatrial node. A. B. D. These waves do not indicate that the electrical impulse originated in the sinoatrial node.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

8. ANS: A
Patients are taught to take a radial pulse, as it is easier to learn than an apical pulse, for 1 minute and to report if it is 5 beats over or under the set pacemaker rate. B. It is difficult for a patient to learn how to take their own apical pulse. C. D. These pulse points are difficult for the patient to learn.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

9. ANS: B
For a pacemaker set at 72 beats per minute, a radial pulse over 60 is not adequate. A. C. D. Patients should be taught to take a radial pulse, as it is easier to learn than an apical pulse, for 1 minute and to report if it is five beats over or under the set pacemaker rate.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

10. ANS: D
The nurse should notify the RN if the pacemaker is five beats over or under the set pacemaker rate for physician notification, as the pacemaker is not functioning properly. A. B. C. These actions could delay detecting a potentially unsafe situation for the patient.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level: Application

11. ANS: C
Absent peripheral pulses are found with ventricular fibrillation. A. B. D. The patient has no measurable heart beat and therefore will not demonstrate dyspnea, pinpoint pupils or rapid capillary refill.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

12. ANS: A
Defibrillation is the best treatment for ventricular fibrillation to terminate it and increase survival. B. Endotracheal intubation will ensure oxygenation however will not affect the lethal heart rhythm. C. Synchronized cardioversion is not indicated for this heart rhythm. D. CPR may need to be started if defibrillation is not effective.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

13. ANS: B
MRI is contraindicated for anyone with a pacemaker or metal implants. A. C. D. These choices are inappropriate and dangerous for a patient with an implanted pacemaker.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

14. ANS: C
F waves are characteristic of atrial flutter. A. B. D. F waves do not indicate atrial fibrillation, ventricular fibrillation, or premature atrial contractions.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application | Integrated Processes: Communication and Documentation | Question to Guide Your Learning: 1

15. ANS: A
The ingestion of caffeine is a common cause of PVCs. The patient should be instructed to avoid caffeine. B. C. D. Exercise, dietary fat, body weight, and fluid level are not identified as causes for PVCs.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

16. ANS: D
Sustained ventricular tachycardia can progress to ventricular fibrillation. A. B. C. Atrial flutter, atrial fibrillation, and complete heart block are not associated with ventricular tachycardia.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

17. ANS: A
Inform the RN promptly so the physician can be notified immediately for treatment. B. Turning the patient onto the left side will not alter the patient’s rhythm. C. Waiting 15 minutes to recheck vital signs is unsafe for the patient. D. Coughing forcefully will not alter the patient’s rhythm.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

18. ANS: D
Sinus tachycardia is 101 or more beats per minute. A. B. C. These rates are not considered as being sinus tachycardia.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

19. ANS: D
Grounded microwave ovens may be safely used around pacemakers, which are now encased for protection. A. B. C. The patient is going to have activity, limb movement, and weight lifting restrictions after the insertion of a pacemaker.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

20. ANS: B
The sinus node is located in the right atrium. A. C. D. The sinus node is not located in the left atrium or right or left ventricles.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

21. ANS: D
An electrical impulse that originates in the sinus node travels from there to the atrioventricular node. A. B. C. The electrical impulse that originates in the sinus node does not travel to the ventricle, Bundle of His, or to the Purkinje fibers.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

22. ANS: C
The normal P-R interval is 0.12 to 0.20 second. A. B. The P-R interval is longer than 0.02 to 0.10 seconds. D. The P-R interval is shorter than 0.21 seconds.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

23. ANS: C
Lightheadedness is a manifestation of PVCs. A. B. D. Headache, confusion, and tingling extremities are not manifestations of PVCs.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

24. ANS: A
A premature atrial contraction (PAC) is a cardiac contraction that originates in the atrium. B. C. D. Premature atrial contractions do not originate in the ventricle, Bundle of His, or atrioventricular node.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

25. ANS: C
PACs are usually not dangerous, and often no treatment is required other than correcting the cause if they are frequent, so continue to monitor the patient. A. B. D. It is not necessary to take the other actions at this time.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

26. ANS: C
R-on-T phenomenon can trigger life-threatening dysrhythmias. Antidysrhythmic drugs that depress myocardial activity are used to treat PVCs. A. B. D. A few PVCs do not usually require treatment.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

27. ANS: A
After the rhythm regularity is determined, the heart rate is counted. For regular rhythms, use the method that is very accurate by counting the number of small boxes between two R waves and divide that number into 1500. This gives the bpm, because 1500 small boxes equal 1 minute. B. C. D. Regularity is not used to calculate ST segment, P-R interval, or QRS interval.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

28. ANS: B
The sinoatrial node initiates the normal heartbeat. A. C. D. A normal heartbeat does not indicate that the Bundle of His, Purkinje’s fibers, or atrioventricular node are functioning normally.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis

29. ANS: C
The nurse should alert the supervising RN and patient’s physician immediately as the ST segment depression indicates cardiac ischemia. The patient requires prompt treatment to prevent complications. A. Reviewing the ECG recordings in the patient’s chart is wasting valuable time. B. Auscultating chest sounds and other physical assessment parameters is wasting time. D. Continuing to monitor the cardiac tracing could lead to a potentially lethal situation.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Coordinated Care | Cognitive Level: Application

30. ANS: A
Immediate defibrillation is the best treatment for terminating ventricular fibrillation. B. C. D. The patient needs emergency intervention. Hyperoxygenation and IV medications will not be appropriate at this time.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

31. ANS: B
A history of cigarette smoking raises the risk of developing atrial fibrillation even after quitting. Other causes of atrial fibrillation include aging (increases after age 60 and is the most common sustained dysrhythmia), rheumatic or ischemic heart diseases, heart failure, hypertension, pericarditis, pulmonary embolism, and postoperative coronary artery bypass surgery. Medications can also cause this dysrhythmia. A. C. D. Asthma, elevated cholesterol levels, and Parkinson’s disease do not increase the risk of developing atrial fibrillation.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

32. ANS: B
For a 12 lead ECG, 12 different views of the patient’s heart will be provided. A. C. D. A 12 lead ECG will not provide 6, 18, or 24 views of the patient’s heart.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

33. ANS: D
The sinoatrial node normally fires at 60 to 100 beats/minute. A. B. C. The sinoatrial node fires more frequently than 20 to 85 per minute.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

34. ANS: C
The ventricular rate is 20 to 40 bpm. A. The sinoatrial node is the primary pacemaker of the heart and normally fires at a rate of 60 to 100 beats per minute (bpm). D. The AV node has an inherent rate of 40 to 60 bpm. C. The aortic valve does not have a mechanism to provide heart pacing.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

35. ANS: B
The ventricular rate is 20 to 40 bpm. A. The sinoatrial node is the primary pacemaker of the heart and normally fires at a rate of 60 to 100 beats per minute (bpm). D. The AV node has an inherent rate of 40 to 60 bpm. C. The aortic valve does not have a mechanism to provide heart pacing.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

36. ANS: D
The normal QRS interval is between 0.06 to 0.10 seconds. The nurse does not need to do anything for this rhythm. A. The patient does not need CPR. B. The nurse does not need to be immediately notified. C. The patient does not need to be defibrillated.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

37. ANS: B
Sinus bradycardia has the same cardiac cycle components as NSR. The only difference between the two is a slower rate caused by fewer impulses originating from the SA node. A. The heart rate is low which does not indicate tachycardia. C. D. There is no evidence to suggest that this patient is experiencing ventricular fibrillation or ventricular tachycardia.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

MULTIPLE RESPONSE

38. ANS: A, B, C
After a pacemaker insertion, the patient should check the incision daily and report evidence of inflammation or infection. Symptoms of dizziness, fainting, irregular heartbeat, or palpitations should be reported to a physician. D. E. F. Hemorrhage, pulmonary edema, and infection are not potential complications after pacemaker insertion.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Safety and Infection Control | Cognitive Level: Application

39. ANS: B, C, D, F
The patient should wear medical alert identification; report symptoms such as dizziness, irregular heartbeats, and palpitations; avoid magnetic fields and high voltage; and avoid lifting more than 10 pounds. A. Grounded appliances are not a hazard. E. Normal activity is resumed after 6 weeks, including sports.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

40. ANS: B, E
Atrial fibrillation is an irregular rhythm with a normal QRS interval. A. P waves are absent. C. F waves are seen in atrial flutter. D. There is no PR as P waves are absent. F. Premature ventricular contractions that occur every other beat are referred to as bigeminy.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

41. ANS: A, B, D, E, F
The nurse should monitor for skin burns, blood pressure, respiratory problems, rhythm disturbances, and changes in the ST segment. C. It is unlikely that the patient will experience sensory disturbances after cardioversion.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

42. ANS: A, B, C, D, F
The nurse should monitor radial and apical pulses, lung sounds, level of consciousness, and adverse effects of medication. E. Activity level is usually restricted during an acute dysrhythmia.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

43. ANS: A, C, D
The P waves on the ECG tracing are examined to see if (1) there is one P wave in front of every QRS; (2) the P waves are regularly occurring; and (3) the P waves all look alike. B. P waves should not have different shapes. E. A P wave should not be present at the end of every QRS.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

44. ANS: C
For normal sinus rhythm to be present, the heart rhythm should be regular, heart rate: 60 to 100 bpm, P waves should be rounded, upright, precede each QRS complex, and appear alike, the PR interval should be 0.12 to 0.20 seconds. C. For normal sinus rhythm the QRS interval should be less than or equal to 0.10 seconds.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis