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A 38-year-old female is brought to the Emergency Department with complaints of her "heart beating out of her chest". She is diaphoretic, tachypneic and her BP is 70/40. The cardiac monitor shows supraventricular tachycardia. Valsalva maneuvers and three doses of Adenosine have not been successful. The nurse should immediately: a.) prepare the patient for synchronized cardioversion. b.) give Epinephrine 1 mg IV and repeat in 3 minutes. c.) give Adenosine 6 mg IV per protocol. d.) perform unilateral carotid massage. Prior to discharge from the Emergency Department, the nurse prints a rhythm strip on a patient and notices that the P wave cannot be detected and the QRS complex is 0.24 seconds. This is a change in the patient's condition. What is the best action for the nurse to take? a.) Measure the PR interval. b.) Prepare the patient for discharge. c.) Notify the physician of this abnormal strip. d.) Continue to monitor for abnormalities. Rationale: c.) is correct because notifying the physician of the abnormal rhythm would be the most appropriate response. The patient has experienced a rhythm change and requires further treatment. a.) is not correct for measuring the PR would not be possible as there is no P wave present. Since the QRS interval and other parameters given are abnormal, discharging the patient would not be appropriate at this point. b.) is not correct as discharging the patient is not appropriate or safe practice. d.) is not correct because continuing to monitor the patient without any other actions would be inappropriate as the patient has experienced a change in condition. A patient is to have synchronized cardioversion for treatment of atrial flutter. He has received Heparin 500 units subcutaneously. Which of the following interventions should now be performed? a.) Assist the MD in intubating the patient to stabilize airway. b.) Sedate the patient with Versed 2 mg IV push per protocol. c.) Set the defibrillator in asynchronous mode and charge to 300 joules. d.) Steadily increase the voltage until the beats are captured. Rationale: b.) is correct since cardioversion is very painful, the patient should be sedated prior to the procedure.

a.) is not correct as intubation is usually not indicated prior to cardioversion. c.) is not correct as synchronized cardioversion is performed at less voltage than defibrillation (360 joules). The defibrillator should be set in synchronous mode so the shock will be delivered on the R wave. d.) is not correct because steadily increasing the voltage until the beats are captured is indicative of pacemaker therapy and not synchronized cardioversion. When a patient has long-term atrial fibrillation, the nurse would expect to include which drug in the plan of care to minimize the greatest risk that is commonly associated with atrial fibrillation? a.) Beta blockers b.) Digitalis c.) Anticoagulants d.) Antiarrhythmics

Rationale: c.) is correct because it reflects the greatest risk or complication of thrombi or emboli that occurs with long-term atrial fibrillation. Coumadin is often given prophylactically to prevent stroke, clots, or emboli from developing when hospitalizing a patient with longterm atrial fibrillation. The nurse should understand that which of the following treatments for Second Degree Type II AV Block would be appropriate? (Select all that apply) a.) Temporary pacemaker insertion b.) Close monitoring without intervention c.) Atropine to increase heart rate if symptomatic d.) Coronary stent placement to improve blood flow to myocardium e.) An implantable defibrillator surgically implanted Rationale: Rationale: a,c, and d are correct. Temporary pacing may be needed and atropine will temporarily improve heart rate cardiac output until the pacemaker can be inserted. b.) is incorrect because Type II has a tendency to develop complete heart block where adequate cardiac output is not maintained and arrest is likely. Type I can be monitored and minimal treatment is needed unless unstable hemodynamics are present. e.) is incorrect because a defibrillator is not called for since it is the ventricle that is trying to maintain the cardiac output from the decreased conduction between the atria and the ventricles. An implanted pacemaker may be needed permanently.

The nurse would expect which of the following to be the first choice to treat a stable patient with ventricular tachycardia? a.) Amiodarone b.) Procainamide c.) Synchronized cardioversion d.) Atropine A 21-year-old female is seen in the Emergency Department for vomiting and diarrhea for 3 days. Her BP is 94/64 and her EKG rhythm shows that she is sinus tachycardia. The best action for the nurse to take initially is to: a.) request pain medication for the patient. b.) cardiovert the patient immediately. c.) give Adenosine 6 mg IV push. d.) start IV and bolus normal saline per protocol. Rationale: d.) is correct because the patient is dehydrated due to vomiting and diarrhea and needs IV fluids. The rhythm strip is sinus tachycardia and the cause is treated. a.) is not correct because no information is given regarding the presence of pain. b.) is not correct because Cardioversion is not an appropriate action for sinus tachycardia. c.) is not correct Adenosine is only given for SVT.

Answer: D. A pulse would be assessed for first. Then the patient will be defibrillized and chest compressions will begin immediately. You are the nurse working on the telemetry unit and you have finally gotten to sit down to work on some charting. Suddenly the heart monitors at the station start beeping. Patient in room 18 is showing this rhythm on the monitor. The medical team advances together into the room and finds them unconscious. What is priority action by the nurse? A) Prepare to administer adenosine to the patient B) Begin chest compressions C) Prepare for defibrillation D) Check for a pulse

Answer: C. Anemia can contribute to sinus tachycardia. The nurse sees the following rhythm on the monitor. Which of the following lab values does the nurse identify as being most likely to have caused this dysrhythmia? a) K 3.0 b) Ca 10.5 c) Hgb 9 d) Magnesium 2.1

Answer: A. Following defibrillation, CPR is immediately initiated if a perfusable rhythm is not initiated. The client may need to be shocked again, but chest compressions must begin first. The patient who has recently been experiencing runs of ventricular tachycardia suddenly loses consciousness. The patient is defibrillated, and the rate returns as the following. What should the nurse do first? A) Begin compressions B) Shock the client again immediately C) Prepare for intubation D) Administer adenosine

Answer: B. Antiarrhythmic medications are prescribed with the use of an ICD in order to prevent the tachycardic (or other deadly arrhythmia) from occurring in the first place. This makes sure that the ICD is used only when absolutely necessary. A patient with cardiomyopathy has been given an ICD. Which of the following medications would the nurse expect to see in the MAR for this patient? A) Warfarin B) Cardizem C) Nitroglycerin D) Digoxin

Answer: B. Atrial flutter places the client at high risk for development of clot formation in the atria. Because the client is stable at this time, cardioversion or adenosine would not be performed at this time. Before cardioversion can occur in a patient, anticoagulant therapy should be begun at least 48 hours beforehand if possible. The patient with a history of hypertension and diabetes has the following rhythm strip. The patient's vitals are as follows: BP 145/89, HR 90, SpO2 95%, RR 19. Which of the following does the nurse expect to do at this time? a) Prepare the client for cardioversion STAT b) Begin administering anticoagulants c) Grab the crash cart for administration of adenosine d) Teach the client about possibility of pacemaker installation

Answer: A, B, and D. Adenosine is administered as a very quick IV push. The physician must be present in the room and the crash cart must be on hand. An ekg monitor should be in the room to monitor the effectiveness of the medication. The nurse is preparing to administer adenosine to the patient with the following rhythm which is symptomatic. What should the nurse plan on having in the patient room? a) Physician b) Crash cart c) IV pump d) EKG monitor e) Lidocaine Answer: B. This finding would be expected upon administration of adenosine. The rhythm should then begin again in some other rhythm, hopefully normal sinus rhythm. It would be important to document the exact time of this change and continue to monitor the change back to NSR. If this change does not occur, or if another rhythm is produced, appropriate action would then be taken based on the result. The nurse has just administered adenosine via IV push and sees the following rhythm on the monitor. What is the nurse's priority intervention? a) Apply conductive gel and defibrillate the patient b) Document the findings and continue to monitor c) Administer another mg of the medication d) Begin chest compressions

Answer: B. With SVT (Supraventricular tachycardia), the first thing to do would be to instruct the pt. to perform the Valsalva maneuver by bearing down. You, the nurse, note the following rhythm on the EKG monitor for a patient named billy. What is the first thing the nurse should do? a) Check for a pulse b) Tell Billy to try to poop c) Prepare to defibrillate billy d) Prepare to administer Amiodorone

Answer(s): 2, 3 The ATRIAL rate is 220-300 bpm. Ventricular is about 75-150. The rhythm is regular, with the P wave appearing as little flutter or a "saw tooth pattern". The PR interval is not measurable r/t this saw-tooth P wave. The QRS is normal. A group of nursing students are discussing atrial flutter. These students recognize that which of the following are seen with atrial flutter? Select all that apply: 1) Ventricular rate of 220-300 bpm. 2) Regular rhythm 3) Saw-tooth pattern 4) Measurable PR interval 5) Long QRS interval Answer: 2) Cardioversion is used if the patient is unstable. Anticoagulants are used if the arrhythmia has stuck around for 48 hr +. Adenosine may be used with a narrow QRS and regular RR interval. I made up Altemose. A nursing student is aware that which of the following is the treatment for unstable atrial flutter? 1) Adenosine (Adenocard) 6 mg rapid IVP. 2) Cardioversion with adjacent Heparin therapy 3) Defibrillation STAT followed by CPR. 4) Altemose 3 mg IVP over 1-2 seconds.

Answer: 2) Patients with a-fib are at risk for pulmonary and systemic emboli, and new onset of confusion may indicate a stroke in this patient. Patients with atrial flutter may feel more tired some days than others. A nurse working on a CVT unit receives report from day shift. After receiving report, which patient should the nurse see first? 1) A 23-year-old professional tennis player with a HR of 47 bpm. 2) A 69-year-old male with atrial fibrillation who has new onset confusion. 3) A 72-year-old female with atrial flutter who reports feeling unusually tired today and yesterday. 4) A 33-year-old female with sinus tachycardia who is asking for her at-home Metoprolol. Answer: 1) Although electrolytes are likely the culprit, the nurse first needs to first assess the patient. Then, the nurse should look in the patient's chart and evaluate or request an order for electrolyte levels. This may eventually need to be documented, but the nurse can be held liable for neglect if he/she does not assess the patient first. The physician may or may not need to be contacted. A nurse on a CVT unit views the monitor and sees the patient in room 452 has just begun having occasional PVCs. Which action should the nurse take first? 1) Check on the patient 2) Check last magnesium and potassium levels 3) Document the occurrence and watch for further PVCs 4) Contact the physician Answer: 3) This is describing ventricular tachycardia (QRS is a giveaway), and the treatment for a stable patient is Amiodarone or cardioversion. If the patient were unstable, we'd go ahead and defibrillate. Which of the following does the nursing student realize is the treatment for a stable patient presenting with QRS intervals above 0.12 seconds with a regular rhythm and a rate of 100-250 bpm? 1) Atropine 2) Defibrillation 3) Amiodarone 4) Adenosine Answer: d) We cannot defibrillate asystole. A The nurse in the intensive care unit (ICU) hears an alarm sound in the patient's room. Arriving in the room, the patient is unresponsive, without a pulse, and a flat line on

the monitor. What is the first action by the nurse? a) Administer atropine 0.5 mg b) Administer epinephrine c) Defibrillate with 360 joules d) Begin cardiopulmonary resuscitation (CPR) Answer(s): 2, 3, 4, 5 Diarrhea will not stimulate a vagal response, but vomiting can. Chronic constipation will cause a consistent vagal response. Digoxin, beta blockers, and calcium channel blockers can all contribute to first degree blocks. Relate this to bradycardia. A group of nursing students are studying AV blocks and ask their instructor, "what causes a first-degree block?" The nursing instructor responds that which of the following can cause a first-degree block: Select all that apply 1) Diarrhea 2) Chronic constipation 3) Diltiazem 4) Digoxin 5) Metoprolol Answer: 3 Patients with atrial fibrillation are at incredibly high risk for clots, even with anticoagulation therapy. Shortness of breath could indicate a PE, and this should be immediately investigated by the nurse. The patient should be NPO for at least 4 hr. prior to the procedure related to anesthesia use, but this is not as urgent of a concern. The patient should also withhold Digoxin therapy for 48 hours to ensure that, once cardioverted, NSR returns. A 26-year-old client with atrial fibrillation that has not responded to medication therapy has arrived at the hospital for an elective cardioversion. Which of the following patient statements most concerns the nurse? 1) "I can't wait to stop taking this Coumadin. I've been on this crap for weeks now." 2) "I'm starving. I haven't eaten anything in 3 hours." 3) "I feel really short of breath, can I lie down?" 4) "I haven't taken my Digoxin since 9 o'clock last night. Is that okay?" Answer: B - prolonged hiccups indicate pacemaker failure. Other signs and symptoms of pacemaker failure are dysrhythmias, dizziness, faintness, chest pain, shortness of breath, increase or decrease in apical rate. Which of the following signs and symptoms indicate pacemaker failure? a) excessive thirst b) prolonged hiccups c) flushing of the skin d) increased urine output Answer: A, C, D, and E. A cellphone should not be used near the pacemaker and it's best to keep the phone about half a foot away from the pacemaker. It is not necessary for the client to avoid using a microwave or other electrical devices. However, magnets

should be kept away from the device. In order to prevent disruption of the leads after implantation (the most common complication), patients are often taught to limit activity on the affected side for awhile after implantation. Pulses are a good indicator of whether the pacemaker is supplying the body with enough cardiac output. The nurse is providing discharge teaching to the client who has just received a pacemaker. Which of the following should the nurse include in the plan of care? SATA: A) Use your cell phone on the opposite side of your pacemaker B) You should avoid using a microwave from now on C) For the next week, it would be best to limit activity on the side with your new pacemaker D) You will need to inform airport security about your pacemaker before you fly anywhere E) It would be a good idea to check your pulse daily

Prior to discharge from the ED, the nurse prints a rhythm strip on a patient and notices that the P wave cannot be detected and QRS complex is at 0.24 seconds. What is the best action for the nurse to take? A. Measure the PR interval B. Prepare the patient for discharge C. Notify the physician of this abnormal strip. D. continue to monitor for abnormalities C. Notify the physician of the abnormal strip. A client with a first degree heart block has an ECG taken during an episode of chest pain. The nurse knows that which ECG finding would be an indication of first degree heart block? A. presence of Q waves B. Tall, peaked T waves C. Prolonged PR interval D. Widened QRS complex C. Prolonged PR Interval. The nurse is assessing an ECG strip for a client. The P waves and QRS complexes are regular. The PR interval is 0.14 second and the QRS complexes measure is 0.08 second. The overall heart rate is 82 bpm. The nurse interprets the cardiac rhythm to be which rhythm? A. Sinus bradycardia B. sick sinus syndrome

C. Normal sinus rhythm D. First degree heart block C. Normal Sinus Rhythm The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. No P waves or QRS complexes are seen; instead, the monitor screen shows an irregular wavy line. The nurse interprets that the client is experiencing which rhythm? A. Sinus tachycardia B. Ventricular fibrillation C. Ventricular tachycardia D. Premature ventricular contractions (PVC) B. Ventricular fibrillation A client with rapid rate atrial fibrillation asks a nurse why the physician is going to perform a carotid massage. The nurse responds that this procedure may stimulate the... A. Vagus Nerve to decrease the heart rate B. Vagus Nerve to increase heart rate C. Diaphragmatic nerve to decrease heart rate D. Diaphragmatic nerve to overdrive the rhythm. A. Vagus nerve to decrease the heart rate. The nurse is determining whether the client's rhythm strip demonstrates proper firing of the SA node. Which waveform indicates proper function of the SA node? A. The QRS complex is present B. The PR interval is 0.24 second C. P wave precedes every QRS complex D. The ST segment is elevated C. P wave precedes every QRS complex

Question 1 WRONG A nurse is assessing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats per minute. The nurse assesses the cardiac rhythm as: Normal sinus rhythm

Sinus bradycardia

C Sick sinus syndrome D First-degree heart block. Question 1 Explanation: measurements are normal, measuring 0.12 to 0.20 second and 0.4 to 0.10 second, respectively. Question 2 CORRECT A nurse notices frequent artifact on the ECG monitor for a client whose leads are connected by cable to a console at the bedside. The nurse examines the client to determine the cause. Which of the following items is unlikely to be responsible for the artifact?

A Frequent movement of the client Tightly secured cable connections

C Leads applied over hairy areas D Leads applied to the limbs Question 2 Explanation: Motion artifact, or “noise,” can be caused by frequent client movement, electrode placement on limbs, and insufficient adhesion to the skin, such as placing electrodes over hairy areas of the skin. Electrode placement over bony prominences also should be avoided. Signal interference can also occur with electrode removal and cable disconnection. Question 3

WRONG A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but over 100. The nurse determines that the client is experiencing:

A Premature ventricular contractions Ventricular tachycardia

Ventricular fibrillation

D Sinus tachycardia Question 3 Explanation: Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (usually greater than 0.14 second), and a rate between 100 and 250 impulses per minute. The rhythm is usually regular. Question 4 WRONG A nurse is viewing the cardiac monitor in a client’s room and notes that the client has just gone into ventricular tachycardia. The client is awake and alert and has good skin color. The nurse would prepare to do which of the following? Immediately defibrillate

B Prepare for pacemaker insertion Administer amiodarone (Cordarone) i...