- A patient is having complications from abdominal surgery and remains NPO. Because enteral tube feedings are not possible, the decision is to initiate parenteral feedings. What are the major complications for this therapy?
| a. | Aspiration pneumonia and sepsis |
| b. | Sepsis and fluid and electrolyte imbalances |
| c. | Fluid overload and pulmonary edema |
| d. | Hypoglycemia and renal insufficiency |
ANS: B
Because of the high dextrose concentration, including the fluid and electrolyte content, the patient is placed at high risk for sepsis and fluid and electrolyte imbalances. Aspiration pneumonia is a potential complication of enteral feedings; sepsis is a potential complication of parenteral nutrition. Fluid overload is possible but unlikely and is not a major complication of parenteral nutrition. Hyperglycemia is more of a concern than hypoglycemia with parenteral nutrition; however, renal insufficiency is not related to parenteral nutrition.
DIF: Cognitive Level: Remember/Knowledge REF: p. 85
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- A patient is being ventilated and has been started on enteral feedings with a nasogastric small-bore feeding tube. What is the primary reason the nurse must frequently assess tube placement?
| a. | To assess for paralytic ileus |
| b. | To maintain the patency of the feeding tube |
| c. | To monitor for skin breakdown on the nose |
| d. | To prevent aspiration of the feedings |
ANS: D
Patients who are on a ventilator and who are receiving tube feedings are at a high risk for aspiration and ventilator-associated pneumonia. Assessment of tube placement will neither determine presence of paralytic ileus nor maintain patency. Assessment of tube placement is performed to minimize aspiration risk, not skin breakdown on the nose.
DIF: Cognitive Level: Remember/Knowledge REF: p. 85 | Table 6-4
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The patient is to start parenteral nutrition. The nurse knows to prepare which site for catheter insertion?
| a. | Basilic vein |
| b. | Femoral vein |
| c. | Radial artery |
| d. | Subclavian vein |
ANS: D
Total parenteral nutrition is administered through a central intravenous line, such as the subclavian vein. Arteries are never used. The femoral site is avoided. The basilic vein is not a central site.
DIF: Cognitive Level: Remember/Knowledge REF: p. 80
OBJ: Discuss practice guidelines related to nutritional support.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- A patient has been admitted to the critical care unit after a stroke. After “failing” a swallow study, the patient is placed on enteral feedings. Following placement of a nasogastric tube for tube feeding, what is the next critical step?
| a. | Administer medications. |
| b. | Cap off and wait 24 hours before starting feedings. |
| c. | Obtain a chest radiograph. |
| d. | Start the tube feeding. |
ANS: C
Correct placement must be verified by radiograph before use of the tube for either feeding or administering medications. There is no reason to cap the tube and wait; once placement is verified, the tube can be used.
DIF: Cognitive Level: Apply/Application REF: p. 86 | Table 6-4
OBJ: Discuss practice guidelines related to nutritional support.
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity
- A critically ill patient has a nonhealing wound and malnutrition. Which component of nutritional supplementation is most important for this patient to receive?
| a. | Arginine |
| b. | Omega-3 fatty acids |
| c. | Branched-chain amino acids |
| d. | Vitamin A |
ANS: D
Vitamin A is vital for wound healing. Arginine is also important in wound healing but is more important for trauma and septic patients, as are omega-3 fatty acids. Branched-chain amino acids are very important for stressed patients who have liver dysfunction or ARDS.
DIF: Cognitive Level: Remember/Knowledge REF: p. 82 | Table 6-1
OBJ: Discuss practice guidelines related to nutritional support.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- A patient is being fed through a nasogastric tube placed in his stomach. The nurse would carry out which intervention to minimize aspiration risk?
| a. | Add blue dye to the formula. |
| b. | Assess the residual every hour. |
| c. | Elevate the head of the bed 30 degrees. |
| d. | Provide feedings via continuous infusion. |
ANS: C
The head of the bed should be kept elevated at least 30 degrees if possible during tube feedings to minimize reflux. Blue dye should not be used. Neither continuous feedings nor checking for residual will minimize aspiration.
DIF: Cognitive Level: Apply/Application REF: p. 86 | Table 6-4
OBJ: Discuss practice guidelines related to nutritional support.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- A patient who is receiving continuous enteral feedings has just vomited 250 mL of milky green fluid. What action by the nurse takes priority?
| a. | Notify the provider. |
| b. | Assess the patient’s lungs and oxygen saturation. |
| c. | Stop the tube feeding. |
| d. | Slow the rate of the infusion. |
ANS: C
Nausea and vomiting are signs of tube feeding intolerance. The nurse should first stop the feeding. Then the nurse can assess for other signs of intolerance and aspiration. After a complete assessment, the nurse would notify the provider.
DIF: Cognitive Level: Apply/Application REF: p. 85
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- A patient is receiving enteral feedings and reports fullness and abdominal discomfort. What action by the nurse is best?
| a. | Connect the feeding tube to suction. |
| b. | Continue the tube feeding. |
| c. | Decrease the tube feeding. |
| d. | Assess the patient’s gastric residual. |
ANS: D
The patient may not be tolerating the tube feeding. The nurse should assess the gastric residual and hold the feeding if it is greater than 500 mL. The other actions are not warranted; the nurse needs further information before proceeding.
DIF: Cognitive Level: Apply/Application REF: pp. 85-86 | Table 6-4
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- In addition to residual stomach volume, what other evidence suggests feeding intolerance?
| a. | Abdominal distension |
| b. | Absence of tympany on percussion |
| c. | Active bowel sounds |
| d. | Elevated blood glucose by fingerstick |
ANS: A
Abdominal distension is expected if the feedings are not being absorbed. Tympany occurs along with distension.
DIF: Cognitive Level: Remember/Knowledge REF: pp. 85-86 | Table 6-4
OBJ: Discuss methods for evaluating nutritional status.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Approximately 5 days after starting tube feedings, a patient develops extreme diarrhea. A stool specimen is collected to check for which possible cause?
| a. | Clostridium difficile |
| b. | Escherichia coli |
| c. | Occult blood |
| d. | Ova and parasites |
ANS: A
Patients receiving enteral nutrition who develop diarrhea are evaluated for antibiotic- associated causes, including Clostridium difficile.
DIF: Cognitive Level: Remember/Knowledge REF: p. 86 | Table 6-4
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- A patient with acute pancreatitis is started on parenteral nutrition. The student nurse listed possible interventions for this patient. Which intervention needs correction before finalizing the plan of care?
| a. | Change the intravenous tubing every 24 hours. |
| b. | Infuse antibiotics through the intravenous line. |
| c. | Monitor the blood glucose every 6 hours. |
| d. | Monitor the fluid and electrolyte balance. |
ANS: B
Medications should not be infused through the IV line infusing parenteral nutrition. The other actions are correct.
DIF: Cognitive Level: Apply/Application REF: p. 85
OBJ: Discuss practice guidelines related to nutritional support.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- In evaluating a patient’s nutrition, the nurse would monitor which blood test as the most sensitive indicator of protein synthesis and catabolism?
| a. | Albumin |
| b. | BUN |
| c. | Prealbumin |
| d. | Triglycerides |
ANS: C
Prealbumin is the most sensitive indicator of protein synthesis and catabolism.
DIF: Cognitive Level: Remember/Knowledge REF: p. 87 Laboratory Alert Box
OBJ: Discuss methods for evaluating nutritional status.
TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity
- A patient is receiving enteral tube feedings and has developed drug-nutrient interactions. The nurse recognizes which drug as having the potential for causing drug-nutrient reactions?
| a. | Aspirin |
| b. | Enoxaparin |
| c. | Ibuprofen |
| d. | Phenytoin |
ANS: D
Bioavailability of phenytoin is reduced when administered with enteral feedings. The other drugs do not have significant drug-nutrient interactions.
DIF: Cognitive Level: Remember/Knowledge REF: p. 85
OBJ: Describe interventions to achieve nutritional goals.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Which statement is true about normal function of the gastrointestinal (GI) tract?
| a. | Failure of the tight junctions allows bacteria to invade the GI tract. |
| b. | The gut lacks protective mechanisms; thus, infection is always a concern. |
| c. | Water is reabsorbed at the beginning of the colon. |
| d. | Without nutritional stimulation, mucosal villi atrophy. |
ANS: D
Mucosal villi replenish every 3 to 4 days; without nutritional stimulation, they atrophy. The other statements are false.
DIF: Cognitive Level: Remember/Knowledge REF: p. 77
OBJ: Review the anatomy and physiology related to utilization of nutrients.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- An important nutritional consideration in the elderly population is
| a. | a decrease in protein requirements. |
| b. | an increase in caloric requirements with age. |
| c. | the potential for drug-nutrient interaction related to polypharmacy. |
| d. | the presence of other diseases that decrease caloric needs. |
ANS: C
Patients taking multiple medications have a greater potential for drug-nutrient interactions; older adults may be taking multiple medications.
DIF: Cognitive Level: Remember/Knowledge REF: p. 79
OBJ: Describe interventions to achieve nutritional goals.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Health Promotion and Maintenance
- Objective data designating that the nutrition goals are not being met include
| a. | hyperglycemia, normovolemia, and increased protein level. |
| b. | overhydration, hypoglycemia, and weight gain. |
| c. | weight gain, inconsistent glucose, and normovolemia. |
| d. | weight loss, elevated glucose, and dehydration. |
ANS: D
When nutritional goals are not being met, the patient experiences weight loss, elevated glucose levels, and either overhydration or dehydration.
DIF: Cognitive Level: Remember/Knowledge REF: p. 87
OBJ: Describe interventions to achieve nutritional goals.
TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity
- A patient with a history of emphysema, diabetes, and hyperlipidemia is in the critical care unit on a ventilator. The nutrition assessment notes that the patient has a protein and vitamin deficiency and is underweight. Which formula for nutritional assessment is most appropriate?
| a. | Elemental protein formula |
| b. | Fiber-added formula |
| c. | High medium–chain triglyceride formula |
| d. | Lactose-free formula |
ANS: B
Added fiber helps to control blood glucose and reduce hyperlipidemia.
DIF: Cognitive Level: Analyze/Analysis REF: p. 83
OBJ: Describe interventions to achieve nutritional goals.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- Select the physiological reasoning behind enteral therapy as the preferred source of nutritional therapy.
| a. | Gut overgrowth increases. |
| b. | Gastroparesis increases. |
| c. | Bacterial translocation is initiated. |
| d. | Gut mucosa is preserved. |
ANS: D
Enteral feedings prevent bacterial overgrowth and potential bacterial translocation from the gastrointestinal tract and preserve the gut mucosa.
DIF: Cognitive Level: Remember/Knowledge REF: p. 81
OBJ: Review the anatomy and physiology related to utilization of nutrients.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse identifies which patient at greatest risk for malabsorption of protein?
| a. | The patient with gallbladder obstruction |
| b. | The patient with ileitis |
| c. | The patient with distal colon resection |
| d. | The patient with jejunal tumor |
ANS: B
The ileum is where protein is broken down and absorbed; the patient with ileitis would be at greatest risk for protein malabsorption.
DIF: Cognitive Level: Remember/Knowledge REF: p. 78
OBJ: Review the anatomy and physiology related to utilization of nutrients.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The best nursing approach to prevent feeding tube obstruction is to
| a. | dilute the feeding to make it flow more easily. |
| b. | flush the tube every 4 hours with 20 to 30 mL of tap water. |
| c. | pass a stylet daily to keep the tubing clear. |
| d. | use a larger bore tube where possible. |
ANS: B
Flushing the tubing every 4 hours helps prevent obstruction. Diluting tube feedings can cause water intoxication. Stylets are never used to clear a tube, and the smallest bore possible should be used for best tolerance.
DIF: Cognitive Level: Apply/Application REF: p. 84
OBJ: Discuss practice guidelines related to nutritional support.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Patients experiencing severe physiological stress increase their nutritional requirements to:
| a. | 20 kcal/kg/day. |
| b. | 30 kcal/kg/day. |
| c. | 35 kcal/kg/day. |
| d. | 50 kcal/kg/day. |
ANS: C
Severely stressed individuals require 35 kcal/kg/day; 50 kcal/kg/day exceeds caloric needs. A total of 20 kcal/kg/day is less than normal caloric requirements. A total of 30 kcal/kg/day is the caloric requirement for a moderately stressed individual.
DIF: Cognitive Level: Remember/Knowledge REF: Table 6-2
OBJ: Describe interventions to achieve nutritional goals.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Malnutrition contributes to infection risk by
| a. | hampering normal gastrointestinal motility. |
| b. | impairing immune function. |
| c. | increasing blood glucose. |
| d. | increasing drug interactions. |
ANS: B
Malnutrition impairs immune function.
DIF: Cognitive Level: Remember/Knowledge
REF: p. 84 Evidence Based Practice
OBJ: Review the anatomy and physiology related to utilization of nutrients.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- A patient, who has a tube feeding, requires a chest x-ray study for evaluation of a cough. To reduce the risk of aspiration, the nurse:
| a. | helps the radiology technician to position the patient to avoid dislodging the tube. |
| b. | slows the rate of the feedings until placement has been verified. |
| c. | cuts the infusion rate by half. |
| d. | stops feedings 10 to 15 minutes before placing flat to obtain the radiograph. |
ANS: D
Temporarily stopping feedings when flat minimizes the risk of aspiration if the patient will be supine.
DIF: Cognitive Level: Analyze/Analysis REF: p. 86
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
MULTIPLE RESPONSE
- Which statements about total parenteral nutrition are correct? (Select all that apply.)
| a. | assessing fluid volume status and preventing infection are important nursing considerations. |
| b. | fingerstick glucose levels are assessed every 6 hours and prn. |
| c. | total parenteral nutrition is administered through a feeding tube and pump. |
| d. | total parenteral nutrition with added lipids provides adequate levels of protein, carbohydrates, and fats. |
| e. | soy-based lipids should not be given during the first week of a critical illness. |
ANS: A, B, D, E
All are correct except administration via a feeding tube and pump. A tube and pump are used to deliver enteral nutrition.
DIF: Cognitive Level: Remember/Knowledge REF: pp. 80-81
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- Which interventions are critical during intravenous lipid administration? (Select all that apply.)
| a. | Assess glucose levels every 6 hours. |
| b. | Change the tubing every 24 hours. |
| c. | Hold lipids when administering antibiotics through the same line. |
| d. | Monitor triglyceride levels periodically. |
| e. | Maintain elevation of the head of the bed. |
ANS: B, D
Lipids are very good media for bacterial growth; lipid tubing should be changed every 24 hours. Triglyceride levels must be monitored until stable when administering lipids. Glucose is monitored during treatment with parenteral nutrition, which contains a high level of glucose. Medications are not administered through the IV lines containing lipids or parenteral nutrition. Elevating the head of the bed is important for enteral (tube) feedings to prevent aspiration.
DIF: Cognitive Level: Apply/Application
REF: p. 85 |p. 87 Laboratory Alert Box
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- Calorie-dense feedings: (Select all that apply.)
| a. | are most useful in heart failure and liver disease. |
| b. | are most useful in malabsorption syndromes. |
| c. | contain 2 kcal/mL and 70 g protein/L. |
| d. | include increased fiber. |
| e. | are especially good for patients with lung disease. |
ANS: A, C
Calorie-dense feedings are used when volume should be minimized and protein requirements are high, such as in heart failure or liver disease. They contain 2 kcal/mL and 70 g protein/L. Specific formulas, such as Oxepa, are available for lung disease.
DIF: Cognitive Level: Remember/Knowledge REF: p. 83 | Table 6-3
OBJ: Describe interventions to achieve nutritional goals.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment
- Risks of total parenteral nutrition include: (Select all that apply.)
| a. | diarrhea. |
| b. | elevated blood sugar. |
| c. | infection at the catheter site. |
| d. | volume overload. |
| e. | aspiration. |
ANS: B, C, D
Diarrhea and aspiration are more common with enteral tube feedings; the other risks are common with total parenteral nutrition.
DIF: Cognitive Level: Remember/Knowledge REF: p. 85
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment
- Which of the following statements is true about insulin and parenteral nutrition? (Select all that apply.)
| a. | The amount of parenteral insulin is adjusted based on the previous 24-hour laboratory values. |
| b. | Insulin may be added to a parenteral nutrition solution. |
| c. | Subcutaneous insulin is used on a sliding scale during parenteral nutrition. |
| d. | Supplemental insulin is rarely required for patients receiving parenteral nutrition. |
| e. | Lingering hyperglycemia after parenteral nutrition has stopped requires continuing insulin. |
ANS: A, B, C
Hyperglycemia is common when receiving parenteral nutrition; insulin may be administered on a sliding scale for glucose control and/or added to the parenteral solution. The amount of insulin added to the parenteral solution is calculated based on the previous 24-hour laboratory values. Hypoglycemia can result from continuing the insulin after the parenteral nutrition is discontinued.
DIF: Cognitive Level: Remember/Knowledge
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- A patient with severe burns had a dietitian consultation for nutritional support. The patient weighs 145 pounds. What recommendations by the dietitian does the nurse anticipate initiating? (Select all that apply.)
| a. | At least 2307 kcal/day |
| b. | Juven formula |
| c. | 2 cal HN formula |
| d. | At least 1648 kcal/day |
| e. | Perative formula |
ANS: A, B
The severely stressed patient requires around 35 kcal/kg/day. This patient weighs 145 pounds, which is 65.9 kg. So this patient needs at least 2307 kcal/day. Juven is an appropriate formula; 2 cal HN is used for patients with heart and/or liver disease and Perative is used for patients with impaired GI function.
DIF: Cognitive Level: Analyze/Analysis REF: p. 83 | Table 6-2 | Table 6-3
OBJ: Discuss the recommended nutritional support for a burn patient.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
ORDERING
- The correct order of actions for a patient starting enteral nutrition with a feeding tube is: _______________, _______________, _______________, _______________, _______________.
- initiate tube feeding
- insert feeding tube
- flush tube to verify patency
- obtain chest radiograph
- assess residuals
ANS:
B, D, C, A, E
Initially the feeding tube will be inserted and final placement verified via chest radiograph. The next step is to flush the feeding tube and start the tube feedings. Residuals are checked every 4 hours.
DIF: Cognitive Level: Apply/Application REF: pp. 80-82
OBJ: Discuss practice guidelines related to nutritional support.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
Chapter 07: Dysrhythmia Interpretation and Management
Sole: Introduction to Critical Care Nursing, 7th Edition
MULTIPLE CHOICE
- The nurse is caring for a patient who is on a cardiac monitor. The nurse realizes that the sinus node is the pacemaker of the heart because it is
| a. | the fastest pacemaker cell in the heart. |
| b. | the only pacemaker cell in the heart. |
| c. | the only cell that does not affect the cardiac cycle. |
| d. | located in the left side of the heart. |
ANS: A
The cardiac cycle begins with an impulse that is generated from a small concentrated area of pacemaker cells high in the right atria called the sinoatrial node (sinus node or SA node). The SA node has the fastest rate of discharge and thus is the dominant pacemaker of the heart. The AV node has pacemaker properties and can discharge an impulse if the SA node fails. The ventricles have pacemaker capabilities if the sinus node or the AV node ceases to generate impulses.
DIF: Cognitive Level: Remember/Knowledge REF: p. 90
OBJ: Explain the relationships between electrical and mechanical events in the heart.
TOP: Nursing Process Step: N/A
MSC: NCLEX Client Needs Category: Physiological Integrity
- One of the functions of the atrioventricular (AV) node is to
| a. | pace the heart if the ventricles fail. |
| b. | slow the impulse arriving from the SA node. |
| c. | send the impulse to the SA node. |
| d. | allow for ventricular filling during systole. |
ANS: B
The impulse from the SA node quickly reaches the atrioventricular (AV) node located in the area called the AV junction, between the atria and the ventricles. Here the impulse is slowed to allow time for ventricular filling during relaxation or ventricular diastole. The AV node has pacemaker properties and can discharge an impulse if the SA node (not the ventricle) fails. The electrical impulse is then rapidly conducted through the bundle of His to the ventricles (not the SA node) via the left and right bundle branches.
DIF: Cognitive Level: Remember/Knowledge REF: p. 90
OBJ: Explain the relationships between electrical and mechanical events in the heart.
TOP: Nursing Process Step: N/A
MSC: NCLEX Client Needs Category: Physiological Integrity
- The normal rate for the SA node when the patient is at rest is
| a. | 40 to 60 beats per minute. |
| b. | 60 to 100 beats per minute. |
| c. | 20 to 40 beats per minute. |
| d. | more than100 beats per minute. |
ANS: B
The sinus node reaches threshold at a rate of 60 to 100 times per minute. Because this is the fastest pacemaker in the heart, the SA node is the dominant pacemaker of the heart. The AV node has an inherent rate of 40 to 60 beats per minute and the His-Purkinje system can fire at a rate of 20 to 40 beats per minute. Sinus tachycardia results when the SA node fires faster than 100 beats per minute.
DIF: Cognitive Level: Remember/Knowledge REF: p. 90
OBJ: Explain the relationships between electrical and mechanical events in the heart.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse caring for patients with cardiac monitoring understands that when an electrical signal is aimed directly at the positive electrode, the inflection will be:
| a. | negative. |
| b. | upside down. |
| c. | upright. |
| d. | equally positive and negative. |
ANS: C
When an electrical signal is aimed directly at the positive electrode, an upright inflection is visualized. If the impulse is going away from the positive electrode, a negative deflection is seen; and if the signal is perpendicular to the imaginary line between the positive and negative poles of the lead, the tracing is equiphasic, with equally positive and negative deflection.
DIF: Cognitive Level: Understand/Comprehension REF: p. 92
OBJ: Explain the relationships between electrical and mechanical events in the heart.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The patient is admitted with a condition that requires cardiac rhythm monitoring. To apply the monitoring electrodes, the nurse must first
| a. | apply a moist gel to the chest. |
| b. | make certain that the electrode gel is dry. |
| c. | avoid soaps to avoid skin irritation. |
| d. | clip chest hair if needed. |
ANS: D
Adequate skin preparation of electrode sites requires clipping the hair, cleansing the skin, and drying vigorously (moisture gels are not applied). Cleansing includes washing with soap and water, or alcohol, to remove skin debris and oils. Before application, the electrodes are checked to ensure that the gel is moist. It is difficult for electrodes to adhere to the chest in the presence of chest hair. Clipping, not shaving, is recommended since shaving may create small nicks that can become a portal for infection.
DIF: Cognitive Level: Apply/Application REF: p. 96
OBJ: Explain the relationships between electrical and mechanical events in the heart.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse using cardiac monitoring understands that each horizontal box on the electrocardiogram (ECG) paper indicates
| a. | 200 milliseconds or 0.20 seconds duration. |
| b. | 40 milliseconds or 0.04 seconds duration. |
| c. | 3 seconds duration. |
| d. | millivolts of amplitude. |
ANS: B
ECG paper contains a standardized grid where the horizontal axis measures time and the vertical axis measures voltage or amplitude. Horizontally, the smaller boxes denote 0.04 seconds each or 40 milliseconds; the larger box contains five smaller boxes and thus equals 0.20 seconds or 200 milliseconds.
DIF: Cognitive Level: Understand/Comprehension REF: p. 97
OBJ: Explain the relationships between electrical and mechanical events in the heart.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse is examining the patient’s cardiac rhythm strip in lead II and notices that all of the P waves are upright and look the same except one that has a different shape and is inverted. The nurse realizes that the P wave with the abnormal shape is probably
| a. | from the SA node because all P waves come from the SA node. |
| b. | from some area in the atria other than the SA node. |
| c. | indicative of ventricular depolarization. |
| d. | normal even though it is inverted in lead II. |
ANS: B
Normally a P wave indicates that the SA node initiated the impulse that depolarized the atrium. However, a change in the shape of the P wave may indicate that the impulse arose from a site in the atria other than the SA node. The P wave represents atrial depolarization. It is usually upright in leads I and II and has a rounded, symmetrical shape. The amplitude of the P wave is measured at the center of the waveform and normally does not exceed three boxes, or 3 millimeters, in height.
DIF: Cognitive Level: Remember/Knowledge REF: p. 98
OBJ: Explain the relationships between electrical and mechanical events in the heart.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse caring for patients on cardiac monitors assesses the patient with a prolonged QT interval for
| a. | electrolyte disturbances such as hypokalemia. |
| b. | symptomatic bradycardias. |
| c. | the development of lethal dysrhythmias. |
| d. | difficulty maintaining the blood pressure. |
ANS: C
The QT interval is measured from the beginning of the QRS complex to the end of the T wave. This interval measures the total time taken for ventricular depolarization and repolarization. Abnormal prolongation of the QT interval increases vulnerability to lethal dysrhythmias, such as ventricular tachycardia and fibrillation. The nurse monitors the patient for the development of these rhythms and is prepared to intervene should they occur. A prolonged QT is not associated with bradycardias, hypokalemia, or blood pressure irregularities.
DIF: Cognitive Level: Apply/Application REF: p. 100
OBJ: Explain the relationships between electrical and mechanical events in the heart.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The patient has an irregular heart rhythm. To determine an accurate heart rate, the nurse would first
| a. | identify the markers on the ECG paper that indicate a 6-second strip. |
| b. | count the number of small boxes between two consecutive P waves. |
| c. | count the number of small boxes between two consecutive QRS complexes. |
| d. | divides the number of complexes in a 6-second strip by 10. |
ANS: A
The optimal method of determining a heart rate from an ECG strip when the patient has an irregular heart rate is to count the number of P waves or QRS waves within a 6-second strip to obtain both atrial and ventricular heart rates per minute. In order to do this accurately, the nurse first much identify the markers on the ECG paper that indicate a 6-second strip. The other methods are not as accurate with an irregular heart rate.
DIF: Cognitive Level: Apply/Application REF: p. 101
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse is calculating the rate for a regular rhythm. There are 20 small boxes between each P wave and 20 small boxes between each R wave. What is the ventricular rate?
| a. | 50 beats/min |
| b. | 75 beats/min |
| c. | 85 beats/min |
| d. | 100 beats/min |
ANS: B
The rule of 1500 is used to calculate the exact rate of a regular rhythm. The number of small boxes between the highest points of two consecutive R waves is counted, and that number of small boxes is divided into 1500 to determine the ventricular rate. 1500/20 = 75 beats/min. This method is accurate only if the rhythm is regular.
DIF: Cognitive Level: Apply/Application REF: p. 101
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- The patient is admitted with a fever and rapid heart rate. The patient’s temperature is 103° F (39.4° C). The nurse places the patient on a cardiac monitor and finds the patient’s atrial and ventricular rates are above 105 beats per minute. P waves are clearly seen and appear normal in configuration. QRS complexes are normal in appearance and 0.08 seconds wide. The rhythm is regular, and blood pressure is normal. The nurse should focus on providing:
| a. | medications to lower heart rate. |
| b. | treatment to lower temperature. |
| c. | treatment to lower cardiac output. |
| d. | treatment to reduce heart rate. |
ANS: B
Sinus tachycardia results when the SA node fires faster than 100 beats per minute. All other components of the ECG are normal. Sinus tachycardia is a normal response to stimulation of the sympathetic nervous system. Sinus tachycardia is also a normal finding in children younger than 6 years. The fast heart rhythm may cause a decrease in cardiac output because of the shorter filling time for the ventricles. Lowering cardiac output further may complicate the situation. The dysrhythmia itself is not treated, but the cause is identified and treated appropriately. For example, if the patient has a fever or is in pain, the fever (and infection) or pain is treated appropriately.
DIF: Cognitive Level: Apply/Application REF: p. 105
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse notices sinus bradycardia on the patient’s cardiac monitor. The nurse should
| a. | give atropine to increase heart rate. |
| b. | begin transcutaneous pacing of the patient. |
| c. | start a dopamine infusion to stimulate heart function. |
| d. | assess for hemodynamic instability. |
ANS: D
Sinus bradycardia may be a normal heart rhythm for some individuals such as athletes, or it may occur during sleep. Assess for hemodynamic instability related to the bradycardia. If the patient is symptomatic, interventions include administration of atropine. If atropine is not effective in increasing heart rate, then transcutaneous pacing, dopamine infusion, or epinephrine infusion may be administered. Atropine is avoided for treatment of bradycardia associated with hypothermia.
DIF: Cognitive Level: Apply/Application REF: p. 106
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- Which of the following is true about a patient diagnosed with sinus arrhythmia?
| a. | The heart rate varies, dependent on vagal tone and respiratory pattern. |
| b. | Immediate treatment is essential to prevent death. |
| c. | Sinus arrhythmia is not well tolerated by most patients. |
| d. | PR and QRS interval measurements are prolonged. |
ANS: A
Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate increases slightly during inspiration and slows slightly during exhalation because of changes in vagal tone. The ECG tracing demonstrates an alternating pattern of faster and slower heart rate that changes with the respiratory cycle. Interval measurements are normal. This rhythm is tolerated well, and no treatment is required. The PR and QRS intervals are normal.
DIF: Cognitive Level: Remember/Knowledge REF: p. 106
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: N/A
MSC: NCLEX Client Needs Category: Physiological Integrity
- The patient is admitted with sinus pauses causing periods of loss of consciousness. The patient is asymptomatic, awake and alert, but fatigued. He answers questions appropriately. When admitting this patient, the nurse should first
| a. | prepare the patient for temporary pacemaker insertion. |
| b. | prepare the patient for permanent pacemaker insertion. |
| c. | assess the patient’s medication profile. |
| d. | apply transcutaneous pacemaker paddles. |
ANS: C
AV nodal blocking medications (such as beta blockers, calcium channel blockers, and digoxin) and increased vagal tone may cause sinus exit block. Causes are explored, and prescribed medications may need to be adjusted or discontinued. If patients are symptomatic, significant numbers of pauses may require treatment, including temporary (including transcutaneous) and permanent implantation of a pacemaker.
DIF: Cognitive Level: Apply/Application REF: pp. 106-107
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The patient’s heart rate is 165 beats per minute. The cardiac monitor shows a rapid rate with narrow QRS complexes. The P waves cannot be seen, but the rhythm is regular. The patient’s blood pressure has dropped from 124/62 mm Hg to 78/30 mm Hg. The patient’s skin is cold and diaphoretic, and the patient is complaining of nausea. The nurse prepares the patient for
| a. | administration of beta blockers. |
| b. | administration of atropine. |
| c. | transcutaneous pacemaker insertion. |
| d. | emergent cardioversion. |
ANS: D
If an abnormal P wave cannot be visualized on the ECG but the QRS complex is narrow, the term supraventricular tachycardia (SVT) is often used. This is a generic term that describes any tachycardia that is not ventricular in origin; it is also used when the source above the ventricles cannot be identified, usually because the rate is too fast. Treatment is directed at assessing the patient’s tolerance of the tachycardia. If the rate is higher than 150 beats per minute and the patient is symptomatic, emergent cardioversion is considered. Cardioversion is the delivery of a synchronized electrical shock to the heart by an external defibrillator. Beta blockers are a possibility if the patient is not symptomatic. Atropine is used in the treatment of bradycardia. If atropine is not effective in increasing heart rate, then transcutaneous pacing is implemented.
DIF: Cognitive Level: Analyze/Analysis REF: p. 109
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse is reading the cardiac monitor and notes that the patient’s heart rhythm is extremely irregular and that there are no discernible P waves. The ventricular rate is 90 beats per minute, and the patient is hemodynamically stable. The nurse realizes that the patient’s rhythm is
| a. | atrial fibrillation. |
| b. | atrial flutter. |
| c. | atrial flutter with rapid ventricular response. |
| d. | junctional escape rhythm. |
ANS: A
Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction. No discernible P waves can be identified, resulting in a wavy baseline and an extremely irregular ventricular response. Atrial flutter arises from a single irritable focus in the atria. The atrial focus fires at an extremely rapid, regular rate, between 240 and 320 beats per minute. The P waves are called flutter waves and may have a sawtooth appearance. Atrial flutter with rapid ventricular response occurs when atrial impulses cause a ventricular response greater than 100 beats per minute. A junctional escape rhythm is a ventricular rate between 40 and 60 beats per minute with a regular rhythm. P waves may be absent, inverted, or follow the QRS complex. QRS complex is normal.
DIF: Cognitive Level: Analyze/Analysis REF: pp. 111-112
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The patient’s heart rhythm shows an inverted P wave with a PR interval of 0.06 seconds. The heart rate is 54 beats per minute. The nurse recognizes the rhythm is due to the
| a. | loss of sinus node activity. |
| b. | increased rate of the AV node. |
| c. | increased rate of the SA node. |
| d. | decreased rate of the AV node. |
ANS: A
Junctional escape rhythm occurs when the dominant pacemaker, the SA node, fails to fire. The normal heart rate of the AV node is 40 to 60 beats per minute, so the AV node rate has neither increased nor decreased. P waves may be inverted. An increased SA node rate would override the AV node.
DIF: Cognitive Level: Remember/Knowledge REF: p. 114
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The patient’s heart rate is 70 beats per minute, but the P waves come after the QRS complex. The nurse correctly determines that the patient’s heart rhythm is
| a. | a normal junctional rhythm. |
| b. | an accelerated junctional rhythm. |
| c. | a junctional tachycardia. |
| d. | atrial fibrillation. |
ANS: B
The normal intrinsic rate for the AV node and junctional tissue is 40 to 60 beats per minute, but rates can accelerate. An accelerated junctional rhythm has a rate between 60 and 100 beats per minute, and the rate for junctional tachycardia is greater than 100 beats per minute. If P wave precedes QRS, it is inverted or upside down; the P wave may not be visible, or it may follow the QRS. If a P wave is present before the QRS, the PR interval is shortened less than 0.12 milliseconds. Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction. The AV node is bombarded with hundreds of atrial impulses and conducts these impulses in an unpredictable manner to the ventricles.
DIF: Cognitive Level: Analyze/Analysis REF: p. 114
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The patient is having premature ventricular contractions (PVCs). The nurse’s greatest concern should be:
| a. | the proximity of the R wave of the PVC to the T wave of a normal beat. |
| b. | the fact that PVCs are occurring, because they are so rare. |
| c. | whether the number of PVCs is decreasing. |
| d. | whether the PVCs are wider than 0.12 seconds. |
ANS: A
The peak of the T wave through the downslope of the T wave is considered the vulnerable period, which coincides with partial repolarization of the ventricles. If a PVC occurs during the T wave, ventricular tachycardia may occur. When the R wave of PVC falls on the T wave of a normal beat, it is referred to as the R-on-T phenomenon. PVCs may occur in healthy individuals and usually do not require treatment. The nurse must determine if PVCs are increasing in number by evaluating the trend. If PVCs are increasing, the nurse should evaluate for potential causes, such as electrolyte imbalances, myocardial ischemia or injury, and hypoxemia. Runs of nonsustained ventricular tachycardia may be a precursor to the development of sustained ventricular tachycardia. Because the stimulus depolarizes the ventricles in a slower, abnormal way, the QRS complex appears widened and has a bizarre shape. The QRS complex is wider than 0.12 seconds and often wider than 0.16 seconds.
DIF: Cognitive Level: Analyze/Analysis REF: p. 116
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse notices ventricular tachycardia on the heart monitor. When the patient is assessed, the patient is found to be unresponsive with no pulse. The nurse should
| a. | treat with intravenous amiodarone or lidocaine. |
| b. | begin cardiopulmonary resuscitation and advanced life support. |
| c. | provide electrical cardioversion. |
| d. | ignore the rhythm because it is benign. |
ANS: B
Ventricular tachycardia (VT) is a rapid, life-threatening dysrhythmia originating from a single ectopic focus in the ventricles. Determine whether the patient has a pulse. If no pulse is present, provide emergent basic and advanced life-support interventions, including defibrillation. If a pulse is present and the blood pressure is stable, the patient can be treated with intravenous amiodarone or lidocaine. Cardioversion is used as an emergency measure in patients who become hemodynamically unstable but continue to have a pulse. It also may be used in nonemergency situations, such as when a patient has asymptomatic VT.
DIF: Cognitive Level: Apply/Application REF: p. 119
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse is talking with the patient when the monitor alarms and shows a wavy baseline without a PQRST complex. The nurse should
| a. | defibrillate the patient immediately. |
| b. | initiate basic life support. |
| c. | initiate advanced life support. |
| d. | assess the patient and the electrical leads. |
ANS: D
Ventricular fibrillation (VF) is a chaotic rhythm characterized by a quivering of the ventricles, which results in total loss of cardiac output and pulse. VF is a life-threatening emergency, and the more immediate the treatment is, the better the survival will be. VF produces a wavy baseline without a PQRST complex. Because a loose lead or electrical interference can produce a waveform similar to VF, it is always important to immediately assess the patient for pulse and consciousness.
DIF: Cognitive Level: Apply/Application REF: pp. 119-120
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Implementation | Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse notices that the patient has a first-degree AV block. Everything else about the rhythm is normal. The nurse should
| a. | prepare to place the patient on a transcutaneous pacemaker. |
| b. | give the patient atropine to shorten the PR interval. |
| c. | monitor the rhythm and patient’s condition. |
| d. | give the patient an antiarrhythmic medication. |
ANS: C
First-degree AV block is a common dysrhythmia in the elderly and in patients with cardiac disease. As the normal conduction pathway ages or becomes diseased, impulse conduction becomes slower than normal. It is well tolerated. No treatment is required. Continue to monitor the patient and the rhythm.
DIF: Cognitive Level: Apply/Application REF: pp. 212-122
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Implementation | Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse understands that in a third-degree AV block
| a. | every P wave is conducted to the ventricles. |
| b. | some P waves are conducted to the ventricles. |
| c. | none of the P waves are conducted to the ventricles. |
| d. | the PR interval is prolonged. |
ANS: C
Third-degree block is often called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. Normally every P wave is conducted to the ventricles. If some of the P waves are conducted but others are not, further assessment is needed to determine the type of block present. A prolonged PR interval is a first-degree AV block, and is well tolerated and requires no treatment.
DIF: Cognitive Level: Remember/Knowledge REF: p. 123
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: N/A
MSC: NCLEX Client Needs Category: Physiological Integrity
- The patient is asymptomatic but is diagnosed with second-degree heart block Mobitz I. The patient is on digitalis medication at home. The nurse should expect that
| a. | the patient has had an anterior wall myocardial infarction. |
| b. | the physician will order the digitalis to be continued in the hospital. |
| c. | a digitalis level would be ordered upon admission. |
| d. | the patient will require a transcutaneous pacemaker. |
ANS: C
Digitalis toxicity is a major cause of this rhythm, and further digitalis doses should not be given until a digitalis level is obtained. Other causes of Mobitz I include AV nodal blocking drugs, acute inferior wall myocardial infarction or right ventricular infarction, ischemic heart disease, and excess vagal response. This type of block is usually well tolerated, and no treatment is indicated unless the dropped beats occur frequently.
DIF: Cognitive Level: Analyze/Analysis REF: pp. 122-123
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The patient is scheduled to have a permanent pacemaker implanted. The patient asks the nurse, “How long will the battery in this thing last?” The nurse should answer,
| a. | “Life expectancy is about 1 year. Then it will need to be replaced.” |
| b. | “Pacemaker batteries can last up to 25 years with constant use.” |
| c. | “Battery life varies depending on usage, but it can last up to 10 years.” |
| d. | “Pacemakers are used to treat temporary problems, so the batteries don’t last long.” |
ANS: C
Implanted permanent pacemakers are used to treat chronic conditions. These devices have a battery life of up to 10 years, which varies based on the manufacturer’s recommendations and the usage of the device.
DIF: Cognitive Level: Understand/Comprehension REF: p. 124
OBJ: Explain the basic concepts of cardiac pacing.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The patient is in chronic junctional escape rhythm with no atrial activity noted. Studies have demonstrated normal AV node function. This patient may be a candidate for which type of pacing?
| a. | Atrial pacing |
| b. | Ventricular pacing |
| c. | Dual-chamber pacing |
| d. | Transcutaneous pacing |
ANS: A
Pacemakers may be used to stimulate the atrium, ventricle, or both chambers (dual-chamber pacemakers). Atrial pacing is used to mimic normal conduction and to produce atrial contraction, thus providing atrial kick. This is the case in the scenario provided. Ventricular pacing stimulates ventricular depolarization and is commonly used in emergency situations or when pacing is required infrequently. Dual-chamber pacing allows for stimulation of both atria and ventricles as needed to synchronize the chambers and mimic the normal cardiac cycle. However, with this patient, ventricular and AV function are normal.
DIF: Cognitive Level: Analyze/Analysis REF: p. 126
OBJ: Explain the basic concepts of cardiac pacing.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The patient has a permanent pacemaker inserted. The provider has set the pacemaker to the demand mode at a rate of 60 beats per minute. The nurse realizes that
| a. | the pacemaker will pace only if the patient’s intrinsic heart rate is less than 60 beats per minute. |
| b. | the demand mode often competes with the patient’s own rhythm. |
| c. | the demand mode places the patient at risk for the R-on-T phenomenon. |
| d. | the fixed-rate mode is safer and is the mode of choice. |
ANS: A
Pacemakers can be operated in a demand mode or a fixed-rate (asynchronous) mode. The demand mode paces the heart when no intrinsic or native beat is sensed. For example, if the rate control is set at 60 beats per minute, the pacemaker will only pace if the patient’s heart rate drops to less than 60. The fixed-rate mode paces the heart at a set rate, independent of any activity the patient’s heart generates. The fixed-rate mode may compete with the patient’s own rhythm and deliver an impulse on the T wave (R-on-T phenomenon), with the potential for producing ventricular tachycardia or fibrillation. The demand mode is safer and is the mode of choice.
DIF: Cognitive Level: Understand/Comprehension REF: p. 126
OBJ: Explain the basic concepts of cardiac pacing.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The patient has a permanent pacemaker in place with a demand rate set at 60 beats/min. The cardiac monitor is showing a heart rate of 44 beats/min with no pacemaker spikes. The nurse recognizes this as:
| a. | normal pacemaker function. |
| b. | failure to capture. |
| c. | failure to pace. |
| d. | failure to sense. |
ANS: C
Failure to pace or fire occurs when the pacemaker fails to initiate an electrical stimulus when it should fire. The problem is noted by absence of pacer spikes on the rhythm strip. Causes of failure to pace include battery or pulse generator failure, fracture or displacement of a pacemaker wire, or loose connections. This is not normal pacemaker function. When the pacemaker generates an electrical impulse (pacer spike) and no depolarization is noted, it is described as a failure to capture. On the ECG, a pacer spike is noted, but it is not followed by a P wave (atrial pacemaker) or a QRS complex (ventricular pacemaker). When the pacemaker does not sense the patient’s own cardiac rhythm and initiates an electrical impulse, it is called failure to sense. Failure to sense manifests as pacer spikes that fall too closely to the patient’s own rhythm, earlier than the programmed rate.
DIF: Cognitive Level: Remember/Knowledge REF: p. 127
OBJ: Explain the basic concepts of cardiac pacing.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The rhythm on the cardiac monitor is showing numerous pacemaker spikes, but no P waves or QRS complexes following the spikes. The nurse recognizes this as:
| a. | normal pacemaker function. |
| b. | failure to capture. |
| c. | failure to pace. |
| d. | failure to sense. |
ANS: B
When the pacemaker generates an electrical impulse (pacer spike) and no depolarization is noted, it is described as a failure to capture. On the ECG, a pacer spike is noted, but it is not followed by a P wave (atrial pacemaker) or a QRS complex (ventricular pacemaker). This is not normal pacemaker function. Failure to pace or fire occurs when the pacemaker fails to initiate an electrical stimulus when it should fire. The problem is noted by absence of pacer spikes on the rhythm strip. When the pacemaker does not sense the patient’s own cardiac rhythm and initiates an electrical impulse, it is called failure to sense. Failure to sense manifests as pacer spikes that fall too closely to the patient’s own rhythm, earlier than the programmed rate.
DIF: Cognitive Level: Remember/Knowledge REF: p. 127
OBJ: Explain the basic concepts of cardiac pacing.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | Normal sinus rhythm |
| b. | Sinus bradycardia |
| c. | Sinus tachycardia |
| d. | Sinus arrhythmia |
ANS: A
Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P and QRS waves are consistent in shape. Sinus tachycardia results when the SA node fires faster than 100 beats per minute. Bradycardia is defined as a heart rate less than 60 beats per minute. Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate slightly increases during inspiration and slightly slows during exhalation because of changes in vagal tone.
DIF: Cognitive Level: Analyze/Analysis REF: p. 105 | Fig 7-24
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | Normal sinus rhythm |
| b. | Sinus bradycardia |
| c. | Sinus tachycardia |
| d. | Sinus arrhythmia |
ANS: C
Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P and QRS waves are consistent in shape. Sinus tachycardia results when the SA node fires faster than 100 beats per minute. Bradycardia is defined as a heart rate less than 60 beats per minute. Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate slightly increases during inspiration and slightly slows during exhalation because of changes in vagal tone.
DIF: Cognitive Level: Analyze/Analysis REF: p. 105 | Fig 7-25
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | Normal sinus rhythm |
| b. | Sinus bradycardia |
| c. | Sinus tachycardia |
| d. | Sinus arrhythmia |
ANS: B
Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P and QRS waves are consistent in shape. Sinus tachycardia results when the SA node fires faster than 100 beats per minute. Bradycardia is defined as a heart rate less than 60 beats per minute. Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate increases slightly during inspiration and slows slightly during exhalation because of changes in vagal tone.
DIF: Cognitive Level: Analyze/Analysis REF: p. 106 | Fig 7-26
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | Sinus rhythm with PACs |
| b. | Normal sinus rhythm |
| c. | Sinus tachycardia |
| d. | Sinus bradycardia |
ANS: A
The underlying rhythm is identified first. Following this step, the dysrhythmia that is occurring to disrupt the underlying rhythm is then determined. A premature atrial contraction (PAC) is a single ectopic beat arising from atrial tissue, not the sinus node. The PAC occurs earlier than the next normal beat and interrupts the regularity of the underlying rhythm. The P wave of the PAC has a different shape than the sinus P wave because it arises from a different area in the atria; it may follow or be in the T wave of the preceding normal beat. If the early P wave is in the T wave, this T wave will look different from the T wave of a normal beat. Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P and QRS waves are consistent in shape. Sinus tachycardia results when the SA node fires faster than 100 beats per minute. Bradycardia is defined as a heart rate less than 60 beats per minute.
DIF: Cognitive Level: Analyze/Analysis REF: p. 107 | Fig 7-29
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | Atrial flutter with variable conduction |
| b. | Ventricular fibrillation |
| c. | Atrial fibrillation |
| d. | Atrial flutter with RVR (rapid ventricular response) |
ANS: A
Atrial flutter arises from a single irritable focus in the atria. The atrial focus fires at an extremely rapid, regular rate, between 240 and 320 beats per minute. The P waves are called flutter waves and may have a sawtooth appearance. The ventricular response may be regular or irregular based on how many flutter waves are conducted through the AV node. Atrial flutter with RVR occurs when atrial impulses cause a ventricular response greater than 100 beats per minute. Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction.
DIF: Cognitive Level: Analyze/Analysis REF: pp. 110-111 | Fig 7-33
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | Atrial fibrillation |
| b. | Atrial flutter |
| c. | Atrial flutter with RVR |
| d. | Junctional escape rhythm |
ANS: A
Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction. The AV node is bombarded with hundreds of atrial impulses and conducts these impulses in an unpredictable manner to the ventricles. The atrial rate may be as high 700 and no discernible P waves can be identified, resulting in a wavy baseline and an extremely irregular ventricular response. Atrial flutter arises from a single irritable focus in the atria. The atrial focus fires at an extremely rapid, regular rate, between 240 and 320 beats per minute. The P waves are called flutter waves and may have a sawtooth appearance. The ventricular response may be regular or irregular based on how many flutter waves are conducted through the AV node. Atrial flutter with RVR occurs when atrial impulses cause a ventricular response greater than 100 beats per minute. A junctional escape rhythm is a ventricular rate between 40 and 60 beats per minute with a regular rhythm. P waves may be absent, inverted, or follow the QRS complex. If a P wave is present before the QRS complex, the PR interval is shortened to less than 0.12 milliseconds. QRS complex is normal.
DIF: Cognitive Level: Analyze/Analysis REF: pp. 111-112 | Fig 7-34
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | Junctional rhythm |
| b. | An accelerated junctional rhythm |
| c. | A junctional tachycardia |
| d. | Atrial fibrillation |
ANS: A
The normal intrinsic rate for the AV node and junctional tissue is 40 to 60 beats per minute, but rates can accelerate. An accelerated junctional rhythm has a rate between 60 and 100 beats per minute, and the rate for junctional tachycardia is greater than 100 beats per minute. If a P wave precedes QRS, it is inverted or upside down; the P wave may not be visible, or it may follow the QRS. If a P wave is present before the QRS, the PR interval is shortened to less than 0.12 milliseconds. Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction. The AV node is bombarded with hundreds of atrial impulses and conducts these impulses in an unpredictable manner to the ventricles.
DIF: Cognitive Level: Analyze/Analysis REF: pp. 113-114 | Fig 7-37
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | Sinus rhythm with multifocal premature ventricular contractions |
| b. | Sinus rhythm with unifocal premature ventricular contractions |
| c. | Sinus rhythm with bigeminal premature ventricular contractions |
| d. | Sinus rhythm with paired premature ventricular contractions (couplets) |
ANS: A
A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs arising from multiple foci are not identical and are called multifocal PVCs. PVCs may occur in a predictable pattern, such as every other beat (bigeminal), every third beat (trigeminal), or every fourth beat (quadrigeminal). PVCs can also occur sequentially. Two PVCs in a row are called a pair (or couplets), and three or more in a row are called nonsustained ventricular tachycardia.
DIF: Cognitive Level: Analyze/Analysis REF: pp. 116-117 | Fig 7-41B
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | Sinus rhythm with multifocal premature ventricular contractions |
| b. | Sinus rhythm with unifocal premature ventricular contractions |
| c. | Sinus rhythm with trigeminal premature ventricular contractions |
| d. | Sinus rhythm with paired premature ventricular contractions (couplets) |
ANS: B
A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs arising from multiple foci are not identical and are called multifocal PVCs. PVCs may occur in a predictable pattern, such as every other beat (bigeminal), every third beat (trigeminal), or every fourth beat (quadrigeminal). PVCs also can occur sequentially. Two PVCs in a row are called a pair, and three or more in a row are called nonsustained ventricular tachycardia.
DIF: Cognitive Level: Analyze/Analysis REF: pp. 116-117 | Fig 7-41A
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | Sinus rhythm with multifocal premature ventricular contractions |
| b. | Sinus rhythm with unifocal premature ventricular contractions |
| c. | Sinus rhythm with bigeminal premature ventricular contractions |
| d. | Sinus rhythm with paired premature ventricular contractions (couplets) |
ANS: C
A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs arising from multiple foci are not identical and are called multifocal PVCs. PVCs may occur in a predictable pattern, such as every other beat (bigeminal), every third beat (trigeminal), or every fourth beat (quadrigeminal). PVCs can also occur sequentially. Two PVCs in a row are called a pair (couplet), and three or more in a row are called nonsustained ventricular tachycardia.
DIF: Cognitive Level: Analyze/Analysis
REF: p. 109 | pp. 116-117 | Fig 7-41A | Box 7-4
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | Sinus rhythm with multifocal premature ventricular contractions |
| b. | Sinus rhythm with unifocal premature ventricular contractions |
| c. | Sinus rhythm with bigeminal premature ventricular contractions |
| d. | Sinus rhythm with paired premature ventricular contractions (couplets) |
ANS: D
A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs arising from multiple foci are not identical and are called multifocal PVCs. PVCs may occur in a predictable pattern, such as every other beat (bigeminal), every third beat (trigeminal), or every fourth beat (quadrigeminal). PVCs can also occur sequentially. Two PVCs in a row are called a pair (couplet), and three or more in a row are called nonsustained ventricular tachycardia.
DIF: Cognitive Level: Analyze/Analysis REF: pp. 116-117 | Fig 7-41C
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | R-on-T phenomenon leading to ventricular fibrillation |
| b. | Sinus rhythm with multifocal premature ventricular contractions |
| c. | Nonsustained ventricular tachycardia |
| d. | Sinus rhythm with bigeminal premature ventricular contractions |
ANS: A
The peak of the T wave through the downslope of the T wave is considered the vulnerable period, which coincides with partial repolarization of the ventricles. If a PVC occurs during the T wave, ventricular tachycardia may occur. When the R wave of a PVC falls on the T wave of a normal beat, it is referred to as the R-on-T phenomenon. This strip does not show sinus rhythm, multi-focal PVCs (PVCs that are from different places in the heart and therefore look different), non-sustained ventricular tachycardia, or bigeminal premature ventricular contractions (where every other beat is a PVC).
DIF: Cognitive Level: Analyze/Analysis REF: p. 116 | Fig 7-42 B
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The patient is alert and talking when the nurse notices the following rhythm. The patient’s blood pressure is 90/44 mm Hg. The nurse should
| a. | defibrillate immediately. |
| b. | begin basic life support. |
| c. | begin advanced life support. |
| d. | treat with intravenous amiodarone or lidocaine. |
ANS: D
Ventricular tachycardia (VT) is a rapid, life-threatening dysrhythmia originating from a single ectopic focus in the ventricles. It is characterized by at least three PVCs in a row. VT occurs at a rate greater than 100 beats per minute, but the rate is usually around 150 beats per minute and may be up to 250 beats per minute. Depolarization of the ventricles is abnormal and produces a widened QRS complex. The patient may or may not have a pulse. Determine whether the patient has a pulse. If no pulse is present, provide emergent basic and advanced life-support interventions, including defibrillation. If a pulse is present and the blood pressure is stable, the patient can be treated with intravenous amiodarone or lidocaine.
DIF: Cognitive Level: Analyze/Analysis REF: pp. 117-118 | Fig 43B
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.
TOP: Nursing Process Step: Implementation | Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse notes the following rhythm on the heart monitor. The patient is unresponsive and not breathing. The nurse should
| a. | treat with intravenous amiodarone or lidocaine. |
| b. | provide emergent basic and advanced life support. |
| c. | provide electrical cardioversion. |
| d. | ignore the rhythm because it is benign. |
ANS: B
Ventricular fibrillation (VF) is a chaotic rhythm characterized by a quivering of the ventricles, which results in total loss of cardiac output and pulse. VF is a life-threatening emergency, and the more immediate the treatment, the better the survival will be. VF produces a wavy baseline without a PQRST complex. Because a loose lead or electrical interference can produce a waveform similar to VF, it is always important to immediately assess the patient for pulse and consciousness. If no pulse is present, provide emergent basic and advanced life-support interventions, including defibrillation. IV medications can be used as part of advanced life support. Cardioversion is not warranted since the patient is pulseless. This rhythm is not benign and cannot be ignored.
DIF: Cognitive Level: Analyze/Analysis REF: pp. 119-120 | Fig 7-45A
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Implementation | Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | Idioventricular rhythm |
| b. | Accelerated idioventricular rhythm |
| c. | Ventricular tachycardia |
| d. | Ventricular fibrillation |
ANS: A
Idioventricular rhythm is an escape rhythm that is generated by the Purkinje fibers. This rhythm emerges only when the SA and AV nodes fail to initiate an impulse. The Purkinje fibers are capable of an intrinsic rate of 20 to 40 beats per minute. Because this last pacemaker is located in the ventricles, the QRS complex appears wide and bizarre with a slow rate. No P waves are present. If the rate is between 40 and 100 beats per minute, this rhythm is called accelerated idioventricular rhythm (AIVR). Ventricular tachycardia (VT) is a rapid, life-threatening dysrhythmia originating from a single ectopic focus in the ventricles. It is characterized by at least three PVCs in a row. VT occurs at a rate greater than 100 beats per minute, but the rate is usually around 150 beats per minute and may be up to 250 beats per minute. VF produces a wavy baseline without a PQRST complex. Because a loose lead or electrical interference can produce a waveform similar to VF, it is always important to immediately assess the patient for pulse and consciousness.
DIF: Cognitive Level: Analyze/Analysis REF: pp. 120-121 | Fig 7-46A
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | Normal sinus rhythm |
| b. | Sinus rhythm with second-degree AV block |
| c. | Complete heart block |
| d. | Sinus rhythm with first-degree AV block |
ANS: D
In first-degree block, P and QRS waves are consistent in shape. P waves are small and rounded. A P wave precedes every QRS complex, which is followed by a T wave. PR interval is prolonged and is greater than 0.20 seconds. QRS complex and QT/QTc measurements are normal. Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. In a complete heart block, the atria and ventricles beat independently of each other. A first-degree AV block means the PR interval is greater than 0.20 seconds.
DIF: Cognitive Level: Analyze/Analysis REF: pp. 121-122 | Fig 7-49
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | First-degree AV block |
| b. | Second-degree AV block Mobitz I (Wenckebach phenomenon) |
| c. | Second-degree AV block Mobitz II |
| d. | Third-degree AV block (complete heart block) |
ANS: B
Also called a Mobitz I or Wenckebach phenomenon, second-degree AV block type I is represented on the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. In first-degree AV block, a P wave precedes every QRS complex, and every P wave is followed by a QRS; however, the PR interval is >0.20 seconds. Second-degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout with the exception of the dropped beat(s). Third-degree block is often called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse and it is not conducted to the ventricles. One hallmark of third-degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform.
DIF: Cognitive Level: Analyze/Analysis REF: pp. 122-123 | Fig 7-50A
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | First-degree AV block |
| b. | Second-degree AV block Mobitz I (Wenckebach phenomenon) |
| c. | Second-degree AV block Mobitz II |
| d. | Third-degree AV block (complete heart block) |
ANS: C
Second-degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout with the exception of the dropped beat(s). Also called a Mobitz I or Wenckebach phenomenon, second-degree AV block type I is represented on the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. In first-degree AV block, a P wave precedes every QRS complex, and every P wave is followed by a QRS. Third-degree block is often called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse and it is not conducted to the ventricles. One hallmark of third-degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform.
DIF: Cognitive Level: Analyze/Analysis REF: pp. 122-123 | Fig 7-51A
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | First-degree AV block |
| b. | Second-degree AV block Mobitz I (Wenckebach phenomenon) |
| c. | Second-degree AV block Mobitz II |
| d. | Third-degree AV block (complete heart block) |
ANS: D
Third-degree block is often called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse and it is not conducted to the ventricles. One hallmark of third-degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform. Second-degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout with the exception of the dropped beat(s). Also called a Mobitz I or Wenckebach phenomenon, second-degree AV block type I is represented on the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. In first-degree AV block, a P wave precedes every QRS complex, and every P wave is followed by a QRS.
DIF: Cognitive Level: Analyze/Analysis REF: pp. 123-124 | Fig 7-52B
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | Atrial pacing |
| b. | Ventricular pacing |
| c. | Dual-chamber pacing |
| d. | Transcutaneous pacing |
ANS: A
Pacemakers may be used to stimulate the atrium, ventricle, or both chambers (dual-chamber pacemakers). Atrial pacing is used to mimic normal conduction and to produce atrial contraction, thus providing atrial kick. This is the case in the scenario provided. Ventricular pacing stimulates ventricular depolarization and is commonly used in emergency situations or when pacing is required infrequently. Dual-chamber pacing allows for stimulation of both atria and ventricles as needed to synchronize the chambers and mimic the normal cardiac cycle. However, with this patient, ventricular and AV function are normal. Transcutaneous pacing is delivered through the skin via external electrode pads connected to an external pacemaker.
DIF: Cognitive Level: Analyze/Analysis REF: pp. 126-127 | Fig 7-58
OBJ: Explain the basic concepts of cardiac pacing.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | Atrial pacing |
| b. | Ventricular pacing |
| c. | Dual-chamber pacing |
| d. | Transcutaneous pacing |
ANS: B
Pacemakers may be used to stimulate the atrium, ventricle, or both chambers (dual-chamber pacemakers). Atrial pacing is used to mimic normal conduction and to produce atrial contraction, thus providing atrial kick. Ventricular pacing stimulates ventricular depolarization and is commonly used in emergency situations or when pacing is required infrequently. This patient’s pacemaker is stimulating the ventricles. Dual-chamber pacing allows for stimulation of both atria and ventricles as needed to synchronize the chambers and mimic the normal cardiac cycle. There is no evidence of a dual pacemaker since the atrial spike is not seen on the ECG strip. Transcutaneous pacing is accomplished via skin electrodes.
DIF: Cognitive Level: Analyze/Analysis REF: pp. 126-127 | Fig 7-59
OBJ: Explain the basic concepts of cardiac pacing.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | Atrial pacing |
| b. | Ventricular pacing |
| c. | Dual-chamber pacing |
| d. | Transcutaneous pacing |
ANS: C
Pacemakers may be used to stimulate the atrium, ventricle, or both chambers (dual-chamber pacemakers). Atrial pacing is used to mimic normal conduction and to produce atrial contraction, thus providing atrial kick. Ventricular pacing stimulates ventricular depolarization and is commonly used in emergency situations or when pacing is required infrequently. Dual-chamber pacing allows for stimulation of both atria and ventricles as needed to synchronize the chambers and mimic the normal cardiac cycle. This is the case in the scenario provided as seen by pacemaker spikes in both the atrial and ventricular position.
DIF: Cognitive Level: Analyze/Analysis REF: pp. 126-127 | Fig 7-60
OBJ: Explain the basic concepts of cardiac pacing.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | Normal pacemaker function |
| b. | Failure to capture |
| c. | Failure to pace |
| d. | Failure to sense |
ANS: C
Failure to pace or fire occurs when the pacemaker fails to initiate an electrical stimulus when it should fire. The problem is noted by absence of pacer spikes on the rhythm strip. Note that after the 3-second mark, the pacemaker failed to fire. When the pacemaker generates an electrical impulse (pacer spike) and no depolarization is noted, it is described as a failure to capture. On the ECG, a pacer spike is noted, but it is not followed by a P wave (atrial pacemaker) or a QRS complex (ventricular pacemaker) within the appropriate time frame. When the pacemaker does not sense the patient’s own cardiac rhythm and initiates an electrical impulse, it is called failure to sense. Failure to sense manifests as pacer spikes that fall too closely to the patient’s own rhythm, earlier than the programmed rate. This is not normal pacemaker function.
DIF: Cognitive Level: Analyze/Analysis REF: p. 127 | Fig 7-61
OBJ: Explain the basic concepts of cardiac pacing.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Interpret the following rhythm:
| a. | Normal pacemaker function |
| b. | Failure to capture |
| c. | Failure to pace |
| d. | Failure to sense |
ANS: D
When the pacemaker does not sense the patient’s own cardiac rhythm and initiates an inappropriate electrical impulse, it is called failure to sense. Failure to sense manifests as pacer spikes that fall too closely to the patient’s own rhythm, earlier than the programmed rate. This is not normal pacemaker function. When the pacemaker generates an electrical impulse (pacer spike) and no depolarization is noted, it is described as a failure to capture. On the ECG, a pacer spike is noted, but it is not followed by a P wave (atrial pacemaker) or a QRS complex (ventricular pacemaker). Failure to pace or fire occurs when the pacemaker fails to initiate an electrical stimulus when it should fire. The problem is noted by absence of pacer spikes on the rhythm strip. When the pacemaker does not sense the patient’s own cardiac rhythm and initiates an electrical impulse, it is called failure to sense.
DIF: Cognitive Level: Analyze/Analysis REF: p. 127 | Fig 63
OBJ: Explain the basic concepts of cardiac pacing.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
MULTIPLE RESPONSE
- The normal width of the QRS complex is which of the following? (Select all that apply.)
| a. | 0.06 to 0.10 seconds. |
| b. | 0.12 to 0.20 seconds. |
| c. | 1.5 to 2.5 small boxes. |
| d. | 3.0 to 5.0 small boxes. |
| e. | 0.04 seconds or greater. |
ANS: A, C
The waveform that initiates the QRS complex (whether it is a Q wave or an R wave) marks the beginning of the interval. The normal width of the QRS complex is 0.06 to 0.10 seconds. This width equals 1.5 to 2.5 small boxes. The normal PR interval is 0.12 to 0.20 seconds, three to five small boxes wide; not the QRS interval. A pathological Q wave has a width of 0.04 seconds and a depth that is greater than one fourth of the R wave amplitude; therefore, the QRS complex would be wider than that.
DIF: Cognitive Level: Remember/Knowledge REF: p. 99
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Which of the following are common causes of sinus tachycardia? (Select all that apply.)
| a. | Hyperthyroidism |
| b. | Hypovolemia |
| c. | Hypothyroidism |
| d. | Heart Failure |
| e. | Sleep |
ANS: A, B, D
Common causes of sinus tachycardia include hyperthyroidism, hypovolemia, heart failure, anemia, exercise, use of stimulants, fever, and sympathetic response to fear or pain and anxiety. Hypothyroidism and sleep tend to slow the heart rate.
DIF: Cognitive Level: Remember/Knowledge REF: p. 105
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Sinus bradycardia is a symptom of which of the following? (Select all that apply.)
| a. | Calcium channel blocker medication |
| b. | Beta blocker medication |
| c. | Athletic conditioning |
| d. | Hypothermia |
| e. | Hyperthyroidism |
ANS: A, B, C, D
Vasovagal response; medications such as digoxin or AV nodal blocking agents, including calcium channel blockers and beta blockers; myocardial infarction; normal physiological variant in the athlete; disease of the sinus node; increased intracranial pressure; hypoxemia; and hypothermia may cause sinus bradycardia. Hyperthyroidism is a cause of sinus tachycardia.
DIF: Cognitive Level: Remember/Knowledge REF: p. 106
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse is caring for a patient who has atrial fibrillation. Sequelae that place the patient at greater risk for mortality/morbidity include which of the following? (Select all that apply.)
| a. | Stroke |
| b. | Ashman beats |
| c. | Pulmonary emboli |
| d. | Prolonged PR interval |
| e. | Decreased cardiac output |
ANS: A, C, E
One complication of atrial fibrillation is thromboembolism. The blood that collects in the atria is agitated by fibrillation, and normal clotting is accelerated. Small thrombi, called mural thrombi, begin to form along the walls of the atria. These clots may dislodge, resulting in pulmonary embolism or stroke. The ineffectual contraction of the atria results in loss of “atrial kick.” If too many impulses conduct to the ventricles, atrial fibrillation with rapid ventricular response may result and compromise cardiac output. Ashman beats are not clinically significant. No recognizable or discernible P waves are present; therefore, PR interval is absent.
DIF: Cognitive Level: Remember/Knowledge REF: p. 111 |p. 113
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The possible P waveforms that are associated with junctional rhythms include which of the following? (Select all that apply.)
| a. | No P wave |
| b. | Inverted P wave |
| c. | Shortened PR interval |
| d. | P wave after the QRS complex |
| e. | Normal P wave and PR interval |
ANS: A, B, C, D
Because of the location of the AV node—in the center of the heart—impulses generated may be conducted forward, backward, or both. With the potential of forward, backward, or bidirectional impulse conduction, three different P waveforms may be associated with junctional rhythms: When the AV node impulse moves forward, P waves may be absent because the impulse enters the ventricle first. The atria receives the wave of depolarization at the same time as the ventricles; thus, because of the larger muscle mass of the ventricles, there is no P wave. When the AV node impulse is conducted backward, the impulse enters the atria first. When depolarization occurs backward, an inverted P wave is created. Once the atria have been depolarized, the impulse moves down the bundle of His and depolarizes both ventricles normally. A short PR interval (<0.12 second) is noted. When the impulse is conducted both forward and backward, P waves may be present after the QRS complex.
DIF: Cognitive Level: Remember/Knowledge REF: pp. 113-114
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The patient is in third-degree heart block (complete heart block) and is symptomatic. The treatment for this patient is which of the following? (Select all that apply.)
| a. | Transcutaneous pacemaker |
| b. | Atropine IV |
| c. | Temporary transvenous pacemaker |
| d. | Permanent pacemaker |
| e. | Amiodarone IV |
ANS: A, C, D
Treatments include transcutaneous or transvenous pacing and implanting a permanent pacemaker. Atropine reduces vagal tone, but that is not a cause of complete heart block and will produce more P waves, but the P waves will still not be associated with the QRS complexes. It is important to note that the only treatment is pacing. Amiodarone IV is used to suppress ventricular dysrhythmia and is not used to treat third-degree heart block.
DIF: Cognitive Level: Remember/Knowledge REF: pp. 123-124
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
