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# Chapter 36: Nursing Management: Dysrhythmias

Test Bank

MULTIPLE CHOICE

1. To determine whether there is a delay in impulse conduction through the atria, the nurse will
measure the length of the patients
a.P wave.
b.PR interval.
c.QT interval.
d.QRS complex.
ANS: A
The P wave represents the depolarization of the atria. The P-R interval represents
depolarization of the atria, atrioventricular (AV) node, bundle of His, bundle branches, and the
Purkinje fibers. The QRS represents ventricular depolarization. The Q-T interval represents
depolarization and repolarization of the entire conduction system.

## DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

2. The nurse needs to estimate quickly the heart rate for a patient with a regular heart rhythm.
Which method will be best to use?
a. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS
complexes.
b. Count the number of large squares in the R-R interval and divide by 300.
c. Use the 3-second markers to count the number of QRS complexes in 6 seconds
and multiply by 10.
d. Calculate the number of small squares between one QRS complex and the next
and divide into 1500.
ANS: C
This is the quickest way to determine the ventricular rate for a patient with a regular rhythm.
All the other methods are accurate, but take longer.

## DIF: Cognitive Level: Application TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

3. A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to
have a heart rate of how many beats/minute?
a. 15 to 20
b. 20 to 40
c. 40 to 60
d. 60 to 100
ANS: C
If the sinoatrial (SA) node fails to discharge, the atrioventricular (AV) node will automatically
discharge at the normal rate of 40 to 60. The slower rates are typical of the bundle of His and
the Purkinje system and may be seen with failure of both the SA and AV node to discharge.
The normal SA node rate is 60 to 100 beats/minute.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

4. The nurse obtains a monitor strip on a patient who has had a myocardial infarction and makes
the following analysis: P wave not apparent, ventricular rate 162, R-R interval regular, P-R
interval not measurable, and QRS complex wide and distorted, QRS duration 0.18 second.
The nurse interprets the patients cardiac rhythm as
a. atrial fibrillation.
b. sinus tachycardia.
c. ventricular fibrillation.
d. ventricular tachycardia.
ANS: D
The absence of P waves, wide QRS, rate >150, and the regularity of the rhythm indicate
ventricular tachycardia. Atrial fibrillation is grossly irregular, has a narrow QRS
configuration, and has fibrillatory atrial activity. Sinus tachycardia has P waves. Ventricular
fibrillation is irregular and does not have a consistent QRS duration.

## DIF: Cognitive Level: Application TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

5. The nurse notes that a patients cardiac monitor shows that every other beat is earlier than
expected, has no P wave, and has a QRS complex with a wide and bizarre shape. How will the
nurse document the rhythm?
a. Ventricular couplets
b. Ventricular bigeminy
c. Ventricular R-on-T phenomenon
d. Ventricular multifocal contractions
ANS: B
Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and
bizarre looking. Pairs of wide QRS complexes are described as couplets. There is no
indication that the premature ventricular contractions (PVCs) are multifocal or that the R-on-T
phenomenon is occurring.

## DIF: Cognitive Level: Application TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

6. A patient has a normal cardiac rhythm and a heart rate of 72 beats/minute, except that the PR
interval is 0.24 seconds. The appropriate intervention by the nurse is to
a. notify the patients health care provider immediately.
c. prepare the patient for temporary pacemaker insertion.
d. document the finding and continue to monitor the patient.
ANS: D
First-degree atrioventricular (AV) block is asymptomatic and requires ongoing monitoring
because it may progress to more serious forms of heart block. The rate is normal, so there is
no indication that atropine is needed. Immediate notification of the health care provider about
an asymptomatic rhythm is not necessary.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity

7. A patient who was admitted with a myocardial infarction experiences a 50-second episode of
ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute.
Which action should the nurse take next?
a. Notify the health care provider.
b. Perform synchronized cardioversion.
c. Administer the PRN IV lidocaine (Xylocaine).
d. Document the rhythm and monitor the patient.
ANS: C
The burst of sustained ventricular tachycardia indicates that the patient has significant
ventricular irritability, and antidysrhythmic medication administration is needed to prevent
further episodes. The nurse should notify the health care provider after the medications are
administered. Defibrillation is not indicated given that the patient is currently in a sinus
rhythm. Documentation and continued monitoring are not adequate responses to this situation.

## DIF: Cognitive Level: Application TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

8. After the nurse administers IV atropine to a patient with symptomatic type 1, second-degree
atrioventricular (AV) block, which finding indicates that the medication has been effective?
a. Increase in the patients heart rate
b. Decrease in premature contractions
c. Increase in peripheral pulse volume
d. Decrease in ventricular ectopic beats
ANS: A
Atropine will increase the heart rate and conduction through the AV node. Because the
medication increases electrical conduction, not cardiac contractility, the quality of the
peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have
ventricular ectopy or premature contractions.

## DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

9. A patient with dilated cardiomyopathy has an atrial fibrillation that has been unresponsive to
drug therapy for several days. The nurse anticipates that the patient may need teaching about
a. electrical cardioversion.
c. anticoagulant therapy with warfarin (Coumadin).
d. insertion of an implantable cardioverter-defibrillator (ICD).
ANS: C
Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant
treatment for 3 weeks before attempting cardioversion; this is done to prevent embolization of
clots from the atria. Adenosine is not used to treat atrial fibrillation. Cardioversion may be
done after several weeks of Coumadin therapy. ICDs are used for patients with recurrent
ventricular fibrillation.

## DIF: Cognitive Level: Application TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

10. Which information will the nurse include when teaching a patient who is scheduled to have a
permanent pacemaker inserted for treatment of chronic atrial fibrillation with slow ventricular
response?
a. The pacemaker prevents or minimizes ventricular irritability.
b. The pacemaker paces the atria at rates up to 500 impulses/minute.
c. The pacemaker discharges if ventricular fibrillation and cardiac arrest occur.
d. The pacemaker stimulates a heart beat if the patients heart rate drops too low.
ANS: D
The permanent pacemaker will discharge when the ventricular rate drops below the set rate.
The pacemaker will not decrease ventricular irritability or discharge if the patient develops
ventricular fibrillation. Since the patient has a slow ventricular rate, overdrive pacing will not
be used.

## DIF: Cognitive Level: Application TOP: Nursing Process: Implementation

MSC: NCLEX: Psychosocial Integrity

11. A patient has received instruction on the management of a new permanent pacemaker before
discharge from the hospital. The nurse recognizes that teaching has been effective when the
patient tells the nurse,
a. It will be 6 weeks before I can take a bath or return to my usual activities.
b. I will notify the airlines when I make a reservation that I have a pacemaker.
c. I wont lift the arm on the pacemaker side up very high until I see the doctor.
d. I must avoid cooking with a microwave oven or being near a microwave in use.
ANS: C
The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to
avoid displacing the pacemaker leads. The patient should notify airport security about the
presence of a pacemaker before going through the metal detector, but there is no need to
notify the airlines when making a reservation. Microwave oven use does not affect the
pacemaker. The insertion procedure involves minor surgery that will have a short recovery
period.

## DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

12. Which action by a new nurse who is caring for a patient who has just had an implantable
cardioverter-defibrillator (ICD) inserted indicates a need for more education about care of
patients with ICDs?
a. The nurse assists the patient to do active range of motion exercises for all
extremities.
b. The nurse assists the patient to fill out the application for obtaining a Medic Alert
ID and bracelet.
c. The nurse gives atenolol (Tenormin) to the patient without consulting first with the
health care provider.
d. The nurse teaches the patient that sexual activity usually can be resumed once the
surgical incision is healed.
ANS: A
The patient should avoid moving the arm on the ICD insertion site until healing has occurred
in order to prevent displacement of the ICD leads. The other actions by the new nurse are
appropriate for this patient.

## DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation

MSC: NCLEX: Safe and Effective Care Environment

13. Which action should the nurse take when preparing for cardioversion of a patient with
supraventricular tachycardia who is alert and has a blood pressure of 110/66 mm Hg?
a. Turn the synchronizer switch to the off position.
b. Perform cardiopulmonary resuscitation (CPR) until the paddles are in correct
position.
c. Set the defibrillator/cardioverter energy to 300 joules.
d. Administer a sedative before cardioversion is implemented.
ANS: D
When a patient has a nonemergency cardioversion, sedation is used just before the procedure.
The synchronizer switch is turned on for cardioversion. The initial level of joules for
cardioversion is low (e.g., 50). CPR is not indicated for this patient.

## DIF: Cognitive Level: Application TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

## 14. A 19-year-old has a mandatory electrocardiogram (ECG) before participating on a college

swim team and is found to have sinus bradycardia, rate 52. BP is 114/54, and the student
denies any health problems. What action by the nurse is appropriate?
a. Allow the student to participate on the swim team.
b. Refer the student to a cardiologist for further assessment.
c. Obtain more detailed information about the students health history.
d. Tell the student to stop swimming immediately if any dyspnea occurs.
ANS: A
In an aerobically trained individual, sinus bradycardia is normal. The students normal BP and
negative health history indicate that there is no need for a cardiology referral or for more
detailed information about the health history. Dyspnea during an aerobic activity such as
swimming is normal.

## DIF: Cognitive Level: Application TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

15. When analyzing the waveforms of a patients electrocardiogram (ECG), the nurse will need to
investigate further upon finding a
a. T wave of 0.16 second.
b. P-R interval of 0.18 second.
c. Q-T interval of 0.34 second.
d. QRS interval of 0.14 second.
ANS: D
Because the normal QRS interval is 0.04 to 0.10 seconds, the patients QRS interval of 0.14
seconds indicates that the conduction through the ventricular conduction system is prolonged.
The P-R interval, Q-T interval, and T wave interval are within the normal range.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

16. A patient has ST segment changes that indicate an acute inferior wall myocardial infarction.
Which lead will be best for monitoring the patient?
a.I
b.II
c.V6
d.MCL1
ANS: B
Lead II reflects the inferior area of the heart that is experiencing the ST segment changes and
will best reflect any electrocardiographic (ECG) changes that indicate further damage to the
myocardium. The other leads do not reflect the inferior part of the myocardial wall and will
not provide data about further ischemic changes.

## DIF: Cognitive Level: Analysis TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

17. Which laboratory result for a patient whose cardiac monitor shows multifocal premature
ventricular contractions (PVCs) is most important for the nurse to communicate to the health
care provider?
a. Blood glucose 228 mg/dL
b. Serum chloride 90 mEq/L
c. Serum sodium 133 mEq/L
d. Serum potassium 2.8 mEq/L
ANS: D
Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular
tachycardia, and ventricular fibrillation; the health care provider will need to prescribe a
potassium infusion to correct this abnormality. Although the other laboratory values also are
abnormal, they are not likely to be the etiology of the patients PVCs and do not require
immediate correction.

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TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

18. A patients cardiac monitor has a pattern of undulations of varying contours and amplitude
with no measurable ECG pattern. The patient is unconscious and pulseless. Which action
should the nurse take first?
a. Defibrillate at 360 joules.
d. Prepare for endotracheal intubation.
ANS: A
The patients rhythm and assessment indicate ventricular fibrillation and cardiac arrest; the
initial action should be to defibrillate. If a defibrillator is not immediately available or is
unsuccessful in converting the patient to a better rhythm, the other actions may be appropriate.

## DIF: Cognitive Level: Application OBJ: Special Questions: Prioritization

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
19. A patients cardiac monitor shows sinus rhythm, rate 60 to 70. The P-R interval is 0.18
seconds at 1:00 AM, 0.20 seconds at 2:30 PM, and 0.23 seconds at 4:00 PM. Which action
should the nurse take at this time?
a. Prepare for possible temporary pacemaker insertion.
b. Administer atropine sulfate 1 mg IV per agency protocol.
c. Document the patients rhythm and assess the patients response to the rhythm.
d. Call the health care provider before giving the prescribed metoprolol (Lopressor).
ANS: D
The patient has progressive first-degree atrioventricular (AV) block, and the b-blocker should
be held until discussing the medication with the health care provider. Documentation and
assessment are appropriate but not fully adequate responses. The patient with first-degree AV
block usually is asymptomatic, and a pacemaker is not indicated. Atropine is sometimes used
for symptomatic bradycardia, but there is no indication that this patient is symptomatic.

## DIF: Cognitive Level: Application OBJ: Special Questions: Prioritization

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

20. A patient develops sinus bradycardia at a rate of 32 beats/minute, has a BP of 80/36 mm Hg,
and is complaining of feeling faint. Which action should the nurse take?
a. Continue to monitor the rhythm and BP.
b. Apply the transcutaneous pacemaker (TCP).
c. Have the patient perform the Valsalva maneuver.
d. Give the scheduled dose of diltiazem (Cardizem).
ANS: B
The patient is experiencing symptomatic bradycardia, and treatment with TCP is appropriate.
Continued monitoring of the rhythm and BP is an inadequate response. Calcium channel
blockers will further decrease the heart rate, and the diltiazem should be held. The Valsalva
maneuver will further decrease the rate.

## DIF: Cognitive Level: Application OBJ: Special Questions: Prioritization

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

21. A 21-year-old student arrives at the student health center at the end of the quarter complaining
that, My heart is skipping beats. An electrocardiogram (ECG) shows occasional premature
ventricular contractions (PVCs). What action should the nurse take first?
a. Have the patient transported to the hospital emergency department (ED).
b. Administer O2 at 2 to 3 L/min using nasal prongs.
d. Question the patient about current stress level and coffee use.
ANS: D
In a patient with a normal heart, occasional PVCs are a benign finding. The timing of the
PVCs suggests stress or caffeine as possible etiologic factors. It is unlikely that the patient has
coronary artery disease, and this should not be the first question the nurse asks. The patient is
hemodynamically stable, so there is no indication that the patient needs to be seen in the ED
or that oxygen needs to be administered.

## DIF: Cognitive Level: Application OBJ: Special Questions: Prioritization

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

22. The nurse has received change-of-shift report about the following patients on the telemetry
unit. Which patient should the nurse see first?
a. A patient with atrial fibrillation, rate 88, who has a new order for warfarin
b. A patient with type 1 second-degree atrioventricular (AV) block, rate 60, who is
dizzy when ambulating
c. A patient who is in a sinus rhythm, rate 98, after having electrical cardioversion 2
hours ago
d. A patient whose implantable cardioverter-defibrillator (ICD) fired three times
today who has a dose of amiodarone (Cordarone) due
ANS: D
The frequent firing of the ICD indicates that the patients ventricles are very irritable, and the
priority is to assess the patient and administer the amiodarone. The other patients may be seen

## DIF: Cognitive Level: Analysis OBJ: Special Questions: Prioritization

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

23. A patient who is on the telemetry unit develops atrial flutter, rate 150, with associated dyspnea
and diaphoresis. Which of these actions that are included in the hospital dysrhythmia protocol
should the nurse take first?
a. Obtain a 12-lead electrocardiogram (ECG).
b. Give O2 at 3 to 4 L/min.
c. Take the patients blood pressure and respiratory rate.
d. Notify the health care provider of the change in rhythm.
ANS: B
Since this patient has dyspnea in association with the new rhythm, the nurses initial actions
should be to address the patients airway, breathing, and circulation (ABC) by oxygen
administration. The other actions also are important and should be implemented rapidly.

## DIF: Cognitive Level: Application OBJ: Special Questions: Prioritization

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

24. A patient whose cardiac monitor shows sinus tachycardia, rate 102, is apneic and no pulses are
palpable by the nurse. What is the first action that the nurse should take?
a. Start CPR.
b. Defibrillate.
c. Administer atropine per hospital protocol.
d. Give 100% oxygen per non-rebreather mask.
ANS: A
The patients clinical manifestations indicate pulseless electrical activity and the nurse should
immediately start CPR. The other actions would not be of benefit to this patient.

## DIF: Cognitive Level: Application OBJ: Special Questions: Prioritization

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
25. A patient experiences dizziness and shortness of breath for several days. During cardiac
monitoring in the emergency department (ED), the nurse obtains the following
electrocardiographic (ECG) tracing.

## a. sinus rhythm with premature ventricular contractions (PVCs).

b. junctional escape rhythm.
c. third-degree atrioventricular (AV) block.
d. sinus rhythm with premature atrial contractions (PACs).
ANS: C
The inconsistency between the atrial and ventricular rates and the variable P-R interval
indicate that the rhythm is third-degree AV block. Sinus rhythm with PACs or PVCs will have
a normal rate and consistent P-R intervals with occasional PACs or PVCs. A junctional escape
rhythm will not have P waves.

DIF: Cognitive Level: Application OBJ: Special Questions: Alternate Item Format
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

26. A patient who is complaining of a racing heart and nervousness comes to the emergency
department. The nurse places the patient on a cardiac monitor and obtains the following
electrocardiographic (ECG) tracing.

## Which action should the nurse take next?

a.Get ready to perform electrical cardioversion.
b.Have the patient perform the Valsalva maneuver.
c.Obtain the patients blood pressure and oxygen saturation.
d.Prepare to give b-blocker medication to slow the heart rate.
ANS: C
The patient has sinus tachycardia, which may have multiple etiologies such as pain,
dehydration, anxiety, and myocardial ischemia; further assessment is needed before
determining the treatment. Vagal stimulation or b-blockade may be used after further
assessment of the patient. Electrical cardioversion is used for some tachydysrhythmias, but
would not be used for sinus tachycardia.

## DIF: Cognitive Level: Analysis

OBJ: Special Questions: Alternate Item Format, Prioritization
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

COMPLETION

## 1. When analyzing an electrocardiographic (ECG) rhythm strip of a patient with a regular

cardiac rhythm, the nurse finds there are 25 small blocks from one R wave to the next. The
nurse calculates the patients heart rate as ____________________.

ANS:
60
There are 1500 small blocks in a minute, and the nurse will divide 1500 by 25.

DIF: Cognitive Level: Knowledge OBJ: Special Questions: Alternate Item Format
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. When a patient requires defibrillation, in which order will the nurse accomplish the following
steps? Put a comma and space between each answer choice (a, b, c, d, etc.)
____________________
a. Turn the defibrillator on.
b. Deliver the electrical charge.
c. Select the appropriate energy level.
d. Place the paddles on the patients chest.
e. Check the location of other personnel and call out all clear.

ANS:
A, C, D, E, B
This order will result in rapid defibrillation without endangering hospital personnel.

## DIF: Cognitive Level: Analysis OBJ: Special Questions: Prioritization

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity