Chapter 30 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 30

Question 1

Type: MCMA

A patient is in the critical care area with ventricular tachycardia. The nurse realizes that the patient will require which action?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Immediate assessment and probable emergency intervention

2. Cardioversion, if the ventricular tachycardia is sustained and symptomatic

3. Probable drug intervention

4. Close observation for 1 hour prior to calling the physician

5. Defibrillation to convert the rhythm in the awake patient

Correct Answer: 1,2,3

Rationale 1: The nurse should immediately assess the patient to see how the potentially life-threatening rhythm is being tolerated.

Rationale 2: The nurse should be prepared to cardiovert the patient in ventricular tachycardia with a pulse according to standing prescriptions. The nurse in critical care needs to be aware of standing prescriptions for each patient prior to an emergent event and to have the necessary emergency equipment and medications ready.

Rationale 3: If the patient is hemodynamically stable, drug intervention may correct this arrhythmia.

Rationale 4: Observation prior to calling a physician is not an appropriate action when a potentially life-threatening rhythm is identified.

Rationale 5: Defibrillation is only performed in ventricular tachycardia when the patient is pulseless; otherwise, time is taken to synchronize for cardioversion.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 30-4

Question 2

Type: MCSA

Which is the priority nursing intervention for a patient with a junctional escape rhythm?

1. Assess the patient for symptoms associated with this rhythm.

2. Contact the physician immediately for emergency orders.

3. Eliminate caffeine from the diet.

4. Prepare for a pacemaker insertion.

Correct Answer: 1

Rationale 1: Junctional escape rhythms may be monitored if the patient is not symptomatic. It is most important to assess the patient to see how he or she is affected by the rhythm.

Rationale 2: After another intervention is performed, calling the physician to report the rhythm may be appropriate.

Rationale 3: Eliminating caffeine is not an appropriate action for this patient. There is no indication of symptoms relating to the rhythm.

Rationale 4: Preparing for a pacemaker insertion is not an appropriate action for this patient. There is no indication of symptoms relating to the rhythm.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 30-4

Question 3

Type: SEQ

The nurse is caring for a patient who develops atrial fibrillation with a heart rate above 100 beats per minute. Place the nursing actions in sequence from the highest priority to the lowest priority.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Assess the patient for comfort level and vital signs.

Choice 2. Check the patency of an intermittent IV.

Choice 3. Check the patients chart for lab results from todays tests.

Choice 4. Call the physician to report the dysrhythmia.

Correct Answer: 1,2,3,4

Rationale 1: Assess the patient first.

Rationale 2: Check the patency of the IV in case it is needed to administer medication.

Rationale 3: Check for lab results to report to the physician.

Rationale 4: Call the physician to report the dysrhythmia and the lab results and receive the physicians orders.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 30-4

Question 4

Type: MCSA

Identify the ECG rhythm.

1. Ventricular fibrillation

2. Atrial flutter

3. Sinus tachycardia

4. Ventricular tachycardia

Correct Answer: 1

Rationale 1: Ventricular fibrillation is too rapid to count and is grossly irregular; P:QRS shows no identifiable P waves; the PR interval is absent; and the QRS interval is bizarre and varies in shape and direction. It is important to identify this rhythm because it is a medical emergency; it is known as cardiac arrest because the heart is not pumping. Death will follow if this condition is not resolved within 4 minutes.

Rationale 2: This rhythm is not atrial flutter.

Rationale 3: This rhythm is not sinus tachycardia.

Rationale 4: This rhythm is not ventricular tachycardia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-3

Question 5

Type: MCSA

Sinus bradycardia (rate 56 beats per minute) is identified in a sleeping patient on telemetry. Which is the priority nursing action?

1. Assess the patients tolerance of the rhythm.

2. Call the physician and report this dysrhythmia.

3. Check the medication administration record and see if there is a PRN medication that will improve this rhythm.

4. Call for an immediate 12-lead electrocardiogram (ECG).

Correct Answer: 1

Rationale 1: The nurse should always assess the patients tolerance of any rhythm. Sinus bradycardia should only be treated if the patient is symptomatic.

Rationale 2: Notifying the physician without first assessing the patients response would not be appropriate.

Rationale 3: The patient should be evaluated first to determine how the dysrhythmia is affecting heart function.

Rationale 4: Ordering an ECG is not indicated at this time.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 30-3

Question 6

Type: MCMA

A patient is in sinus tachycardia. Which nursing interventions are appropriate?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Observe the patient for effects on cardiac function.

2. Administer two tablets of acetaminophen (Tylenol) per physician prescription if the temperature is elevated.

3. Administer normal saline 0.9% IV at the prescribed rate of 200 mL per hour if hypovolemia is suspected as the cause.

4. Give pain medications as prescribed if pain is present.

5. Give atropine per physician prescription to slow the heart rate.

Correct Answer: 1,2,3,4

Rationale 1: An appropriate nursing intervention would be to observe the patient for effects on cardiac function.

Rationale 2: An appropriate nursing intervention would be to treat fever.

Rationale 3: An appropriate nursing intervention would be to treat hypovolemia.

Rationale 4: An appropriate nursing intervention would be to treat pain.

Rationale 5: Atropine acts to increase the heart rate and may be a cause of sinus tachycardia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 30-4

Question 7

Type: MCMA

Loss of capture has occurred in a patient with a temporary pacemaker. Which nursing actions are required?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Prepare for cardiac resynchronization therapy (CRT).

2. Assess the patient to determine response to the pacemaker loss of capture.

3. Document the event by printing the ECG strip and placing it on the patients record.

4. Ask the patient to ambulate to increase cardiac output.

5. Administer nitroglycerin sublingual one dose stat according to physician prescription.

Correct Answer: 1,2,3

Rationale 1: CRT is a type of atrial-synchronized biventricular pacemaker. There is no indication that this therapy would be appropriate.

Rationale 2: The nurse should assess the patient to determine the response to the loss of capture.

Rationale 3: The nurse should document the event by printing an ECG strip and placing it on the patients record.

Rationale 4: Having the patient ambulate would not be indicated for pacemaker malfunction.

Rationale 5: Administering nitroglycerin would not be indicated for pacemaker malfunction. Nitroglycerin is administered for chest pain.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 30-4

Question 8

Type: MCMA

The nurse is notified by the cardiac monitoring technician that a patient on continuous cardiac monitoring is having frequent alarms. When the nurse enters the patients room, the patient is in no apparent distress, sitting in the chair and eating. Which are appropriate nursing interventions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Confirm that lead wires are properly connected.

2. Assess the placement of electrodes.

3. Remove and reapply new electrodes if nonadherent.

4. Assess skin sites and move an electrode if the skin appears irritated.

5. Call for assistance.

Correct Answer: 1,2,3,4

Rationale 1: Nursing actions include assessing lead wire connections.

Rationale 2: Nursing actions include assessing the placement of electrodes.

Rationale 3: Nursing actions include changing electrodes every 24 to 48 hours or removing and reapplying electrodes that are dislodged or nonadherent.

Rationale 4: Nursing actions include assessing and documenting skin condition under the pads and moving pads to alternate sites to avoid skin irritation.

Rationale 5: As the patient is in no apparent distress, assistance is not required.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 30-1

Question 9

Type: SEQ

A patient is having elective synchronized cardioversion. Place the steps of the procedure in the correct order.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Verify patency of IV access.

Choice 2. Administer sedative per physician prescription.

Choice 3. Set cardioverter to synchronize mode.

Choice 4. Charge the cardioverter to the selected energy level.

Choice 5. Ensure that personnel are not in physical contact with the bed or patient.

Correct Answer: 1,2,3,4,5

Rationale 1: IV access is necessary for emergency drug administration and should be verified before the procedure is begun.

Rationale 2: Patient comfort is maintained through administration of the prescribed sedative prior to the cardioversion.

Rationale 3: The correct function of the cardioverter is set to synchronize mode.

Rationale 4: The cardioverter should be charged to the selected energy level.

Rationale 5: If personnel are in contact with the bed or the patient, a shock may be inadvertently delivered to them.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 30-4

Question 10

Type: MCSA

A patients electrocardiogram reveals occasional premature ventricular contractions (PVCs). The nurse manager evaluates that the newly licensed nurse understands the implications of this finding when the nurse makes which statement?

1. PVCs are insignificant in people with no history of heart disease.

2. PVCs typically have no pattern.

3. The frequency of PVCs is not associated with specific events.

4. The incidence of PVCs has no relevance to the patient having had a myocardial infarction.

Correct Answer: 1

Rationale 1: PVCs often have no significance in people without history of heart disease.

Rationale 2: PVCs may be isolated or occur in specific patterns.

Rationale 3: PVCs may be triggered by anxiety or stress; tobacco, alcohol, or caffeine use; hypoxia, acidosis, and electrolyte imbalances; sympathomimetic drugs; and coronary heart disease.

Rationale 4: PVCs may be associated with an increased risk for lethal dysrhythmias, and their incidence and significance are greatest after myocardial infarction.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-3

Question 11

Type: MCSA

The nurse is performing cardiopulmonary resuscitation (CPR) on a patient who is in cardiac arrest. An automatic external defibrillator (AED) is available. Which activity will allow the nurse to assess the patients cardiac rhythm?

1. Apply adhesive patch electrodes to the chest and move away from the patient.

2. Apply standard electrocardiograph monitoring leads to the patient and observe the rhythm.

3. Hold the defibrillator paddles directly against the patients chest.

4. Connect electrocardiograph electrodes to a telephone monitoring device and wait until the rhythm is analyzed.

Correct Answer: 1

Rationale 1: The nurse applies adhesive patch electrodes to the patients chest in the usual defibrillator positions, stops CPR, and orders everyone near the patient to move away and not touch the patient. The defibrillator analyzes the rhythm, which may take up to 30 seconds. The machine then indicates if defibrillation is present.

Rationale 2: Standard electrocardiograph monitoring leads are not used with an AED.

Rationale 3: Defibrillator paddles are not used with an AED.

Rationale 4: Telephone monitoring devices are not used with an AED.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 30-4

Question 12

Type: MCSA

A patient received an implantable cardioverter-defibrillator (ICD). The nurse would include which instruction during discharge teaching for this patient?

1. If a family member is in direct contact with you when the ICD discharges, he or she may experience a shock or tingling sensation.

2. You can activate the ICD whenever you feel a change in your heart rhythm.

3. The batteries of the ICD wont need to be replaced if the ICD never shocks the heart.

4. There should be no discomfort if the ICD discharges. You probably wont notice it.

Correct Answer: 1

Rationale 1: Anyone in direct contact with the patient when the ICD discharges may receive a shock or tingling sensation.

Rationale 2: The ICD is programmed to automatically activate when detecting a potentially lethal cardiac rhythm. It cannot be activated by the patient.

Rationale 3: Batteries must be surgically replaced every 5 years or following manufacturers instructions.

Rationale 4: Some patients experience significant discomfort with ICD discharge.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 30-4

Question 13

Type: MCMA

The nurse is teaching a class for technicians who will watch cardiac monitors. How would the nurse describe the normal lead II appearance of the T wave of the ECG complex?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The T wave is a smooth rounded deflection.

2. The T wave is a negative deflection.

3. The T wave follows the QRS.

4. One T wave should be present in each complex.

5. The end of the T wave should occur 0.20 to 0.25 seconds after its preceding complex begins.

Correct Answer: 1,3,4

Rationale 1: The normal T wave is smooth and rounded.

Rationale 2: The T wave is upright, which is a positive deflection from the baseline.

Rationale 3: The T wave is the next deflection after the QRS.

Rationale 4: There is one T wave in each ECG complex.

Rationale 5: The end of the T wave should occur 0.34 to 0.43 seconds after its preceding complex begins.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-2

Question 14

Type: MCSA

The nurse is reviewing an electrocardiogram (ECG) rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats/minute. What is the correct interpretation based on these characteristics?

1. Normal sinus rhythm

2. Sick sinus syndrome

3. Sinus bradycardia

4. First-degree heart block

Correct Answer: 1

Rationale 1: Normal sinus rhythm is defined as regular rhythm with a rate of 60 to 100 beats per minute. The PR and QRS measurements are normal, 0.12 to 0.20 second and 0.06 to 0.10 second respectively.

Rationale 2: The rhythm is regular, which is not a characteristic of sick sinus syndrome.

Rationale 3: The rate is too fast for sinus bradycardia.

Rationale 4: The PR interval is within normal limits, which does not meet the criteria for first-degree block.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-3

Question 15

Type: MCSA

The patients ECG shows the following characteristics: PR interval 0.08, QRS 0.08, and isoelectric ST segment. The nurse realizes that these characteristics indicate which condition?

1. Faster-than-normal conduction from the SA node to the ventricles, normal conduction through the ventricles, and normal ST segment

2. Faster-than-normal conduction from the SA node to the ventricles, faster-than-normal conduction through the ventricles. and normal ST segment

3. Normal conduction from the SA node to the ventricles, normal conduction through the ventricles, and normal ST segment

4. Normal conduction from the SA node to the ventricles, normal conduction through the ventricles, and abnormal ST segment

Correct Answer: 1

Rationale 1: The PR interval is normally 0.12 second (up to 0.24 second is considered normal in patients over age 65).

Rationale 2: The normal duration of a QRS complex is 0.06 to 0.10 second.

Rationale 3: The PR interval is normally 0.12 second (up to 0.24 second is considered normal in patients over age 65).

Rationale 4: The ST segment, the period from the end of the ARS complex to the beginning of the T wave, should be isoelectric.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-2

Question 16

Type: MCMA

The nurse reviews an ECG tracing and determines that it is not a high-quality tracing. Which factors can negatively influence an ECG tracing?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Patient movement during recording

2. Dense chest hair

3. Incorrect positioning of leads

4. Presence of an IV infusion pump

5. Electrodes in firm contact with the skin

Correct Answer: 1,2,3,4

Rationale 1: Factors that can negatively impact the quality of an ECG tracing include motion artifact, which occurs when the patient moves during the recording.

Rationale 2: Dense chest hair interferes with electrode contact with the skin.

Rationale 3: Factors that can negatively impact the quality of an ECG tracing include incorrect positioning of leads.

Rationale 4: If electrical equipment in the room, such as an IV pump, is not grounded, electrical interference can occur.

Rationale 5: Electrodes that are in firm contact with the skin ensure the accuracy of the test.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 30-1

Question 17

Type: MCSA

The nurse is caring for a patient whose atria do not contract correctly. The nurse would expect this dysfunction to be apparent in which part of the ECG complex?

1. The P wave

2. The U wave

3. The QRS

4. The T wave

Correct Answer: 1

Rationale 1: The P wave represents the depolarization and contraction of the atria.

Rationale 2: A U wave is not present in everyones ECG. It occurs with potassium imbalance and is not associated with the atria.

Rationale 3: The QRS represents the conduction of the electrical impulse from the bundle of His to the ventricles.

Rationale 4: The T wave represents the repolarization of the ventricles. It is not associated with the atria.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-1

Question 18

Type: MCSA

Which statement would the nurse use to describe the Q wave of an electrocardiogram tracing?

1. Rounded and upright and follows the QRS complex

2. Rounded and upright and precedes the QRS complex

3. Negative deflection following the R wave

4. First negative deflection after the P wave

Correct Answer: 4

Rationale 1: T waves are generally rounded and upright and follow the QRS complex.

Rationale 2: P waves are rounded and generally upright and precede the QRS complex.

Rationale 3: The negative deflection following the R wave is the S wave.

Rationale 4: The Q wave is the first negative deflection following the P wave.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-1

Question 19

Type: MCSA

If the PR interval is abnormal, the nurse would assess for conditions affecting the timing of impulse transmission from which parts of the cardiac conduction system?

1. SA node to the ventricles

2. Bundle of His to the ventricles

3. AV node to the ventricles

4. Purkinje fibers to the ventricles

Correct Answer: 1

Rationale 1: The PR interval, sometimes referred to as the PRI or PR segment, represents the time it takes for the impulse to travel from the SA node down the intra-atrial pathways to the ventricles. In other words, it represents the beginning of the atrial contraction to the beginning of the ventricular contraction. The normal PR interval is 0.12 to 0.20 seconds.

Rationale 2: The transmission of impulses from the bundle of His to the ventricles is part of the QRS complex.

Rationale 3: The transmission of impulses from the AV node to the ventricles is part of the QRS complex.

Rationale 4: The transmission of impulses from the Purkinje fibers to the ventricles is part of the QRS complex.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-1

Question 20

Type: MCSA

After a myocardial infarction, a patient has slowing of atrial contraction. The nurse would anticipate seeing the most evidence of this dysfunction in which part of the electrocardiogram tracing?

1. T wave configuration

2. QRS complex

3. QT interval

4. PR interval

Correct Answer: 4

Rationale 1: Slowing of atrial contraction does not change the configuration of the T wave.

Rationale 2: The QRS complex may be unchanged.

Rationale 3: The QT interval would show little change.

Rationale 4: The most significant change will be in PR interval, as this time period reflects the contraction of the atria.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-1

Question 21

Type: MCSA

The nurse is told in report that a patients PR interval is within normal limits. What would the nurse anticipate as a result?

1. The PR interval will be between 0.06 and 0.12 second.

2. The PR interval will extend 8.5 to 11 small boxes on the ECG paper.

3. The PR interval will be between 0.34 and 0.43 second.

4. The PR interval will be between 0.12 and 0.20 second.

Correct Answer: 4

Rationale 1: This PR interval is shorter (faster) than normal.

Rationale 2: An interval equal to 8.5 to 11 small boxes lasts between 0.34 and 0.43 second, which is longer than the normal PR interval.

Rationale 3: The normal QT interval, not PR interval, is between 0.34 and 0.43 second.

Rationale 4: If a PR interval is within normal limits, it will be between 0.12 and 0.20 second, which is equal to 3 to 5 small boxes.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 30-1

Question 22

Type: MCSA

The nurse obtains an ECG monitor strip and makes the following analysis: no apparent P waves, ventricular rate 152 beats per minute and regular, and narrow QRS complex (0.08). How would the nurse interpret this rhythm?

1. Ventricular fibrillation

2. Sinus tachycardia

3. Atrial fibrillation

4. Supraventricular tachycardia

Correct Answer: 4

Rationale 1: Ventricular fibrillation would have no P waves and no QRS complexes.

Rationale 2: There are no apparent P waves; thus it cannot be called sinus tachycardia.

Rationale 3: Atrial fibrillation does not have P waves, but it is always irregular.

Rationale 4: Supraventricular tachycardia (SVT) is a tachycardia generated somewhere above the ventricles. This general term encompasses all fast (tachy) rhythms with normal QRS complexes and heart rates greater than 100 beats per minute.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-3

Question 23

Type: MCSA

The nurse admits a patient into the emergency department who complains of light-headedness and nausea. During the assessment, the nurse determines that the radial pulse is 42 and regular, the QRS complex is within normal limits, and there is no measurable PR interval because there is no consistent relationship between the P waves and the QRS complexes. How would the nurse interpret this dysrhythmia?

1. Third-degree AV heart block

2. Sinus bradycardia

3. Supraventricular tachycardia

4. Sinus arrest

Correct Answer: 1

Rationale 1: Third-degree AV block, or complete block, is the independent excitation and contraction of the atria and ventricles due to the inability of any atrial impulses to reach the ventricles. In other words, the top and bottom of the heart are not communicating; they are beating independently. Hence there are no consistent PR intervals.

Rationale 2: Sinus bradycardia occurs when the SA node is firing at a rate of less than 60 beats per minute. There is a consistent PR interval with sinus bradycardia.

Rationale 3: Supraventricular tachycardia has a rate greater than 100 beats per minute.

Rationale 4: Sinus arrest is a momentary cessation of sinus impulse formation (SA node failure), which causes the absence of the PQRST complex. The remainder of the beats have normal PR intervals.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-3

Question 24

Type: MCMA

The nurse analyzing a patients electrocardiogram tracing would suspect atrial fibrillation if it displayed which characteristics?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The atrial rate can be calculated by counting the P waves in 6 seconds and multiplying by 10.

2. P waves are replaced by f waves, or atrial quivering.

3. The PR intervals are measurable.

4. The ventricular rhythm is irregular.

5. The QT interval cannot be measured because the T waves are buried in the f waves.

Correct Answer: 2,4,5

Rationale 1: In atrial fibrillation there are no P waves; therefore the atrial rate cannot be counted.

Rationale 2: Waves that are seen between R-to-R intervals are called f waves, or atrial quivering.

Rationale 3: Because there are no P waves, the PR interval cannot be measured.

Rationale 4: The ventricular rhythm is irregular in atrial fibrillation.

Rationale 5: Because T waves are buried within the f waves, the QT interval cannot be measured.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-3

Question 25

Type: MCSA

While admitting a patient to the emergency department, the nurse observes the cardiac monitor and identifies the following rhythm: one inverted P wave for every QRS complex and a regular heart rate of 46 beats per minute. How would the nurse interpret this rhythm?

1. Junctional escape rhythm

2. Mobitz II heart block

3. Normal sinus rhythm

4. Complete heart block

Correct Answer: 1

Rationale 1: Junctional escape rhythm results from either an irritable focus in the junctional tissue that discharges before the SA node has had a chance to or because the SA node has failed to fire, making junctional node the secondary pacemaker. The impulse is initiated in the AV junctional tissue and must travel in a backward (retrograde) direction to activate the atria. Therefore, the P wave is inverted or negatively deflected and may occur before, after, or buried in the QRS complex. The intrinsic rate of the AV junction is 40 to 60 beats per minute.

Rationale 2: Mobitz II is a disturbance that occurs below the AV junction, so the P wave is normally configured.

Rationale 3: This is not normal sinus rhythm because it is not initiated by the SA node, as manifested by the inverted P wave.

Rationale 4: Complete heart block is a disturbance originating below the AV junction, so the P wave is normally configured.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-3

Question 26

Type: MCSA

Which ECG findings would the nurse expect in a patient who has both a first-degree heart block and a bundle branch block?

1. An ST segment elevation and a QT interval of < 0.44 second

2. An ST segment elevation and an inverted T wave

3. A PR interval of 0.24 second and a QRS complex width of 0.16 second

4. A QT interval of > 0.44 second and a PR interval of 0.16 second

Correct Answer: 3

Rationale 1: ST elevation and the length of the QT interval are not related to first-degree block or bundle branch block.

Rationale 2: ST segment elevation and inverted T waves are both indicative of myocardial ischemia/injury but are not related to bundle branch block.

Rationale 3: A PR interval of > 0.20 second indicates first-degree block, and a QRS complex width of > 0.12 second is bundle branch block.

Rationale 4: This is a normal PR interval. The QT interval is not associated with bundle branch block.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-3

Question 27

Type: MCSA

The nurse observes sinus bradycardia on a patients cardiac monitor. Which data set indicates the patient is in need of treatment for this rhythm?

1. The patient is light-headed and complaining of chest discomfort.

2. The patients respiratory rate is 16, blood pressure is 114/70, and the patient is pain-free.

3. The patient is alert, oriented X3, and blood pressure is 120/60, with no other complaints.

4. The patients heart rate is 50 and blood pressure is 110/62, with no other complaints.

Correct Answer: 1

Rationale 1: Sinus bradycardia requires treatment when the patient exhibits a decrease in cardiac output manifesting as complaints of angina, syncope, dizziness, shortness of breath, weakness, and possible changes in mental status.

Rationale 2: This normal data indicates the patient is tolerating the bradycardia.

Rationale 3: This normal data indicates the patient is tolerating the bradycardia.

Rationale 4: This normal data indicates the patient is tolerating the bradycardia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-4

Question 28

Type: MCMA

The patient is experiencing frequent premature ventricular contractions (PVCs). The nurse plans this patients care based on which understanding of the clinical significance of PVCs?


Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. PVCs show that the rhythm is regular.

2. PVCs can be a life-threatening cardiac rhythm.

3. PVCs could become the dominant pacemaker.

4. PVCs are neither significant nor dangerous.

5. PVCs can indicate myocardial ischemia and injury.

Correct Answer: 2,3,5

Rationale 1: When PVCs occur, the rhythm is irregular, not regular.

Rationale 2: The presence of PVCs indicates myocardial irritability, which may progress to a life-threatening state.

Rationale 3: When a PVC becomes the dominant pacemaker, the rhythm is ventricular tachycardia, which is life threatening and must be terminated.

Rationale 4: PVCs can be short-lived, isolated, and benign, but this patient is having them frequently. This indicates myocardial irritability, which could lead to a life-threatening situation.

Rationale 5: When the cardiac muscle does not receive adequate blood supply, the muscle becomes ischemic and irritable, resulting in PVCs.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

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