Chapter 4 My Nursing Test Banks

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e
Chapter 4

Question 1

Type: MCSA

A 57-year-old male patient is admitted to the telemetry unit with new onset of weakness and fatigue. The following rhythm is now seen on the monitor and the patient is now complaining of shortness of breath and mild chest discomfort. Which medication would be appropriate for this patient?

1. Give epinephrine 1 mg IV.

2. Give atropine 0.5 mg IV.

3. Give adenosine 6 mg IV.

4. Give amiodarone 300 mg IV.

Correct Answer: 2

Rationale 1: Epinephrine is not indicated for unstable bradycardia.

Rationale 2: Because this patient is complaining of shortness of breath and mild chest discomfort, he is considered to be unstable. For the unstable patient, the treatment of choice for this rhythm (second-degree type I block) is atropine 0.5 to 1 mg IV.

Rationale 3: Adenosine is the treatment for SVT and slows the heart rate down.

Rationale 4: Amiodarone is the treatment for ventricular irritability as seen with ventricular fibrillation and pulseless ventricular tachycardia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-7: Distinguish between second-degree AV block, type I, and second-degree AV block, type II, and complete heart block on an ECG rhythm strip.

Question 2

Type: MCSA

A 78-year-old patient has the following rhythm. Which assessment finding identifies a need for further treatment?

1. Short period of asystole followed by conversion to normal sinus rhythm

2. Warm, dry skin

3. Heart rate of 88 and BP 124/80

4. Heart rate of 42 and BP 78/60

Correct Answer: 4

Rationale 1: A short period of asystole followed by conversion to NSR is usually seen with treatment of SVT with adenosine.

Rationale 2: This finding indicates adequate tissue perfusion and would not be present in a patient with unstable bradycardia.

Rationale 3: This assessment finding would not be present in an unstable patient in third-degree AVB.

Rationale 4: A heart rate of 42 and a BP of 78/60 are not adequate and indicate that the patient is unstable with third-degree heart block.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-7: Distinguish between second-degree AV block, type I, and second-degree AV block, type II, and complete heart block on an ECG rhythm strip.

Question 3

Type: MCSA

A 67-year-old male patient complaining of feeling tired has the following cardiac rhythm. The patient states that he has a history of an irregular heartbeat. His vital signs are BP 134/78; RR 17; SaO2 97% on room air. He denies other complaints at present. The priority action for this patient would be to:

1. Perform a 12-lead ECG and compare it to previously recorded ECGs.

2. Prepare the patient for transcutaneous pacing.

3. Place the patient on 100% via nonrebreather mask.

4. Give Versed 1 mg IVP.

Correct Answer: 1

Rationale 1: This patient is in atrial fibrillation. From the information given, it sounds as if he has a history of atrial fibrillation. It would be correct to perform a 12-lead ECG and compare it to previous tracings.

Rationale 2: This is a stable patient at this time and does not need transcutaneous pacing.

Rationale 3: This is a stable patient at this time and does not need 100% O2.

Rationale 4: The patient does not seem to be anxious. Therefore, Versed is not indicated at this time.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-6: Identify atrial fibrillation (AF) on an ECG rhythm strip and list some of the treatment measures for AF.

Question 4

Type: MCSA

CPR is started on a patient who has developed ventricular fibrillation. The patient is defibrillated once with the resulting rhythm. Which intervention should the nurse implement next?

1. Defibrillate the patient with 360 joules.

2. Administer atropine 1 mg IV push and repeat every 3 minutes.

3. Infuse amiodarone 300 mg IV push slowly.

4. Administer epinephrine 1 mg IV push.

Correct Answer: 4

Rationale 1: Defibrillation is not indicated in asystole.

Rationale 2: Even though atropine is indicated in the asystole protocol, it is not given first and is not repeated every 3 minutes because there is a maximum dose limit.

Rationale 3: Amiodarone is indicated for ventricular dysrhythmias.

Rationale 4: Epinephrine should be given first for the treatment of asystole in addition to CPR.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-8: Identify ventricular tachycardia, ventricular fibrillation, and asystole.

Question 5

Type: MCSA

A patient arrives in the emergency department for chest pain, lightheadedness, and shortness of breath (SOB). The cardiac monitor shows sinus rhythm with the presence of multifocal PVCs. Which order would the nurse question?

1. Oxygen at 4 L/min via nasal cannula

2. Morphine sulfate 2 mg IV

3. Atropine 0.5 mg IV

4. Amiodarone 300 mg IV

Correct Answer: 3

Rationale 1: Oxygen is indicated for shortness of breath.

Rationale 2: Morphine is administered for chest pain.

Rationale 3: Atropine would be questioned because atropine is the drug of choice for unstable bradycardia, not ventricular irritability.

Rationale 4: Amiodarone is the drug of choice to decrease ventricular irritability and multifocal PVCs.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-9: Discuss three antidysrhythmic medications that can be used for ventricular dysrhythmias.

Question 6

Type: MCSA

While assessing a patient in the CCU, the nurse observes the following rhythm on the monitor. The patient is alert and oriented and denies any complaints at present. The nurse should:

1. Administer a precordial thump.

2. Check lead placement on the patient.

3. Begin CPR and call for a defibrillator.

4. Administer epinephrine 1 mg IV every 3 minutes.

Correct Answer: 2

Rationale 1: A precordial thump should not be done.

Rationale 2: Even though the strip looks like asystole, the patient denies complaints and is not in distress and therefore is not in asystole. The most appropriate thing for the nurse to do is to check lead placement on the patients chest.

Rationale 3: The patient is responsive and has respirations and a pulse. CPR and defibrillation is not indicated.

Rationale 4: This medication is not indicated for incorrect lead placement.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-4: List the seven steps of interpreting an ECG rhythm strip.

Question 7

Type: MCSA

The patient in pulseless ventricular tachycardia is defibrillated twice and received appropriate meds given per ACLS protocol. The following rhythm is now present. What should the nurse do next?

1. Continue monitoring and observing the patient for PVCs.

2. Place the patient on a maintenance lidocaine infusion.

3. Realize that the patient has been successfully converted to NSR.

4. Check the patient for a pulse and continue CPR if one is not present.

Correct Answer: 4

Rationale 1: Further assessment is needed to determine if the treatment was successful.

Rationale 2: Lidocaine is not indicated at this time and is used for ventricular dysrhythmias not responsive to other medications.

Rationale 3: Without further assessment, this cannot be determined.

Rationale 4: The return of a pulse should be assessed after defibrillating the patient to determine that the patient is not in pulseless electrical activity (PEA). Without verifying pulses, NSR cannot be determined.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-8: Identify ventricular tachycardia, ventricular fibrillation, and asystole.

Question 8

Type: MCSA

Which patient response indicates that the patient has had a favorable response to atropine?

1. An increase in heart rate to 80 bpm

2. A complaint of a headache from the patient

3. A decrease in heart rate to 40 bpm

4. Conversion to normal sinus rhythm from ventricular tachycardia

Correct Answer: 1

Rationale 1: Atropine is the treatment of choice for most types of bradycardia; the expected outcome for administering this drug would be an increased heart rate to within normal limits.

Rationale 2: A headache is not usually expected with atropine.

Rationale 3: A decrease in heart rate would indicate the need for more atropine or other treatment options.

Rationale 4: Atropine is not given for ventricular irritability.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 4-7: Distinguish between second-degree AV block, type I, and second-degree AV block, type II, and complete heart block on an ECG rhythm strip.

Question 9

Type: MCSA

A 58-year-old female is admitted with the following new onset rhythm. With complications related to this rhythm in mind, priority nursing assessment would be to:

1. Monitor for sudden onset of ventricular tachycardia.

2. Perform neurologic checks every 4 hours.

3. Monitor for deterioration to third-degree block.

4. Assess skin turgor for dehydration.

Correct Answer: 2

Rationale 1: Ventricular tachycardia is not a usual complication associated with atrial fibrillation.

Rationale 2: The patient in atrial fibrillation is at risk for thromboembolism and will need to be placed on anticoagulants. The nurse would need to assess for signs of stroke.

Rationale 3: Third-degree block is not a usual complication of atrial fibrillation.

Rationale 4: Dehydration is seen in sinus tachycardia and not atrial fibrillation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-6: Identify atrial fibrillation (AF) on an ECG rhythm strip and list some of the treatment measures for AF.

Question 10

Type: MCMA

A patient in the emergency department is in supraventricular tachycardia. What are appropriate nursing actions for this patient?

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

Standard Text: Select all that apply.

1. Start CPR and defibrillate at 200 joules.

2. Start oxygen at 2 L/min via nasal cannula.

3. Give atropine 1 mg IVP.

4. Give epinephrine 1 mg IVP.

5. Give adenosine 6 mg IVP.

Correct Answer: 2,5

Rationale 1: CPR and defibrillation is not indicated.

Rationale 2: Oxygen is used to treat supraventricular tachycardia.

Rationale 3: Atropine may increase the heart rate.

Rationale 4: Epinephrine may increase the heart rate.

Rationale 5: This medication is indicated in the treatment of supraventricular tachycardia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-9: Discuss three antidysrhythmic medications that can be used for ventricular dysrhythmias.

Question 11

Type: MCSA

A patient is experiencing chest pain, shortness of breath, and lethargy. The patients vital signs are BP 88/58, HR 40, RR 20. Which nursing action is a priority for this patient?

1. Nitroglycerin 1 tab sublingual

2. Aspirin 325 mg PO

3. Morphine 2 mg IVP

4. Atropine 1 mg IVP

Correct Answer: 4

Rationale 1: Even though the patient is having chest pain, the blood pressure is too low for nitroglycerin.

Rationale 2: There is not enough information to determine if the patient is experiencing a myocardial infarction. Oral medications should also be avoided at this time due to the decrease in level of consciousness.

Rationale 3: Even though the patient is having chest pain, the blood pressure is too low for morphine.

Rationale 4: The patient is actually having unstable bradycardia at this time and atropine would be the best medication to give this patient.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-9: Discuss three antidysrhythmic medications that can be used for ventricular dysrhythmias.

Question 12

Type: MCSA

The nurse receives the following ECG strip at shift report. Which action is most appropriate for this patient?

1. Place the patient on oxygen at 2 L/min via nasal cannula.

2. Give atropine 1 mg IVP per protocol.

3. Start a second IV for normal saline bolus per protocol.

4. Assess the patient.

Correct Answer: 4

Rationale 1: The nurse needs to assess the patient before implementing any further action.

Rationale 2: The nurse needs to assess the patient before implementing any further action.

Rationale 3: The nurse needs to assess the patient before implementing any further action.

Rationale 4: The rhythm strip shows that the patient is in normal sinus rhythm. Further assessment is needed.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-4: List the seven steps of interpreting an ECG rhythm strip.

Question 13

Type: MCSA

A patient is demonstrating second-degree heart block (Wenkebach [type I]). The nurse realizes this rhythm is characterized by:

1. Progressive lengthening of the PR interval until a QRS is dropped

2. Prolonged PR interval greater than 0.22

3. Complete disassociation of the atria and ventricles

4. Consistent PR interval with occasional dropped QRS complexes

Correct Answer: 1

Rationale 1: Second-degree AV block type I, or Wenkebach, is characterized by an inconsistent PR interval that progresses in length until a QRS is dropped. The SA node resets to the previous shortest PR interval and repeats progressive lengthening.

Rationale 2: The presence of a prolonged PR interval without dropped QRS is present with first-degree AV block.

Rationale 3: Complete disassociation is third-degree heart block.

Rationale 4: A consistent PR interval with occasional dropped QRS complexes is consistent with second-degree AV block type II.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-7: Distinguish between second-degree AV block, type I, and second-degree AV block, type II, and complete heart block on an ECG rhythm strip.

Question 14

Type: MCSA

Which assessment finding indicates a patient has had a favorable response to adenosine (Adenocard)?

1. Complaints of a headache

2. Heart rate decreased to 80

3. Converts to sustained asystole

4. Heart rate increased to 64

Correct Answer: 2

Rationale 1: A headache is not a favorable response to adenosine.

Rationale 2: Adenosine is given for supraventricular tachycardia.Converting to a normal heart rate is considered successful treatment.

Rationale 3: A short period of asystole is sometimes experienced immediately after administration but not sustained asystole. This would be an adverse response to adenosine.

Rationale 4: An increase in heart rate to 64 would have indicated a bradycardic rate for which adenosine is not recommended.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 4-9: Discuss three antidysrhythmic medications that can be used for ventricular dysrhythmias.

Question 15

Type: MCSA

A patients cardiac monitor shows a rate of 89 with a PR interval of 0.2 second and a QRS of 0.10 second. What is the most important nursing action?

1. Start the patient on O2 at 4 L/min via nasal cannula.

2. Obtain a 12-lead ECG immediately.

3. Report these abnormal findings to the health care provider.

4. Continue to monitor the patients cardiac status.

Correct Answer: 4

Rationale 1: Supplemental oxygen is not necessary at this time.

Rationale 2: With the information provided an ECG is not necessary.

Rationale 3: Because these parameters are within normal limits, this response would not be appropriate.

Rationale 4: The parameters given are within normal limits; continuing to monitor the patient is the most appropriate action to do.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-4: List the seven steps of interpreting an ECG rhythm strip.

Question 16

Type: MCSA

A patients monitor strip shows an irregular rhythm. Which method of estimating the rate would be best for the nurse to use? The nurse should count the number of:

1. Small blocks between two consecutive R waves and divide by 1500

2. Large blocks between two consecutive R waves and divide by 300

3. QRS complexes in 6 seconds and multiply by 10

4. Large blocks in 3 seconds and multiply by 20

Correct Answer: 3

Rationale 1: Counting the number of small blocks is an estimation method used only in regular rhythms.

Rationale 2: Counting the number of large blocks is an estimation method used only in regular rhythms.

Rationale 3: This is the most accurate method to assess heart rate with an irregular rhythm.

Rationale 4: Counting large blocks in 3 seconds and multiplying by 20 is not an appropriate method of estimating heart rate.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-4: List the seven steps of interpreting an ECG rhythm strip.

Question 17

Type: MCSA

The nurse is analyzing a 6-second ECG rhythm strip with the following findings: P to QRS ratio is 1:1; four regular R waves were present; QRS width was 0.10 second; PR interval was 0.18 second. The nurse documents this rhythm as:

1. Atrioventricular (AV) block with 2:1 ratio

2. Sinus tachycardia noted with AV junctional rhythm

3. AV complete heart block noted

4. Sinus bradycardia

Correct Answer: 4

Rationale 1: An atrioventricular block of 2:1 ratio would mean that there are two atrial deflections (P waves) per one ventricular response (QRS), which is negated by the findings of a P to QRS ratio of 1:1.

Rationale 2: The rate is 40 beats per minute and does not meet the criteria for tachycardia, which is a rate greater than 100 beats per minute. In addition, a junctional rhythm would have an inverted P wave, or it may be hidden in the QRS, which would alter the PR interval.

Rationale 3: Complete heart block would have two separate rates for the atrial initiation of charge (P waves) at one rate and the ventricular initiation of a separate rate and cycle unrelated to the P waves. Therefore, no conduction is occurring between the atria and ventricles and both have set up their escape rhythms to try to compensate.

Rationale 4: Bradycardia is a heart rate below 60, which is validated by the 4 R waves in 3 slash marks = 4 times 10 or a rate of 40 per minute. The P to QRS ratio shows normal conduction between the atria and the ventricle. The QRS width and PR interval are both within normal limits. Therefore, the problem is just a slower than normal heart rate called bradycardia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 4-5: Identify sinus tachycardia and sinus bradycardia on ECG rhythm strips.

Question 18

Type: MCMA

The nurse is interpreting an ECG strip. What would describe paroxysmal supraventricular tachycardia (PSVT)?

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

Standard Text: Select all that apply.

1. QRS width is 0.18 second.

2. Heart rate is between 150 and 250 beats per minute.

3. The P wave is hidden in the preceding T wave; therefore, the PR interval cannot be measured.

4. The increased rate can start abruptly and cease quickly when viewing a cardiac monitor to validate its presence.

5. It is treated with carotid massage.

Correct Answer: 2,3,4

Rationale 1: The QRS width should be less than 0.12 second.

Rationale 2: A heart rate between 150 and 250 beats per minute is used to describe paroxysmal supraventricular tachycardia.

Rationale 3: A P wave hidden in the preceding T wave preventing correct measurement of the PR interval describes paroxysmal supraventricular tachycardia.

Rationale 4: Paroxysmal supraventricular tachycardia is an increased rate that can start abruptly and cease quickly when viewing a cardiac monitor.

Rationale 5: Paroxysmal supraventricular tachycardia has an abrupt beginning and ending and is witnessed by the use of cardiac monitoring. There is no specific treatment for this dysrhythmia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-5: Identify sinus tachycardia and sinus bradycardia on ECG rhythm strips.

Question 19

Type: MCSA

When teaching a class of new nursing graduates, the nurse would expect the students to describe atrial fibrillation on an ECG strip as having:

1. No P wave but waves that can be described similar to a picket fence or sawtooth pattern that are regularly spaced between normal QRS waves

2. No consistent P waves, only an erratic and wavy baseline between normally configured QRS waves

3. A progressive deterioration of the wavy baseline with irregular R to R spacing that leads to ventricular tachycardia and a cardiac arrest situation

4. A QRS width greater than 0.12 second and lasting about 30 seconds before ventricular fibrillation occurs

Correct Answer: 2

Rationale 1: Picket fence or sawtooth patterns are descriptors of atrial flutter, not AF.

Rationale 2: This is a description of atrial fibrillation.

Rationale 3: Ventricular tachycardia is not caused by AF.

Rationale 4: This description is of ventricular tachycardia that leads to ventricular fibrillation and cardiac arrest due to the decline in cardiac output and the eventual asystole or pulseless electrical arrhythmias that require medical intervention to prevent death.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 4-6: Identify atrial fibrillation (AF) on an ECG rhythm strip and list some of the treatment measures for AF.

Question 20

Type: MCMA

What will the nurse include in the plan of care for a patient with atrial fibrillation?

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

Standard Text: Select all that apply.

1. Monitor neurological status every 4 hours.

2. Administer anticoagulants as ordered to minimize risk for an embolic event.

3. Prepare the patient for defibrillation to assist in conversion to normal sinus rhythm.

4. Administer beta blockers (atenolol) and calcium channel blockers (diltiazem) to lower heart rate in order to maximize cardiac output.

5. Use vagal stimulation to control heart rate.

Correct Answer: 1,2,4

Rationale 1: Monitoring the neurological status every 4 hours is an intervention to include when planning care for a patient with atrial fibrillation (AF) due to the increased risk of emboli/thrombi.

Rationale 2: Administering anticoagulants as ordered is an intervention to include when planning care for a patient with atrial fibrillation (AF) due to the patients increased risk of emboli/thrombi.

Rationale 3: Defibrillation is not usually done for AF.

Rationale 4: Administering beta blockers (atenolol) and calcium channel blockers (diltiazem) to lower heart rate in order to maximize cardiac output are interventions to include when planning care for a patient with atrial fibrillation (AF).

Rationale 5: Vagal stimulation is an intervention for atrial tachycardia, not AF.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 4-6: Identify atrial fibrillation (AF) on an ECG rhythm strip and list some of the treatment measures for AF.

Question 21

Type: MCSA

Which criteria will the nurse use when assessing for atrial fibrillation on the ECG strip?

1. Ventricular rate is usually regular in R to R distancing.

2. Atrial rate runs 300 to 500 with an unequal ratio of P to QRS.

3. P waves are regular and vary in ratio to QRS.

4. QRS width is wide due to a conductivity delay.

Correct Answer: 2

Rationale 1: R to R will vary and is not regular.

Rationale 2: This is the correct criteria that the nurse will use when assessing for atrial fibrillation on an ECG strip.

Rationale 3: P to QRS ratio will vary and not be constant.

Rationale 4: A wide QRS is seen 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: 4-6: Identify atrial fibrillation (AF) on an ECG rhythm strip and list some of the treatment measures for AF.

Question 22

Type: MCMA

When evaluating the health history of a patient with complete heart block, what would be considered as potential causes for this condition?

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

Standard Text: Select all that apply.

1. Myocarditis

2. Degenerative heart disease

3. Severe aortic stenosis

4. Digitalis toxicity

5. Currently being treated for acute myocardial infarction

Correct Answer: 1,2,4,5

Rationale 1: Myocarditis can lead to severe damage in the AV node leading to complete heart block.

Rationale 2: Degenerative heart disease can lead to severe damage in the AV node leading to complete heart block.

Rationale 3: Aortic stenosis will cause a bundle branch block pattern but not complete heart block.

Rationale 4: Digitalis toxicity can lead to severe damage in the AV node leading to complete heart block.

Rationale 5: Acute myocardial infarction can lead to severe damage in the AV node leading to complete heart block.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-7: Distinguish between second-degree AV block, type I, and second-degree AV block, type II, and complete heart block on an ECG rhythm strip.

Question 23

Type: MCSA

In order to correctly manage ventricular dysrhythmias, the nurse would expect to implement which treatment?

1. Magnesium sulfate to terminate ventricular tachycardia pattern called torsades de pointes that was noted on the ECG strip

2. Potassium chloride (KCl) replacement for a potassium level of 4 mEq/mL

3. Procainamide for developing coarse ventricular fibrillation

4. Synchronized cardioversion after atropine is given for ventricular tachycardia

Correct Answer: 1

Rationale 1: A magnesium deficiency can result in torsades de pointes. Replacement of magnesium helps the conversion of this dysrhythmia back to normal sinus rhythm (NSR).

Rationale 2: The potassium value of 4 mEq/mL is within the normal range and does not need additional KCL replacement.

Rationale 3: Procainamide is used for ventricular tachycardia (VT) and not for ventricular fibrillation (VF). VF is a cardiac emergency that requires CPR and advanced drug management to correct.

Rationale 4: Atropine will increase the heart rate. Cardioversion might be used for stable VT but not with atropine in the management of VT.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 4-8: Identify ventricular tachycardia, ventricular fibrillation, and asystole.

Question 24

Type: MCSA

What action is appropriate for the nurse to implement when monitoring the ECG of a patient with a transvenous ventricular demand pacemaker? The ECG strip shows QRS complexes without pacer spikes.

1. Plan for immediate removal of pacer lead wires.

2. Continue to observe the patient and the ECG rhythm.

3. Call the health care provider and explain that capture has been lost.

4. Call a code for ventricular fibrillation.

Correct Answer: 2

Rationale 1: Transvenous means that the battery is external and the lead wires are passed through the vein into the heart muscle. There is no need to remove or displace the lead wires because it only comes on when the patients heart rate drops below the programmed set point. On demand means it only comes on sometimes.

Rationale 2: The demand pacemaker only fires when the patients heart rate drops below the preset rate. The patients own rhythm will continue to dominate if it stays above a predetermined rate. The patients QRS complexes will not have a spike. QRS complexes that have a spike indicate that QRS complex is pacemaker generated, not an intrinsic beat.

Rationale 3: If one spike is noted with a QRS following it when the rate is below the set point, then the capture has not been lost. One would see a spike without a QRS if the lead wire was misplaced or capture had been lost.

Rationale 4: The risk of ventricular fibrillation is not present under these conditions.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-11: Describe the four malfunctions of pacemakers.

Question 25

Type: MCMA

The nurse is reviewing the list of a patients prescribed scheduled and prn medications. Which of them will affect cardiac contractility?

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

Standard Text: Select all that apply.

1. Digoxin

2. Dopamine

3. Epinephrine

4. Morphine

5. Atropine

Correct Answer: 1,2,3

Rationale 1: Digoxin enhances the contractility of the heart.

Rationale 2: Dopamine enhances the contractility of the heart.

Rationale 3: Epinephrine enhances the contractility of the heart.

Rationale 4: Morphine does not enhance the contractility of the heart.

Rationale 5: Atropine is an anticholinergic drug that blocks the cholinergic and parasympathetic stimulation of the heart.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-1. List and briefly describe the four properties of cardiac cells.

Question 26

Type: MCMA

The nurse is reviewing normal cardiac conduction with a new graduate nurse. What will the nurse teach when the impulse reaches the bundle of His?

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

Standard Text: Select all that apply.

1. Conduction of the impulse penetrates the atrioventricular valves.

2. Conduction of the impulse bifurcates into the right and left bundle branches.

3. Conduction of the impulse continues to the Purkinje fibers.

4. Conduction of the impulse is slowed because of calcium ions.

5. Conduction creates a flat line after the P wave on the ECG rhythm.

Correct Answer: 1,2,3

Rationale 1: Once the impulse reaches the bundle of His, the impulse penetrates the AV valves.

Rationale 2: Once the impulse reaches the bundle of His and penetrates the AV valves, the impulse bifurcates into the right and left bundle branches.

Rationale 3: Once the impulse reaches the bundle of His and penetrates the AV valves, the impulse bifurcates into the right and left bundle branches and continues until it reaches the Purkinje fibers.

Rationale 4: A slowing of the conduction because of calcium ions occurs when the impulse is moving through the atrioventricular node.

Rationale 5: A flat line after the P wave on the ECG rhythm occurs when the impulse travels through the atrioventricular node.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Teaching and Learning

Learning Outcome: 4-2. Explain the normal cardiac conduction system, beginning with the sinus node and ending with the Purkinje fibers.

Question 27

Type: MCMA

The nurse is reviewing the characteristics of a normal QRS complex on a patients cardiac rhythm strip. What will the nurse identify as characteristics of this 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 first downward deflection after the P wave is the Q wave.

2. The first upward deflection after the P wave is the R wave.

3. The first downward deflection after the R wave is the S wave.

4. It usually measures less than 0.12 seconds or less than 3 small boxes.

5. It ends at the beginning of the T wave.

Correct Answer: 1,2,3,4

Rationale 1: The Q wave is the first downward deflection after the P wave.

Rationale 2: The R wave is the first upward deflection in the QRS complex.

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

Rationale 4: The QRS complex normally measures less than 0.12 second, or less than three small boxes.

Rationale 5: The ST segment begins at the end of the QRS complex and ends at the beginning of the T wave.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-3. Draw a normal cardiac cycle as seen in normal sinus rhythm and identify the waveforms, intervals, and complexes.

Question 28

Type: SEQ

The nurse is preparing to analyze a patients ECG rhythm strip. Place in order the steps the nurse will use to interpret this strip.

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

Choice 1. Determine the heart rhythm.

Choice 2. Measure the heart rate.

Choice 3. Examine the P waves.

Choice 4. Examine the P to QRD ratio.

Choice 5. Measure the PR interval.

Choice 6. Examine the QRS complex.

Choice 7. Interpret the rhythm.

Correct Answer: 1,2,3,4,5,6,7

Rationale 1: This is the first step when analyzing an ECG rhythm.

Rationale 2: This is the second step when analyzing an ECG rhythm.

Rationale 3: This is the third step when analyzing an ECG rhythm.

Rationale 4: This is the fourth step when analyzing an ECG rhythm.

Rationale 5: This is the fifth step when analyzing an ECG rhythm.

Rationale 6: This is the sixth step when analyzing an ECG rhythm.

Rationale 7: This is the final step when analyzing an ECG rhythm.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-4. List the seven steps of interpreting an ECG rhythm strip.

Question 29

Type: MCMA

The nurse determines that a patient is experiencing sinus tachycardia. What did the nurse assess on the patients ECG rhythm strip?

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

Standard Text: Select all that apply.

1. Regular heart rhythm

2. Heart rate 110 beats per minute

3. 1:1 P to QRS ratio

4. PR interval 0.16 second

5. Notched P waves

Correct Answer: 1,2,3,4

Rationale 1: The heart rate in sinus tachycardia is regular.

Rationale 2: The heart rate in sinus tachycardia is greater than 100 beats per minute.

Rationale 3: The P to QRS ratio in sinus tachycardia is 1:1.

Rationale 4: The PR interval in sinus tachycardia is between 0.12 to 0.20 second.

Rationale 5: Notched P waves are not seen in sinus tachycardia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-5. Identify sinus tachycardia and sinus bradycardia on ECG rhythm strips.

Question 30

Type: MCMA

The nurse identifies that a patient is experiencing ventricular tachycardia. What did the nurse assess on the patients ECG rhythm strip?

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

Standard Text: Select all that apply.

1. Three premature ventricular contractions in rapid succession

2. Heart rate 150 beats per minute

3. Absent P waves

4. Absent PR interval

5. Undetectable QRS complex

Correct Answer: 1,2,3,4

Rationale 1: Ventricular tachycardia is a run of three or more premature ventricular contractions in rapid succession.

Rationale 2: In ventricular tachycardia, the heart rate is between 110 to 250 beats per minute.

Rationale 3: In ventricular tachycardia, the P waves are usually absent.

Rationale 4: In ventricular tachycardia there is no PR interval.

Rationale 5: There is a QRS complex in ventricular tachycardia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-8. Identify ventricular tachycardia, ventricular fibrillation, and asystole.

Question 31

Type: MCMA

The nurse is reviewing synchronized cardioversion with a new graduate. What will the nurse include when reviewing this procedure?

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

Standard Text: Select all that apply.

1. The shock is synchronized with the QRS complex.

2. The shock will occur on the R wave.

3. A sedative will be provided before the procedure.

4. Pain medication will be provided before the procedure.

5. The shock will occur on the T wave.

Correct Answer: 1,2,3,4

Rationale 1: In synchronized cardioversion, the shock is synchronized with the QRS complex.

Rationale 2: The defibrillator will be set to the synchronized mode and will recognize QRS complexes to shock on the R wave.

Rationale 3: The patient should be premedicated with sedation prior to the procedure.

Rationale 4: The patient should be premedicated with pain medication before the procedure.

Rationale 5: Shocking on the T wave can cause ventricular tachycardia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Teaching and Learning

Learning Outcome: 4-10. Explain the difference between defibrillation and synchronized cardioversion.

Question 32

Type: MCMA

The nurse is assessing the rhythm strip of a patient for pacemaker malfunctions. What will the nurse assess when analyzing this patients rhythm strip?

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

Standard Text: Select all that apply.

1. Failure to pace

2. Failure to capture

3. Failure to sense

4. Oversensing

5. Failure to discharge

Correct Answer: 1,2,3,4

Rationale 1: Failure to pace occurs when the pacemaker fails to deliver an electrical stimulus (fire) when it should have fired. This can be seen on the ECG as an absence of pacer spikes when the patients heart rate is less than the demand pacer rate is set, indicating that the pacemaker did not fire.

Rationale 2: Failure to capture occurs when the pacemaker fires, but the chamber that is being paced (atria or ventricles, or both) does not depolarize. This is seen on the ECG strip as a pacer spike that is not followed by a P wave or QRS complex.

Rationale 3: Failure to sense occurs when the pacer fails to recognize, or sense, the hearts natural electrical activity. This is seen on the ECG as pacer spikes that occur too closely behind the patients QRS complex.

Rationale 4: Oversensing occurs when the pacer senses extraneous electrical stimuli, or artifact, for actual atrial or ventricular depolarization and therefore fails to fire. This is seen on the ECG as pacemaker spikes that are at a slower rate than the pacemakers preset rate or no paced beats, even though the patients heart rate is slower than the pacers preset rate.

Rationale 5: A pacemaker does not discharge.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-11. Describe the four malfunctions of pacemakers.

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e Test Bank

Copyright 2012 by Pearson Education, Inc.

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