Chapter 22: Management of Patients with Arrhythmias and Conduction Problems

Question 1

1. The nurse is caring for a client who has had an ECG. The nurse notices that leads I, II,
   and III differ from one another on the cardiac rhythm strip. How should the nurse best
   respond?
   A. Recognize that the view of the electrical current changes in relation to the lead
   placement.
   B. Recognize that the electrophysiological conduction of the heart differs with lead
   placement.
   C. Inform the technician that the ECG equipment has malfunctioned.
   D. Inform the health care provider that the client is experiencing a new onset of
   dysrhythmia.

Answer 1

ANS: A
Rationale: Each lead offers a different reference point to view the electrical activity of the heart. The lead displays the configuration of electrical activity of the heart. Differences between leads are not necessarily attributable to equipment malfunction or dysrhythmias.

Question 2

2. The nurse is analyzing a rhythm strip. What component of the ECG corresponds to the
   resting state of the client’s heart?
   A. P wave
   B. T wave
   C. U wave
   D. QRS complex

Answer 2

ANS: B
Rationale: The T wave specifically represents ventricular muscle depolarization, also referred to as the resting state. Ventricular muscle depolarization does not result in the P wave, U wave, or QRS complex.

Question 3

3. The nursing educator is presenting a case study of an adult client who has abnormal
   ventricular depolarization. This pathologic change would be most evident in what
   component of the ECG?
   A. P wave
   B. T wave
   C. QRS complex
   D. U wave

Answer 3

ANS: C
Rationale: The QRS complex represents the depolarization of the ventricles and, as such, the electrical activity of that ventricle.

Question 4

4. An adult client with third-degree AV block is admitted to the cardiac care unit and
   placed on continuous cardiac monitoring. What rhythm characteristic will the ECG most
   likely show?
   A. PP interval and RR interval are irregular.
   B. PP interval is equal to RR interval.
   C. Fewer QRS complexes than P waves
   D. PR interval is constant.

Answer 4

ANS: C
Rationale: In third-degree AV block, no atrial impulse is conducted through the AV node
into the ventricles. As a result, there are impulses stimulating the atria and impulses
stimulating the ventricles. Therefore, there are more P waves than QRS complexes due to the difference in the natural pacemaker (nodes) rates of the heart. The other listed ECG changes are not consistent with this diagnosis.

Question 5

5. A 62-year-old client with atrial fibrillation and a CHA2DS2-VASC score of 3 is being
   discharged home today. Based on this score, which additional medications or
   medications would be prescribed for this client?
   A. No antithrombotic therapy, oral anticoagulant or aspirin
   B. Low molecular weight heparin or intravenous heparin
   C. Warfarin, direct thrombin inhibitor, or factor Xa inhibitor
   D. Antiarrhythmic agents and aspirin

Answer 5

ANS: C
Rationale: Clients with atrial fibrillation are assessed for the risk of stroke using the
mnemonic CHA2DS2-VASC with age, sex, and medical history determining a score. With a score of zero, clients may choose no antithrombotic therapy. With a score of 1, the client may choose no therapy, oral anticoagulant or aspirin. With a score of 2 or greater in men or 3 or greater in women, clients may choose warfarin, direct thrombin, or factor Xa inhibitor. Heparin can be used as a short-term or immediate anticoagulation medication and is not used as part of this scoring process. And intravenous heparin is not typically
used in a home setting for prevention. The antiarrhythmic medication treats atrial
fibrillation and is not part of the scoring process.

Question 6

6. A client has returned to the cardiac care unit after having a permanent pacemaker
   implantation. For which potential complication should the nurse most closely assess this
   client?
   A. Chest pain
   B. Bleeding at the implantation site
   C. Malignant hyperthermia
   D. Bradycardia

Answer 6

ANS: B
Rationale: Bleeding, hematomas, local infections, perforation of the myocardium, and tachycardia are complications of pacemaker implantations. The nurse should monitor for chest pain and bradycardia, but bleeding is a more common immediate complication. Malignant hyperthermia is unlikely because it is a response to anesthesia administration.

Question 7

7. A client the nurse is caring for has a permanent pacemaker implanted, with the
   identification code beginning with VVI. What does this indicate?
   A. Ventricular paced, ventricular sensed, inhibited
   B. Variable paced, ventricular sensed, inhibited
   C. Ventricular sensed, ventricular situated, implanted
   D. Variable sensed, variable paced, inhibited

Answer 7

ANS: A
Rationale: The identification of VVI indicates ventricular paced, ventricular sensed,
inhibited.

Question 8

8. The nurse is caring for an adult client who has gone into ventricular fibrillation. When
   assisting with defibrillating the client, what must the nurse do?
   A. Maintain firm contact between paddles and the client’s skin.
   B. Apply a layer of water as a conducting agent.
   C. Call “all clear” once before discharging the defibrillator.
   D. Ensure the defibrillator is in the sync mode.

Answer 8

ANS: A
Rationale: When defibrillating an adult client, the nurse should maintain good contact between the paddles and the client’s skin. To prevent arcing, apply an appropriate conducting agent (not water) between the skin and the paddles, and ensure the defibrillator is in the nonsync mode. “Clear’’ should be called three times before discharging the paddles.

Question 9

9. A client who is a candidate for an implantable cardioverter defibrillator (ICD) asks the
   nurse about the purpose of this device. What would be the nurse’s best response?
   A. “To detect and treat dysrhythmias such as ventricular fibrillation and ventricular
   tachycardia.”
   B. “To detect and treat bradycardia, which is an excessively slow heart rate.”
   C. “To detect and treat atrial fibrillation, in which your heart beats too quickly and
   inefficiently.”
   D. “To shock your heart if you have a heart attack at home.”

Answer 9

ANS: A
Rationale: The ICD is a device that detects and terminates life-threatening episodes of
ventricular tachycardia and ventricular fibrillation. It does not treat atrial fibrillation, MI, or bradycardia.

Question 10

10. The nurse is caring for a client who has just had an implantable cardioverter
    defibrillator (ICD) placed. What is the priority area for the nurse’s assessment?
    A. Assessing the client’s mobility
    B. Facilitating transthoracic echocardiography
    C. Vigilant monitoring of the client’s ECG
    D. Close monitoring of the client’s peripheral perfusion

Answer 10

ANS: C
Rationale: After a permanent electronic device (pacemaker or ICD) is inserted, the
client’s heart rate and rhythm are monitored by ECG. This is a priority over peripheral circulation and mobility because the consequences of abnormalities are more serious. Echocardiography is not indicated.

Question 11

11. A nurse is caring for a client who is exhibiting ventricular tachycardia (VT). Because
    the client is pulseless, the nurse should prepare for what intervention?
    A. Defibrillation
    B. ECG monitoring
    C. Implantation of a cardioverter defibrillator
    D. Angioplasty

Answer 11

ANS: A
Rationale: Any type of VT in a client who is unconscious and without a pulse is treated in the same manner as ventricular fibrillation: Immediate defibrillation is the action of choice. ECG monitoring is appropriate, but this is an assessment, not an intervention, and will not resolve the problem. An ICD and angioplasty do not address the dysrhythmia.

Question 12

12. A client converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a
    ventricular response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20
    breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin
    and diltiazem are given. The nurse caring for the client understands that the treatment
    has what main goal?
    A. Decrease SA node conduction.
    B. Control ventricular heart rate.
    C. Improve oxygenation.
    D. Maintain anticoagulation.

Answer 12

ANS: B
Rationale: Treatment for atrial fibrillation is to terminate the rhythm or to control
ventricular rate. This is a priority because it directly affects cardiac output. A rapid
ventricular response reduces the time for ventricular filling, resulting in a smaller stroke volume. Control of rhythm is the initial treatment of choice, followed by anticoagulation with heparin and then Coumadin.

Question 13

13. The nurse and the other members of the team are caring for a client who converted
    to ventricular fibrillation (VF). The client was defibrillated unsuccessfully and the client
    remains in VF. The nurse should anticipate the administration of what medication?
    A. Epinephrine 1 mg IV push
    B. Lidocaine 100 mg IV push
    C. Amiodarone 300 mg IV push
    D. Sodium bicarbonate 1 amp IV push

Answer 13

ANS: A
Rationale: Epinephrine should be given as soon as possible after the first unsuccessful
defibrillation and then every 3 to 5 minutes. Antiarrhythmic medications such as
amiodarone and lidocaine are given if ventricular dysrhythmia persists.

Question 14

14. The nurse is planning discharge teaching for a client with a newly inserted permanent
    pacemaker. What is the priority teaching point for this client?
    A. Start lifting the arm above the shoulder right away to prevent chest wall
    adhesion.
    B. Avoid cooking with a microwave oven.
    C. Avoid exposure to strong electromagnetic fields
    D. Avoid walking through store and library antitheft devices

Answer 14

ANS: C
Rationale: High-output electrical generators can reprogram pacemakers and should be
avoided. Recent pacemaker technology allows clients to safely use most household
electronic appliances and devices (e.g., microwave ovens). The affected arm should not be raised above the shoulder for 1 week following placement of the pacemaker. Antitheft alarms may be triggered so clients should be taught to walk through them quickly and avoid standing in or near these devices. These alarms generally do not interfere with pacemaker function.

Question 15

15. A client is brought to the ED and determined to be experiencing symptomatic sinus
    bradycardia. The nurse caring for this client is aware the medication of choice for
    treatment of this dysrhythmia is the administration of atropine. What guidelines will the
    nurse follow when administering atropine?
    A. Administer atropine 0.5 mg as an IV bolus every 3 to 5 minutes to a maximum
    of 3.0 mg.
    B. Administer atropine as a continuous infusion until symptoms resolve.
    C. Administer atropine as a continuous infusion to a maximum of 30 mg in 24
    hours.
    D. Administer atropine 1.0 mg sublingually.

Answer 15

ANS: A
Rationale: Atropine 0.5 mg given rapidly as an intravenous (IV) bolus every 3 to 5
minutes to a maximum total dose of 3.0 mg is the medication of choice in treating
symptomatic sinus bradycardia. By this guideline, the other listed options are
inappropriate.

Question 16

16. An ECG has been ordered for a newly admitted client. What should the nurse do prior
    to electrode placement?
    A. Clean the skin with povidone-iodine solution.
    B. Ensure that the area for electrode placement is dry.
    C. Apply tincture of benzoin to the electrode sites and wait for it to become “tacky.”
    D. Gently abrade the skin by rubbing the electrode sites with dry gauze or cloth.

Answer 16

ANS: D
Rationale: An ECG is obtained by slightly abrading the skin with a clean dry gauze pad and placing electrodes on the body at specific areas. The abrading of skin will enhance signal transmission. Disinfecting the skin is unnecessary and conduction gel is used.

Question 17

17. The nurse is caring for a client who has just undergone catheter ablation therapy. The
    nurse in the step-down unit should prioritize what assessment?
    A. Cardiac monitoring
    B. Monitoring the implanted device signal
    C. Pain assessment
    D. Monitoring the client’s level of consciousness (LOC)

Answer 17

ANS: A
Rationale: Following catheter ablation therapy, the client is closely monitored to ensure the dysrhythmia does not reemerge. This is a priority over monitoring of LOC and pain, although these are valid and important assessments. Ablation does not involve the implantation of a device.

Question 18

18. The ED nurse is caring for a client who has gone into cardiac arrest. During external
    defibrillation, what action should the nurse perform?
    A. Place gel pads over the apex and posterior chest for better conduction.
    B. Ensure no one is touching the client at the time shock is delivered.
    C. Continue to ventilate the client via endotracheal tube during the procedure.
    D. Allow at least 3 minutes between shocks.

Answer 18

ANS: B
Rationale: In external defibrillation, both paddles may be placed on the front of the chest, which is the standard paddle placement. Whether using pads or paddles, the nurse must observe two safety measures. First, maintain good contact between the pads or paddles
and the client’s skin to prevent leaking. Second, ensure that no one is in contact with the client or with anything that is touching the client when the defibrillator is discharged, to minimize the chance that electrical current will be conducted to anyone other than the client. Ventilation should be stopped during defibrillation.

Question 19

19. A group of nurses is participating in orientation to a telemetry unit. The nurse who is
    providing the education should tell the class that ST segments:
    A. are the part of an ECG that reflects systole.
    B. are the part of an ECG used to calculate ventricular rate and rhythm.
    C. are the part of an ECG that reflects the time from ventricular depolarization
    through repolarization.
    D. represent early ventricular repolarization.

Answer 19

ANS: D
Rationale: ST segment is the part of an ECG that reflects the end of the QRS complex to
the beginning of the T wave. The part of an ECG that reflects repolarization of the
ventricles is the T wave. The part of an ECG used to calculate ventricular rate and rhythm is the RR interval. The part of an ECG that reflects the time from ventricular
depolarization through repolarization is the QT interval.

Question 20

20. The nurse is providing care to a client who has just undergone an electrophysiologic
    (EP) study. The client reports being nervous about “things going wrong” during the
    procedure. What is the nurse’s best response?
    A. “This is basically a risk-free procedure.”
    B. “Thousands of clients undergo EP every year.”
    C. “Remember that this is a step that will bring you closer to enjoying good health.”
    D. “The whole team will be monitoring you very closely for the entire procedure.”

Answer 20

ANS: D
Rationale: Clients who are to undergo an EP study may be anxious about the procedure
and its outcome. A detailed discussion involving the client, the family, and the
electrophysiologist usually occurs to ensure that the client can give informed consent and to reduce the client’s anxiety about the procedure. It is inaccurate to state that EP is
“risk-free” and stating that it is common does not necessarily relieve the client’s anxiety. Characterizing EP as a step toward good health does not directly address the client’s anxiety.

Question 21

21. The nurse is caring for a client with complex cardiac history. How should the nurse
    best explain the process of depolarization to a colleague?
    A. Mechanical contraction of the heart muscles
    B. Electrical stimulation of the heart muscles
    C. Electrical relaxation of the heart muscles.
    D. Mechanical relaxation of the heart muscles

Answer 21

ANS: B
Rationale: The electrical stimulation of the heart is called depolarization, and the
mechanical contraction is called systole. Electrical relaxation is called repolarization, and mechanical relaxation is called diastole.

Question 22

22. A cardiac care nurse is caring for a client who is experiencing positive chronotropy.
    What effect should the nurse prepare for?
    A. Exacerbation of an existing dysrhythmia
    B. Initiation of a new dysrhythmia
    C. Resolution of ventricular tachycardia
    D. Increased heart rate

Answer 22

ANS: D
Rationale: Stimulation of the sympathetic system increases heart rate. This phenomenon is known as positive chronotropy. It does not influence dysrhythmias.

Question 23

23. The nurse is caring for a client with refractory atrial fibrillation who underwent the
    maze procedure several months ago. The nurse reviews the result of the client’s most
    recent cardiac imaging, which notes the presence of scarring on the atria. How should the
    nurse best interpret this finding?
    A. Recognize that the procedure was unsuccessful.
    B. Recognize this as a therapeutic goal of the procedure.
    C. Liaise with the care team in preparation for repeating the maze procedure.
    D. Prepare the client for pacemaker implantation.

Answer 23

ANS: B
Rationale: The maze procedure is an open heart surgical procedure for refractory atrial
fibrillation. Small transmural incisions are made throughout the atria. The resulting
formation of scar tissue prevents reentry conduction of the electrical impulse.
Consequently, scar formation would constitute a successful procedure. There is no indication for repeating the procedure or implanting a pacemaker.

Question 24

24. A client is scheduled for catheter ablation therapy. When describing this procedure to
    the client’s family, the nurse should address which aspect of the treatment?
    A. Resetting of the heart’s contractility
    B. Destruction of specific cardiac cells
    C. Correction of structural cardiac abnormalities
    D. Clearance of partially occluded coronary arteries

Answer 24

ANS: B
Rationale: Catheter ablation destroys specific cells that are the cause or central
conduction route of a tachydysrhythmia. It does not “reset” the heart’s contractility and
it does not address structural or vascular abnormalities.

Question 25

25. A client has undergone diagnostic testing and received a diagnosis of sinus
    bradycardia attributable to sinus node dysfunction. When planning this client’s care,
    which nursing diagnosis is most appropriate?
    A. Risk for acute pain
    B. Risk for unilateral neglect
    C. Risk for activity intolerance
    D. Risk for fluid volume excess

Answer 25

ANS: C
Rationale: Sinus bradycardia causes decreased cardiac output that is likely to cause activity intolerance. It does not typically cause pain, fluid imbalances, or neglect of a unilateral nature.

Question 26

26. The nurse is caring for a client on telemetry. The client’s ECG shows atrial fibrillation,
    wide QRS and a fast, irregular ventricular rhythm. What does this ECG show?
    A. Sinus bradycardia
    B. Myocardial infarction
    C. Lupus-like syndrome
    D. Wolff–Parkinson–White (WPW) syndrome

Answer 26

ANS: D
Rationale: In the client with atrial fibrillation, if the QRS is wide and the ventricular
rhythm is very fast and irregular, an accessory pathway should be suspected. An
accessory pathway is typically congenital tissue between the atria, bundle of His, AV
node, Purkinje fibers, or ventricular myocardium. This anomaly is known as Wolff–Parkinson–White (WPW) syndrome. These characteristics are not typical of the other listed cardiac anomalies.

Question 27

27. A client is undergoing preoperative teaching before his cardiac surgery and the nurse
    is aware that a temporary pacemaker will be placed later that day. What is the nurse’s
    responsibility in the care of the client’s pacemaker?
    A. Monitoring for pacemaker malfunction or battery failure
    B. Determining when it is appropriate to remove the pacemaker
    C. Making necessary changes to the pacemaker settings
    D. Selecting alternatives to future pacemaker use

Answer 27

ANS: A
Rationale: Monitoring for pacemaker malfunctioning and battery failure is a nursing responsibility. The other listed actions are health care provider responsibilities.

Question 28

28. The nurse caring for a client whose sudden onset of sinus bradycardia is not
    responding adequately to atropine. What might be the treatment of choice for this client?
    A. Implanted pacemaker
    B. Transcutaneous pacemaker
    C. ICD
    D. Asynchronous defibrillator

Answer 28

ANS: B
Rationale: If a client suddenly develops bradycardia, is symptomatic but has a pulse, and is unresponsive to atropine, emergency pacing may be started with transcutaneous pacing, which most defibrillators are now equipped to perform. An implanted pacemaker is not a time-appropriate option. An asynchronous defibrillator or ICD would not provide
relief.

Question 29

29. The nurse is caring for a client who has had a dysrhythmic event. The nurse is aware
    of the need to assess for signs of diminished cardiac output (CO). What change in status
    may signal to the nurse a decrease in cardiac output?
    A. Increased blood pressure
    B. Bounding peripheral pulses
    C. Changes in level of consciousness
    D. Skin flushing

Answer 29

ANS: C
Rationale: The nurse conducts a physical assessment to confirm the data obtained from the history and to observe for signs of diminished cardiac output (CO) during the
dysrhythmic event, especially changes in level of consciousness. Blood pressure tends to decrease with lowered CO and bounding peripheral pulses are inconsistent with this problem. Pallor, not skin flushing, is expected.

Question 30

30. The nurse is caring for a client who has had a biventricular pacemaker implanted.
    When planning the client’s care, the nurse should recognize what goal of this
    intervention?
    A. Resynchronization
    B. Defibrillation
    C. Angioplasty
    D. Ablation

Answer 30

ANS: A
Rationale: Biventricular (both ventricles) pacing, also called resynchronization therapy, may be used to treat advanced heart failure that does not respond to medication. This type of pacing therapy is not called defibrillation, angioplasty, or ablation therapy.

Question 31

31. When planning the care of a client with an implanted pacemaker, what assessment
    should the nurse prioritize?
    A. Core body temperature
    B. Heart rate and rhythm
    C. Blood pressure
    D. Oxygen saturation level

Answer 31

ANS: B
Rationale: For clients with pacemakers, close monitoring of the heart rate and rhythm is a priority, even though each of the other listed vital signs must be assessed.

Question 32

32. The nurse is assessing a client who had a pacemaker implanted 4 weeks ago. During
    the client’s most recent follow-up appointment, the nurse identifies data that suggest the
    client may be socially isolated and depressed. What nursing diagnosis is suggested by
    these data?
    A. Decisional conflict related to pacemaker implantation
    B. Deficient knowledge related to pacemaker implantation
    C. Spiritual distress related to pacemaker implantation
    D. Ineffective coping related to pacemaker implantation

Answer 32

ANS: D
Rationale: Depression and isolation may be symptoms of ineffective coping with the
implantation. These psychosocial symptoms are not necessarily indicative of issues
related to knowledge or decisions. Further data would be needed to determine a
spiritual component to the client’s challenges.

Question 33

33. The nurse is caring for a client who is in the recovery room following the implantation
    of an ICD. The client has developed ventricular tachycardia (VT). What should the nurse
    assess and document?
    A. ECG to compare time of onset of VT and onset of device’s shock
    B. ECG so health care provider can see what type of dysrhythmia the client has
    C. Client’s level of consciousness (LOC) at the time of the dysrhythmia
    D. Client’s activity at time of dysrhythmia

Answer 33

ANS: A
Rationale: If the client has an ICD implanted and develops VT or ventricular fibrillation,
the ECG should be recorded to note the time between the onset of the dysrhythmia and the onset of the device’s shock or antitachycardia pacing. This is a priority over LOC or activity at the time of onset.

Question 34

34. The staff educator is teaching a CPR class. Which of the following aspects of
    defibrillation should the educator stress to the class?
    A. Apply the paddles directly to the client’s skin.
    B. Use a conducting medium between the paddles and the skin.
    C. Always use a petroleum-based gel between the paddles and the skin.
    D. Any available liquid can be used between the paddles and the skin.

Answer 34

ANS: B
Rationale: Use multifunction conductor pads or paddles with a conducting medium
between the paddles and the skin (the conducting medium is available as a sheet, gel, or paste). Do not use gels or pastes with poor electrical conductivity.

Question 35

35. During a CPR class, a participant asks about the difference between cardioversion and
    defibrillation. What would be the instructor’s best response?
    A. “Cardioversion is done on a beating heart; defibrillation is not.”
    B. “The difference is the timing of the delivery of the electric current.”
    C. “Defibrillation is synchronized with the electrical activity of the heart, but
    cardioversion is not.”
    D. “Cardioversion is always attempted before defibrillation because it has fewer
    risks.”

Answer 35

ANS: B
Rationale: One major difference between cardioversion and defibrillation is the timing of the delivery of electrical current. In cardioversion, the delivery of the electrical current is synchronized with the client’s electrical events; in defibrillation, the delivery of the current is immediate and unsynchronized. Both can be done on beating heart (i.e., in a dysrhythmia). Cardioversion is not necessarily attempted first.

Question 36

36. A client with an ICD calls the cardiologist’s office and talks to the nurse. The client is
    concerned about being defibrillated too often. The nurse tells the client to come to the
    office to be evaluated because the nurse knows that the most frequent complication of
    ICD therapy is what issue?
    A. Infection
    B. Failure to capture
    C. Premature battery depletion
    D. Oversensing of dysrhythmias

Answer 36

ANS: D
Rationale: Inappropriate delivery of ICD therapy, usually due to oversensing of atrial and sinus tachycardias with a rapid ventricular rate response, is the most frequent complication of ICD. Infections, failure to capture, and premature battery failure are less common.