UNIT 6 Dysrhythmias CHAPTER 31

Question 1

The nurse is assessing the client’s cardiac rhythm and notes the following: HR 64, regular rhythm, PR interval 0.20; QRS 0.10. How will the nurse document this rhythm interpretation in the electronic health record?
A. Sinus tachycardia
B. Sinus bradycardia
C. Normal sinus rhythm
D. Sinus arrhythmia

Answer 1

C. Normal sinus rhythm

Question 2

How many seconds is PR interval

Answer 2

0.12-0.20 seconds

Question 3

How many second is the QRS duration

Answer 3

0.06-0.10 seconds

Question 4

The nurse is caring for client who is experiencing occasional premature ventricular contractions. What assessment data are most concerning to the nurse?
A. Potassium 4.8 mEq/L
B. Magnesium 2 mEq/L
C. Heart rate 90
D. History of smoking

Answer 4

D. History of smoking

Question 5

1. While suctioning a client with a tracheostomy, the client becomes diaphoretic and nauseous and the heart rate decreases to 37 beats/min. What is the priority nursing action?
   A. Continue to clear the airway.
   B. Stop suctioning the patient.
   C. Administer atropine.
   D. Call the health care provider immediately.

Answer 5

C. Administer atropine.

Question 6

4. The nurse sees the rhythm above on the ECG. The patient is unresponsive and has no pulse. The nurse calls a code blue and takes what step next?

A. Prepare for defibrillation

B. Administer Epinephrine

C. Start high-quality CPR

D. Notify the physician

Answer 6

The answer is C. The nurse would want to immediately start high-quality CPR and continue this until help arrives

Question 7

2. What should the PR Interval measure for Normal Sinus Rhythm?

A. 0.35-0.44 seconds

B. > 0.12 seconds

C. 0.12-0.20 seconds

D. > 0.20 seconds

Answer 7

C. 0.12-0.20 seconds

Question 8

6. You’re patient is in ventricular fibrillation (v-fib). You’ve started CPR and the airway is supported. A rhythm checked in performed and shows the patient is still in ventricular fibrillation. The NEXT action the code team will take in addition to performing high-quality CPR is to?
   A. Administer Atropine
   B. Defibrillate
   C. Administer Epinephrine
   D. Synchronized cardiovert

Answer 8

The answer is B. Ventricular fibrillation is a shockable rhythm. The team will continue CPR until the machine is ready to deliver a shock (hence defibrillate). Once the machine is ready for defibrillation, the team will shout clear (all members will remove themselves from the patient) and a shock will be delivered. Then CPR will be resumed.