1. Which of the following professional organizations best supports critical care nursing practice?
a. American Association of Critical-Care Nurses
b. American Heart Association
c. American Nurses Association
d. Socie
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1. Which of the following professional organizations best supports critical care nursing practice?
a. American Association of Critical-Care Nurses
b. American Heart Association
c. American Nurses Association
d. Society of Critical Care Medicine - A
The American Association of Critical-Care Nurses is the specialty organization that supports and represents critical care nurses. The American Heart Association supports cardiovascular initiatives. The American Nurses Association supports all nurses. The Society of Critical Care Medicine represents the multiprofessional critical care team under the direction of an intensivist.
2. A nurse has been working as a staff nurse in the surgical intensive care unit for 2 years and is interested in certification. Which credential would be most applicable for the nurse to seek?
a. ACNPC-AG
b. CNML
c. CCRN
d. PCCN - C
The CCRN certification is appropriate for nurses in bedside practice who care for critically ill patients. The ACNPC-AG certification is for acute care nurse practitioners. The CNML is for critical care nurse managers or leaders. The PCCN certification is for staff nurses working in progressive care, intermediate care, or step-down unit settings.
3. The main purpose of certification is to
a. assure the consumer that you will not make a mistake.
b. prepare for graduate school.
c. promote magnet status for your facility.
d. validate knowledge of critical care nursing. - D
Certification assists in validating knowledge of the field, promotes excellence in the profession, and helps nurses to maintain their knowledge of critical care nursing. Certification helps to assure the consumer that the nurse has a minimum level of knowledge; however, it does not ensure that care will be mistake-free. Certification does not prepare one for graduate school; however, achieving certification demonstrates motivation for achievement and professionalism. Magnet facilities are rated on the number of certified nurses; however, that is not the purpose of certification.
4. The synergy model of practice focuses on
a. allowing unrestricted visiting for the patient 24 hours a day.
b. holistic and alternative therapies.
c. the needs of patients and their families, which drive nursing competency.
d. patients' needs for energy and support. - C
The synergy model of practice states that the needs of patients and families influence and drive competencies of nurses. Nursing practice based on the synergy model would involve tailored visiting to meet the patient's and family's needs and the application of alternative therapies if desired by the patient, but that is not the primary focus of the model.
5. The family of your critically ill patient tells you that they have not spoken with the physician in over 24 hours and that they have some questions they want clarified. During morning rounds, you convey this concern to the attending intensivist and arrange a meeting with the family at 4:00 PM. Which competency of critical care nursing does this represent?
a. Advocacy and moral agency in solving ethical issues
b. Clinical judgment and clinical reasoning skills
c. Collaboration with patients, families, and team members
d. Facilitation of learning for patients, families, and team members - C
Although one might consider that all of these competencies are being addressed, communication and collaboration with the family and physician best exemplify the competency of collaboration.
6. The AACN Standards for Acute and Critical Care Nursing Practice use what framework to guide critical care nursing practice?
a. Evidence-based practice
b. Healthy work environment
c. National Patient Safety Goals
d. Nursing process - D
The AACN Standards for Acute and Critical Care Nursing Practice delineate the nursing process as applied to critically ill patients: collect data, determine diagnoses, identify expected outcomes, develop a plan of care, implement interventions, and evaluate care. AACN promotes a healthy work environment, but this is not included in its standards. The Joint Commission has established National Patient Safety Goals, but these are not the AACN standards.
7. The charge nurse is responsible for making the patient assignments on the critical care unit. An experienced, certified nurse is assigned to care for the acutely ill patient with sepsis who also requires continuous renal replacement therapy and mechanical ventilation. The nurse with less than 1 year of experience is assigned to two patients who are more stable. This assignment reflects implementation of the
a. crew resource management model.
b. National Patient Safety Goals.
c. Quality and Safety Education for Nurses (QSEN) model.
d. synergy model of practice. - D
This assignment demonstrates nursing care to meet the needs of the patient. The synergy model notes that the nurse competencies are matched to the patient characteristics. Crew resource management concepts are related to team training; National Patient Safety Goals are specified by The Joint Commission to promote safe care but do not incorporate the synergy model. The Quality and Safety Education for Nurses initiative involves targeted education of undergraduate and graduate nursing students on quality and safety concepts.
8. The vision of the American Association of Critical-Care Nurses is a health care system driven by
a. a healthy work environment.
b. care from a multiprofessional team under the direction of a critical care physician.
c. the needs of critically ill patients and families.
d. respectful, healing, and humane environments. - C
The AACN vision is a health care system driven by the needs of critically ill patients and families where critical care nurses make their optimum contributions. AACN promotes initiatives to support a healthy work environment as well as respectful and healing environments, but that is not the organization's vision. The Society of Critical Care Medicine (SCCM) promotes care from a multiprofessional team under the direction of a critical care physician.
9. The most important outcome of effective communication is to
a. demonstrate caring practices to family members.
b. ensure that patient teaching is done.
c. meet the diversity needs of patients.
d. reduce patient errors. - D
Many errors are directly attributed to faulty communication. Effective communication has been identified as an essential strategy to reduce patient errors and resolve issues related to patient care delivery. Communication may demonstrate caring practices, address diversity needs, and be used for patient/family teaching; however, the main outcome of effective communication is patient safety.
10. You are caring for a critically ill patient whose urine output has been low for 2 consecutive hours. After a thorough patient assessment, you call the intensivist with report. Which information do you convey regarding background?
a. Urine output of 40 mL/2 hours
b. Current vital signs and history of aortic aneurysm repair 4 hours ago
c. A statement that the patient is possibly hypovolemic
d. A request for IV fluids - B
The history and vital signs are part of the background. Information regarding the low urine output is the situation. Information regarding possible hypovolemia is part of the nurse's assessment, and the suggestion for fluids is the recommendation.
11. The family members of a critically ill patient bring a copy of the patient's living will to the hospital, which identifies the patient's wishes regarding health care. You discuss contents of the living will with the patient's physician. This is an example of implementation of which of the AACN Standards of Professional Performance?
a. Acquires and maintains current knowledge of practice
b. Acts ethically on the behalf of the patient and family
c. Considers factors related to safe patient care
d. Uses clinical inquiry and integrates research findings in practice - B
Discussing end-of-life issues is an example of a nurse acting ethically on behalf of the patient and family. The example does not relate to acquiring knowledge, promoting patient safety, or using research in practice.
12. Which of the following assists the critical care nurse in ensuring that care is appropriate and based on research?
a. Clinical practice guidelines
b. Computerized physician order entry
c. Consulting with advanced practice nurses
d. Implementing Joint Commission National Patient Safety Goals - A
Clinical practice guidelines are being implemented to ensure that care is appropriate and based on research. Some physician order entry pathways, but not all, are based on research recommendations. Some advanced practice nurses, but not all, are well versed in evidence-based practices. The National Patient Safety Goals are recommendations to reduce errors using evidence-based practices.
13. Comparing the patient's current (home) medications with those ordered during hospitalization and communicating a complete list of medications to the next provider when the patient is transferred within an organization or to another setting are strategies to:
a. improve accuracy of patient identification.
b. prevent errors related to look-alike and sound-alike medications.
c. reconcile medications across the continuum of care.
d. reduce harms associated with the administration of anticoagulants. - C
These are steps recommended in the National Patient Safety Goals to reconcile medications across the continuum of care. Improving accuracy of patient identification is another National Patient Safety Goal. Preventing errors related to look-alike and sound-alike medications is done to improve medication safety, but is not related to transferring the patient between settings. Reducing harms associated with the administration of anticoagulants is another National Patient Safety Goal.
14. As part of nursing management of a critically ill patient, orders are written to keep the head of the bed elevated at 30 degrees, awaken the patient from sedation each morning to assess readiness to wean from mechanical ventilation, and implement oral care protocols every 4 hours. These interventions are done as a group to reduce the risk of ventilator-associated pneumonia. This group of evidence-based interventions is often called a
a. bundle of care.
b. clinical practice guideline.
c. patient safety goal.
d. quality improvement initiative. - A
A group of evidence-based interventions done as a whole to improve outcomes is termed a bundle of care. This is an example of the ventilator bundle. Oftentimes these bundles are derived from clinical practice guidelines and are monitored for compliance as part of quality improvement initiatives. At some point, these may become part of patient safety goals.
15. You work in an intermediate care unit and have asked to be involved in developing new guidelines to prevent pressure ulcers in your patient population. The nurse manager tells you that you do not yet have enough experience to be on the prevention task force and that your ideas will be rejected by others. This situation is an example of
a. a barrier to handoff communication.
b. a work environment that is unhealthy.
c. ineffective decision making.
d. nursing practice that is not evidence-based. - B
These are examples of an unhealthy work environment. A healthy work environment values communication, collaboration, and effective decision making. It also has authentic leadership. It is not an example of handoff communication, which is communication that occurs to transition patient care from one staff member to another. Neither does it relate to ineffective decision making. As a nurse, you can still implement evidence-based practice, but your influence in the unit is limited by the unhealthy work environment.
16. Which of the following statements describes the core concept of the synergy model of practice?
a. All nurses must be certified in order to have the synergy model implemented.
b. Family members must be included in daily interdisciplinary rounds.
c. Nurses and physicians must work collaboratively and synergistically to influence care.
d. Unique needs of patients and their families influence nursing competencies. - D
The synergy model of practice is care based on the unique needs and characteristics of the patient and family members. Although critical care certification is based on the synergy model, the model does not specifically address certification. Inclusion of family members into the daily rounds is an example of implementation of the synergy model. With the focus on patients and family members with nurse interaction, the synergy model does not address physician collaboration.
17. A nurse who plans care based on the patient's gender, ethnicity, spirituality, and lifestyle is said to
a. be a moral advocate.
b. facilitate learning.
c. respond to diversity.
d. use clinical judgment. - C
Response to diversity considers all of these aspects when planning and implementing care. A moral agent helps resolve ethical and clinical concerns. Consideration of these factors does not necessarily facilitate learning. Clinical judgment uses other factors as well.
MULTIPLE RESPONSE
1. Which of the following is a National Patient Safety Goal? (Select all that apply.)
a. Accurately identify patients.
b. Eliminate the use of patient restraints.
c. Reconcile medications across the continuum of care.
d. Reduce risks of health care-acquired infection.
e. Reduce costs associated with hospitalization. - A, C, D
All except for eliminating the use of restraints and reducing costs are current National Patient Safety Goals. Hospitals have policies regarding the use of restraints and are attempting to reduce the use of restraints; however, this is not a National Patient Safety Goal. Many facilities are actively working on cost reduction, but this is not a National Patient Safety Goal either.
2. Which of the following is (are) official journal(s) of the American Association of Critical-Care Nurses? (Select all that apply.)
a. American Journal of Critical Care
b. Critical Care Clinics of North America
c. Critical Care Nurse
d. Critical Care Nursing Quarterly
e. Critical Care Nursing Management - A, C
American Journal of Critical Care and Critical Care Nurse are two official AACN publications. Critical Care Clinics, Critical Care Nursing Quarterly, and Critical Care Nursing Management are not AACN publications.
3. The first critical care units were (Select all that apply.)
a. burn units.
b. coronary care units.
c. recovery rooms.
d. neonatal intensive care units.
e. high-risk OB units. - B, C
Recovery rooms and coronary care units were the first units designated to care for critically ill patients. Burn, neonatal intensive care, and high-risk OB units were established as specialty units evolved.
4. Which of the following nursing activities demonstrates implementation of the AACN Standards of Professional Performance? (Select all that apply.)
a. Attending a meeting of the local chapter of the American Association of Critical-Care Nurses in which a continuing education program on sepsis is being taught
b. Collaborating with a pastoral services colleague to assist in meeting spiritual needs of the patient and family
c. Participating on the unit's nurse practice council
d. Posting an article from Critical Care Nurse on the management of venous thromboembolism for your colleagues to read
e. Using evidence-based strategies to prevent ventilator-associated pneumonia - A, B, C, D, E
All answers are correct. Attending a program to learn about sepsis—Acquires and maintains current knowledge and competency in patient care. Collaborating with pastoral services—Collaborates with the health care team to provide care in a healing, humane, and caring environment. Posting information for others—Contributes to the professional development of peers and other health care providers. Nurse practice council—Provides leadership in the practice setting. Evidence-based practices—Uses clinical inquiry in practice.
5. Which scenarios contribute to effective handoff communication at change of shift? (Select all that apply.)
a. The nephrology consultant physician is making rounds and asks you for an update on the patient's status and to assist in placing a central line for hemodialysis.
b. The noise level is high because twice as many staff members are present and everyone is giving report in the nurses' station.
c. The unit has decided to use a standardized checklist/tool for change-of-shift reports and patient transfers.
d. You and the oncoming nurse conduct a standardized report at the patient's bedside and review key assessment findings.
e. The off-going nurse is giving the patient medications at the same time as giving handoff report to the oncoming nurse. - C, D
A reporting tool and bedside report improve handoff communication by ensuring standardized communication and review of assessment findings. Conducting report at the bedside also reduces noise that commonly occurs at the nurses' station during a change of shift. The nephrologist has created an interruption that can impede handoff with the next nurse. Likewise, noise in the nurses' station can cause distractions that can impair concentration and listening. Giving medications at the same time as handoff report could lead to serious errors both in medication administration and in the report itself.
6. Which strategy is important in addressing issues associated with the aging workforce? (Select all that apply.)
a. Allowing nurses to work flexible shift durations
b. Encouraging older nurses to transfer to an outpatient setting that is less stressful
c. Hiring nurse technicians who are available to assist with patient care, such as turning the patient
d. Remodeling patient care rooms to include devices to assist in patient lifting
e. Developing a staffing model that accurately reflects the unit's needs. - A, C, D
Modifying the work environment to reduce physical demands is one strategy to assist the aging workforce. Examples include overhead lifts to prevent back injuries. Twelve-hour shifts can be quite demanding; therefore, allowing nurses flexibility in choosing shifts of shorter duration is a good option as well. Adequate staffing, including both registered nurses and nonlicensed assistive personnel to help with nursing and nonnursing tasks, is helpful. Encouraging experienced, knowledgeable critical care nurses to leave the critical care unit is not wise as the unit loses the expertise of this group.
7. Which of the following strategies will assist in creating a healthy work environment for the critical care nurse? (Select all that apply.)
a. Celebrating improved outcomes from a nurse-driven protocol with a pizza party
b. Implementing a medication safety program designed by pharmacists
c. Modifying the staffing pattern to ensure a 1:1 nurse/patient ratio
d. Offering quarterly joint nurse-physician workshops to discuss unit issues
e. Using the Situation-Background-Assessment-Recommendation (SBAR) technique for handoff communication - A, D, E
Meaningful recognition, true collaboration, and skilled communication are elements of a healthy work environment. Implementing a medication safety program enhances patient safety, but if done without nursing input, it could have negative outcomes. Staffing should be adjusted to meet patient needs and nurse competencies, not have predetermined ratios that are unrealistic and possibly unneeded.
Chapter 07: Dysrhythmia Interpretation and Management
MULTIPLE CHOICE
1. The nurse is caring for a patient who is on a cardiac monitor. The nurse realizes that the sinus node is the pacemaker of the heart because it is
a. the fastest pacemaker cell in the heart.
b. the only pacemaker cell in the heart.
c. the only cell that does not affect the cardiac cycle.
d. located in the left side of the heart. - A
The cardiac cycle begins with an impulse that is generated from a small concentrated area of pacemaker cells high in the right atria called the sinoatrial node (sinus node or SA node). The SA node has the fastest rate of discharge and thus is the dominant pacemaker of the heart. The AV node has pacemaker properties and can discharge an impulse if the SA node fails. The ventricles have pacemaker capabilities if the sinus node or the AV node ceases to generate impulses.
2. One of the functions of the atrioventricular (AV) node is to
a. pace the heart if the ventricles fail.
b. slow the impulse arriving from the SA node.
c. send the impulse to the SA node.
d. allow for ventricular filling during systole. - B
The impulse from the SA node quickly reaches the atrioventricular (AV) node located in the area called the AV junction, between the atria and the ventricles. Here the impulse is slowed to allow time for ventricular filling during relaxation or ventricular diastole. The AV node has pacemaker properties and can discharge an impulse if the SA node (not the ventricle) fails. The electrical impulse is then rapidly conducted through the bundle of His to the ventricles (not the SA node) via the left and right bundle branches.
3. The normal rate for the SA node when the patient is at rest is
a. 40 to 60 beats per minute.
b. 60 to 100 beats per minute.
c. 20 to 40 beats per minute.
d. more than100 beats per minute. - B
The sinus node reaches threshold at a rate of 60 to 100 times per minute. Because this is the fastest pacemaker in the heart, the SA node is the dominant pacemaker of the heart. The AV node has an inherent rate of 40 to 60 beats per minute and the His-Purkinje system can fire at a rate of 20 to 40 beats per minute. Sinus tachycardia results when the SA node fires faster than 100 beats per minute.
4. The nurse caring for patients with cardiac monitoring understands that when an electrical signal is aimed directly at the positive electrode, the inflection will be:
a. negative.
b. upside down.
c. upright.
d. equally positive and negative. - C
When an electrical signal is aimed directly at the positive electrode, an upright inflection is visualized. If the impulse is going away from the positive electrode, a negative deflection is seen; and if the signal is perpendicular to the imaginary line between the positive and negative poles of the lead, the tracing is equiphasic, with equally positive and negative deflection.
5. The patient is admitted with a condition that requires cardiac rhythm monitoring. To apply the monitoring electrodes, the nurse must first
a. apply a moist gel to the chest.
b. make certain that the electrode gel is dry.
c. avoid soaps to avoid skin irritation.
d. clip chest hair if needed. - D
Adequate skin preparation of electrode sites requires clipping the hair, cleansing the skin, and drying vigorously (moisture gels are not applied). Cleansing includes washing with soap and water, or alcohol, to remove skin debris and oils. Before application, the electrodes are checked to ensure that the gel is moist. It is difficult for electrodes to adhere to the chest in the presence of chest hair. Clipping, not shaving, is recommended since shaving may create small nicks that can become a portal for infection.
6. The nurse using cardiac monitoring understands that each horizontal box on the electrocardiogram (ECG) paper indicates
a. 200 milliseconds or 0.20 seconds duration.
b. 40 milliseconds or 0.04 seconds duration.
c. 3 seconds duration.
d. millivolts of amplitude. - B
ECG paper contains a standardized grid where the horizontal axis measures time and the vertical axis measures voltage or amplitude. Horizontally, the smaller boxes denote 0.04 seconds each or 40 milliseconds; the larger box contains five smaller boxes and thus equals 0.20 seconds or 200 milliseconds.
7. The nurse is examining the patient's cardiac rhythm strip in lead II and notices that all of the P waves are upright and look the same except one that has a different shape and is inverted. The nurse realizes that the P wave with the abnormal shape is probably
a. from the SA node because all P waves come from the SA node.
b. from some area in the atria other than the SA node.
c. indicative of ventricular depolarization.
d. normal even though it is inverted in lead II. - B
Normally a P wave indicates that the SA node initiated the impulse that depolarized the atrium. However, a change in the shape of the P wave may indicate that the impulse arose from a site in the atria other than the SA node. The P wave represents atrial depolarization. It is usually upright in leads I and II and has a rounded, symmetrical shape. The amplitude of the P wave is measured at the center of the waveform and normally does not exceed three boxes, or 3 millimeters, in height.
8. The nurse caring for patients on cardiac monitors assesses the patient with a prolonged QT interval for
a. electrolyte disturbances such as hypokalemia.
b. symptomatic bradycardias.
c. the development of lethal dysrhythmias.
d. difficulty maintaining the blood pressure. - C
The QT interval is measured from the beginning of the QRS complex to the end of the T wave. This interval measures the total time taken for ventricular depolarization and repolarization. Abnormal prolongation of the QT interval increases vulnerability to lethal dysrhythmias, such as ventricular tachycardia and fibrillation. The nurse monitors the patient for the development of these rhythms and is prepared to intervene should they occur. A prolonged QT is not associated with bradycardias, hypokalemia, or blood pressure irregularities.
9. The patient has an irregular heart rhythm. To determine an accurate heart rate, the nurse would first
a. identify the markers on the ECG paper that indicate a 6-second strip.
b. count the number of small boxes between two consecutive P waves.
c. count the number of small boxes between two consecutive QRS complexes.
d. divides the number of complexes in a 6-second strip by 10. - A
The optimal method of determining a heart rate from an ECG strip when the patient has an irregular heart rate is to count the number of P waves or QRS waves within a 6-second strip to obtain both atrial and ventricular heart rates per minute. In order to do this accurately, the nurse first much identify the markers on the ECG paper that indicate a 6-second strip. The other methods are not as accurate with an irregular heart rate.
10. The nurse is calculating the rate for a regular rhythm. There are 20 small boxes between each P wave and 20 small boxes between each R wave. What is the ventricular rate?
a. 50 beats/min
b. 75 beats/min
c. 85 beats/min
d. 100 beats/min - B
The rule of 1500 is used to calculate the exact rate of a regular rhythm. The number of small boxes between the highest points of two consecutive R waves is counted, and that number of small boxes is divided into 1500 to determine the ventricular rate. 1500/20 = 75 beats/min. This method is accurate only if the rhythm is regular.
11. The patient is admitted with a fever and rapid heart rate. The patient's temperature is 103F (39.4C). The nurse places the patient on a cardiac monitor and finds the patient's atrial and ventricular rates are above 105 beats per minute. P waves are clearly seen and appear normal in configuration. QRS complexes are normal in appearance and 0.08 seconds wide. The rhythm is regular, and blood pressure is normal. The nurse should focus on providing:
a. medications to lower heart rate.
b. treatment to lower temperature.
c. treatment to lower cardiac output.
d. treatment to reduce heart rate. - B
Sinus tachycardia results when the SA node fires faster than 100 beats per minute. All other components of the ECG are normal. Sinus tachycardia is a normal response to stimulation of the sympathetic nervous system. Sinus tachycardia is also a normal finding in children younger than 6 years. The fast heart rhythm may cause a decrease in cardiac output because of the shorter filling time for the ventricles. Lowering cardiac output further may complicate the situation. The dysrhythmia itself is not treated, but the cause is identified and treated appropriately. For example, if the patient has a fever or is in pain, the fever (and infection) or pain is treated appropriately.
12. The nurse notices sinus bradycardia on the patient's cardiac monitor. The nurse should
a. give atropine to increase heart rate.
b. begin transcutaneous pacing of the patient.
c. start a dopamine infusion to stimulate heart function.
d. assess for hemodynamic instability. - D
Sinus bradycardia may be a normal heart rhythm for some individuals such as athletes, or it may occur during sleep. Assess for hemodynamic instability related to the bradycardia. If the patient is symptomatic, interventions include administration of atropine. If atropine is not effective in increasing heart rate, then transcutaneous pacing, dopamine infusion, or epinephrine infusion may be administered. Atropine is avoided for treatment of bradycardia associated with hypothermia.
13. Which of the following is true about a patient diagnosed with sinus arrhythmia?
a. The heart rate varies, dependent on vagal tone and respiratory pattern.
b. Immediate treatment is essential to prevent death.
c. Sinus arrhythmia is not well tolerated by most patients.
d. PR and QRS interval measurements are prolonged. - A
Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate increases slightly during inspiration and slows slightly during exhalation because of changes in vagal tone. The ECG tracing demonstrates an alternating pattern of faster and slower heart rate that changes with the respiratory cycle. Interval measurements are normal. This rhythm is tolerated well, and no treatment is required. The PR and QRS intervals are normal.
14. The patient is admitted with sinus pauses causing periods of loss of consciousness. The patient is asymptomatic, awake and alert, but fatigued. He answers questions appropriately. When admitting this patient, the nurse should first
a. prepare the patient for temporary pacemaker insertion.
b. prepare the patient for permanent pacemaker insertion.
c. assess the patient's medication profile.
d. apply transcutaneous pacemaker paddles. - C
AV nodal blocking medications (such as beta blockers, calcium channel blockers, and digoxin) and increased vagal tone may cause sinus exit block. Causes are explored, and prescribed medications may need to be adjusted or discontinued. If patients are symptomatic, significant numbers of pauses may require treatment, including temporary (including transcutaneous) and permanent implantation of a pacemaker.
15. The patient's heart rate is 165 beats per minute. The cardiac monitor shows a rapid rate with narrow QRS complexes. The P waves cannot be seen, but the rhythm is regular. The patient's blood pressure has dropped from 124/62 mm Hg to 78/30 mm Hg. The patient's skin is cold and diaphoretic, and the patient is complaining of nausea. The nurse prepares the patient for
a. administration of beta blockers.
b. administration of atropine.
c. transcutaneous pacemaker insertion.
d. emergent cardioversion. - D
If an abnormal P wave cannot be visualized on the ECG but the QRS complex is narrow, the term supraventricular tachycardia (SVT) is often used. This is a generic term that describes any tachycardia that is not ventricular in origin; it is also used when the source above the ventricles cannot be identified, usually because the rate is too fast. Treatment is directed at assessing the patient's tolerance of the tachycardia. If the rate is higher than 150 beats per minute and the patient is symptomatic, emergent cardioversion is considered. Cardioversion is the delivery of a synchronized electrical shock to the heart by an external defibrillator. Beta blockers are a possibility if the patient is not symptomatic. Atropine is used in the treatment of bradycardia. If atropine is not effective in increasing heart rate, then transcutaneous pacing is implemented.
16. The nurse is reading the cardiac monitor and notes that the patient's heart rhythm is extremely irregular and that there are no discernible P waves. The ventricular rate is 90 beats per minute, and the patient is hemodynamically stable. The nurse realizes that the patient's rhythm is
a. atrial fibrillation.
b. atrial flutter.
c. atrial flutter with rapid ventricular response.
d. junctional escape rhythm. - A
Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction. No discernible P waves can be identified, resulting in a wavy baseline and an extremely irregular ventricular response. Atrial flutter arises from a single irritable focus in the atria. The atrial focus fires at an extremely rapid, regular rate, between 240 and 320 beats per minute. The P waves are called flutter waves and may have a sawtooth appearance. Atrial flutter with rapid ventricular response occurs when atrial impulses cause a ventricular response greater than 100 beats per minute. A junctional escape rhythm is a ventricular rate between 40 and 60 beats per minute with a regular rhythm. P waves may be absent, inverted, or follow the QRS complex. QRS complex is normal.
17. The patient's heart rhythm shows an inverted P wave with a PR interval of 0.06 seconds. The heart rate is 54 beats per minute. The nurse recognizes the rhythm is due to the
a. loss of sinus node activity.
b. increased rate of the AV node.
c. increased rate of the SA node.
d. decreased rate of the AV node. - A
Junctional escape rhythm occurs when the dominant pacemaker, the SA node, fails to fire. The normal heart rate of the AV node is 40 to 60 beats per minute, so the AV node rate has neither increased nor decreased. P waves may be inverted. An increased SA node rate would override the AV node.
18. The patient's heart rate is 70 beats per minute, but the P waves come after the QRS complex. The nurse correctly determines that the patient's heart rhythm is
a. a normal junctional rhythm.
b. an accelerated junctional rhythm.
c. a junctional tachycardia.
d. atrial fibrillation. - B
The normal intrinsic rate for the AV node and junctional tissue is 40 to 60 beats per minute, but rates can accelerate. An accelerated junctional rhythm has a rate between 60 and 100 beats per minute, and the rate for junctional tachycardia is greater than 100 beats per minute. If P wave precedes QRS, it is inverted or upside down; the P wave may not be visible, or it may follow the QRS. If a P wave is present before the QRS, the PR interval is shortened less than 0.12 milliseconds. Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction. The AV node is bombarded with hundreds of atrial impulses and conducts these impulses in an unpredictable manner to the ventricles.
19. The patient is having premature ventricular contractions (PVCs). The nurse's greatest concern should be:
a. the proximity of the R wave of the PVC to the T wave of a normal beat.
b. the fact that PVCs are occurring, because they are so rare.
c. whether the number of PVCs is decreasing.
d. whether the PVCs are wider than 0.12 seconds. - A
The peak of the T wave through the downslope of the T wave is considered the vulnerable period, which coincides with partial repolarization of the ventricles. If a PVC occurs during the T wave, ventricular tachycardia may occur. When the R wave of PVC falls on the T wave of a normal beat, it is referred to as the R-on-T phenomenon. PVCs may occur in healthy individuals and usually do not require treatment. The nurse must determine if PVCs are increasing in number by evaluating the trend. If PVCs are increasing, the nurse should evaluate for potential causes, such as electrolyte imbalances, myocardial ischemia or injury, and hypoxemia. Runs of nonsustained ventricular tachycardia may be a precursor to the development of sustained ventricular tachycardia. Because the stimulus depolarizes the ventricles in a slower, abnormal way, the QRS complex appears widened and has a bizarre shape. The QRS complex is wider than 0.12 seconds and often wider than 0.16 seconds.
20. The nurse notices ventricular tachycardia on the heart monitor. When the patient is assessed, the patient is found to be unresponsive with no pulse. The nurse should
a. treat with intravenous amiodarone or lidocaine.
b. begin cardiopulmonary resuscitation and advanced life support.
c. provide electrical cardioversion.
d. ignore the rhythm because it is benign. - B
Ventricular tachycardia (VT) is a rapid, life-threatening dysrhythmia originating from a single ectopic focus in the ventricles. Determine whether the patient has a pulse. If no pulse is present, provide emergent basic and advanced life-support interventions, including defibrillation. If a pulse is present and the blood pressure is stable, the patient can be treated with intravenous amiodarone or lidocaine. Cardioversion is used as an emergency measure in patients who become hemodynamically unstable but continue to have a pulse. It also may be used in nonemergency situations, such as when a patient has asymptomatic VT.
21. The nurse is talking with the patient when the monitor alarms and shows a wavy baseline without a PQRST complex. The nurse should
a. defibrillate the patient immediately.
b. initiate basic life support.
c. initiate advanced life support.
d. assess the patient and the electrical leads. - D
Ventricular fibrillation (VF) is a chaotic rhythm characterized by a quivering of the ventricles, which results in total loss of cardiac output and pulse. VF is a life-threatening emergency, and the more immediate the treatment is, the better the survival will be. VF produces a wavy baseline without a PQRST complex. Because a loose lead or electrical interference can produce a waveform similar to VF, it is always important to immediately assess the patient for pulse and consciousness.
22. The nurse notices that the patient has a first-degree AV block. Everything else about the rhythm is normal. The nurse should
a. prepare to place the patient on a transcutaneous pacemaker.
b. give the patient atropine to shorten the PR interval.
c. monitor the rhythm and patient's condition.
d. give the patient an antiarrhythmic medication. - C
First-degree AV block is a common dysrhythmia in the elderly and in patients with cardiac disease. As the normal conduction pathway ages or becomes diseased, impulse conduction becomes slower than normal. It is well tolerated. No treatment is required. Continue to monitor the patient and the rhythm.
23. The nurse understands that in a third-degree AV block
a. every P wave is conducted to the ventricles.
b. some P waves are conducted to the ventricles.
c. none of the P waves are conducted to the ventricles.
d. the PR interval is prolonged. - C
Third-degree block is often called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. Normally every P wave is conducted to the ventricles. If some of the P waves are conducted but others are not, further assessment is needed to determine the type of block present. A prolonged PR interval is a first-degree AV block, and is well tolerated and requires no treatment.
24. The patient is asymptomatic but is diagnosed with second-degree heart block Mobitz I. The patient is on digitalis medication at home. The nurse should expect that
a. the patient has had an anterior wall myocardial infarction.
b. the physician will order the digitalis to be continued in the hospital.
c. a digitalis level would be ordered upon admission.
d. the patient will require a transcutaneous pacemaker. - C
Digitalis toxicity is a major cause of this rhythm, and further digitalis doses should not be given until a digitalis level is obtained. Other causes of Mobitz I include AV nodal blocking drugs, acute inferior wall myocardial infarction or right ventricular infarction, ischemic heart disease, and excess vagal response. This type of block is usually well tolerated, and no treatment is indicated unless the dropped beats occur frequently.
25. The patient is scheduled to have a permanent pacemaker implanted. The patient asks the nurse, "How long will the battery in this thing last?" The nurse should answer,
a. "Life expectancy is about 1 year. Then it will need to be replaced."
b. "Pacemaker batteries can last up to 25 years with constant use."
c. "Battery life varies depending on usage, but it can last up to 10 years."
d. "Pacemakers are used to treat temporary problems, so the batteries don't last long." - C
Implanted permanent pacemakers are used to treat chronic conditions. These devices have a battery life of up to 10 years, which varies based on the manufacturer's recommendations and the usage of the device.
26. The patient is in chronic junctional escape rhythm with no atrial activity noted. Studies have demonstrated normal AV node function. This patient may be a candidate for which type of pacing?
a. Atrial pacing
b. Ventricular pacing
c. Dual-chamber pacing
d. Transcutaneous pacing - A
Pacemakers may be used to stimulate the atrium, ventricle, or both chambers (dual-chamber pacemakers). Atrial pacing is used to mimic normal conduction and to produce atrial contraction, thus providing atrial kick. This is the case in the scenario provided. Ventricular pacing stimulates ventricular depolarization and is commonly used in emergency situations or when pacing is required infrequently. Dual-chamber pacing allows for stimulation of both atria and ventricles as needed to synchronize the chambers and mimic the normal cardiac cycle. However, with this patient, ventricular and AV function are normal.
27. The patient has a permanent pacemaker inserted. The provider has set the pacemaker to the demand mode at a rate of 60 beats per minute. The nurse realizes that
a. the pacemaker will pace only if the patient's intrinsic heart rate is less than 60 beats per minute.
b. the demand mode often competes with the patient's own rhythm.
c. the demand mode places the patient at risk for the R-on-T phenomenon.
d. the fixed-rate mode is safer and is the mode of choice. - A
Pacemakers can be operated in a demand mode or a fixed-rate (asynchronous) mode. The demand mode paces the heart when no intrinsic or native beat is sensed. For example, if the rate control is set at 60 beats per minute, the pacemaker will only pace if the patient's heart rate drops to less than 60. The fixed-rate mode paces the heart at a set rate, independent of any activity the patient's heart generates. The fixed-rate mode may compete with the patient's own rhythm and deliver an impulse on the T wave (R-on-T phenomenon), with the potential for producing ventricular tachycardia or fibrillation. The demand mode is safer and is the mode of choice.
28. The patient has a permanent pacemaker in place with a demand rate set at 60 beats/min. The cardiac monitor is showing a heart rate of 44 beats/min with no pacemaker spikes. The nurse recognizes this as:
a. normal pacemaker function.
b. failure to capture.
c. failure to pace.
d. failure to sense. - C
Failure to pace or fire occurs when the pacemaker fails to initiate an electrical stimulus when it should fire. The problem is noted by absence of pacer spikes on the rhythm strip. Causes of failure to pace include battery or pulse generator failure, fracture or displacement of a pacemaker wire, or loose connections. This is not normal pacemaker function. When the pacemaker generates an electrical impulse (pacer spike) and no depolarization is noted, it is described as a failure to capture. On the ECG, a pacer spike is noted, but it is not followed by a P wave (atrial pacemaker) or a QRS complex (ventricular pacemaker). When the pacemaker does not sense the patient's own cardiac rhythm and initiates an electrical impulse, it is called failure to sense. Failure to sense manifests as pacer spikes that fall too closely to the patient's own rhythm, earlier than the programmed rate.
29. The rhythm on the cardiac monitor is showing numerous pacemaker spikes, but no P waves or QRS complexes following the spikes. The nurse recognizes this as:
a. normal pacemaker function.
b. failure to capture.
c. failure to pace.
d. failure to sense. - B
When the pacemaker generates an electrical impulse (pacer spike) and no depolarization is noted, it is described as a failure to capture. On the ECG, a pacer spike is noted, but it is not followed by a P wave (atrial pacemaker) or a QRS complex (ventricular pacemaker). This is not normal pacemaker function. Failure to pace or fire occurs when the pacemaker fails to initiate an electrical stimulus when it should fire. The problem is noted by absence of pacer spikes on the rhythm strip. When the pacemaker does not sense the patient's own cardiac rhythm and initiates an electrical impulse, it is called failure to sense. Failure to sense manifests as pacer spikes that fall too closely to the patient's own rhythm, earlier than the programmed rate.
30. Interpret the following rhythm:
a. Normal sinus rhythm
b. Sinus bradycardia
c. Sinus tachycardia
d. Sinus arrhythmia - A
Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P and QRS waves are consistent in shape. Sinus tachycardia results when the SA node fires faster than 100 beats per minute. Bradycardia is defined as a heart rate less than 60 beats per minute. Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate slightly increases during inspiration and slightly slows during exhalation because of changes in vagal tone.
31. Interpret the following rhythm:
a. Normal sinus rhythm
b. Sinus bradycardia
c. Sinus tachycardia
d. Sinus arrhythmia - C
Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P and QRS waves are consistent in shape. Sinus tachycardia results when the SA node fires faster than 100 beats per minute. Bradycardia is defined as a heart rate less than 60 beats per minute. Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate slightly increases during inspiration and slightly slows during exhalation because of changes in vagal tone.
32. Interpret the following rhythm:
a. Normal sinus rhythm
b. Sinus bradycardia
c. Sinus tachycardia
d. Sinus arrhythmia - B
Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P and QRS waves are consistent in shape. Sinus tachycardia results when the SA node fires faster than 100 beats per minute. Bradycardia is defined as a heart rate less than 60 beats per minute. Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate increases slightly during inspiration and slows slightly during exhalation because of changes in vagal tone.
33. Interpret the following rhythm:
a. Sinus rhythm with PACs
b. Normal sinus rhythm
c. Sinus tachycardia
d. Sinus bradycardia - A
The underlying rhythm is identified first. Following this step, the dysrhythmia that is occurring to disrupt the underlying rhythm is then determined. A premature atrial contraction (PAC) is a single ectopic beat arising from atrial tissue, not the sinus node. The PAC occurs earlier than the next normal beat and interrupts the regularity of the underlying rhythm. The P wave of the PAC has a different shape than the sinus P wave because it arises from a different area in the atria; it may follow or be in the T wave of the preceding normal beat. If the early P wave is in the T wave, this T wave will look different from the T wave of a normal beat. Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P and QRS waves are consistent in shape. Sinus tachycardia results when the SA node fires faster than 100 beats per minute. Bradycardia is defined as a heart rate less than 60 beats per minute.
34. Interpret the following rhythm:
a. Atrial flutter with variable conduction
b. Ventricular fibrillation
c. Atrial fibrillation
d. Atrial flutter with RVR (rapid ventricular response) - A
Atrial flutter arises from a single irritable focus in the atria. The atrial focus fires at an extremely rapid, regular rate, between 240 and 320 beats per minute. The P waves are called flutter waves and may have a sawtooth appearance. The ventricular response may be regular or irregular based on how many flutter waves are conducted through the AV node. Atrial flutter with RVR occurs when atrial impulses cause a ventricular response greater than 100 beats per minute. Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction.
35. Interpret the following rhythm:
a. Atrial fibrillation
b. Atrial flutter
c. Atrial flutter with RVR
d. Junctional escape rhythm - A
Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction. The AV node is bombarded with hundreds of atrial impulses and conducts these impulses in an unpredictable manner to the ventricles. The atrial rate may be as high 700 and no discernible P waves can be identified, resulting in a wavy baseline and an extremely irregular ventricular response. Atrial flutter arises from a single irritable focus in the atria. The atrial focus fires at an extremely rapid, regular rate, between 240 and 320 beats per minute. The P waves are called flutter waves and may have a sawtooth appearance. The ventricular response may be regular or irregular based on how many flutter waves are conducted through the AV node. Atrial flutter with RVR occurs when atrial impulses cause a ventricular response greater than 100 beats per minute. A junctional escape rhythm is a ventricular rate between 40 and 60 beats per minute with a regular rhythm. P waves may be absent, inverted, or follow the QRS complex. If a P wave is present before the QRS complex, the PR interval is shortened to less than 0.12 milliseconds. QRS complex is normal.
36. Interpret the following rhythm:
a. Junctional rhythm
b. An accelerated junctional rhythm
c. A junctional tachycardia
d. Atrial fibrillation - A
The normal intrinsic rate for the AV node and junctional tissue is 40 to 60 beats per minute, but rates can accelerate. An accelerated junctional rhythm has a rate between 60 and 100 beats per minute, and the rate for junctional tachycardia is greater than 100 beats per minute. If a P wave precedes QRS, it is inverted or upside down; the P wave may not be visible, or it may follow the QRS. If a P wave is present before the QRS, the PR interval is shortened to less than 0.12 milliseconds. Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction. The AV node is bombarded with hundreds of atrial impulses and conducts these impulses in an unpredictable manner to the ventricles.
37. Interpret the following rhythm:
a. Sinus rhythm with multifocal premature ventricular contractions
b. Sinus rhythm with unifocal premature ventricular contractions
c. Sinus rhythm with bigeminal premature ventricular contractions
d. Sinus rhythm with paired premature ventricular contractions (couplets) - A
A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs arising from multiple foci are not identical and are called multifocal PVCs. PVCs may occur in a predictable pattern, such as every other beat (bigeminal), every third beat (trigeminal), or every fourth beat (quadrigeminal). PVCs can also occur sequentially. Two PVCs in a row are called a pair (or couplets), and three or more in a row are called nonsustained ventricular tachycardia.
38. Interpret the following rhythm:
a. Sinus rhythm with multifocal premature ventricular contractions
b. Sinus rhythm with unifocal premature ventricular contractions
c. Sinus rhythm with trigeminal premature ventricular contractions
d. Sinus rhythm with paired premature ventricular contractions (couplets) - B
A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs arising from multiple foci are not identical and are called multifocal PVCs. PVCs may occur in a predictable pattern, such as every other beat (bigeminal), every third beat (trigeminal), or every fourth beat (quadrigeminal). PVCs also can occur sequentially. Two PVCs in a row are called a pair, and three or more in a row are called nonsustained ventricular tachycardia.
39. Interpret the following rhythm:
a. Sinus rhythm with multifocal premature ventricular contractions
b. Sinus rhythm with unifocal premature ventricular contractions
c. Sinus rhythm with bigeminal premature ventricular contractions
d. Sinus rhythm with paired premature ventricular contractions (couplets) - C
A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs arising from multiple foci are not identical and are called multifocal PVCs. PVCs may occur in a predictable pattern, such as every other beat (bigeminal), every third beat (trigeminal), or every fourth beat (quadrigeminal). PVCs can also occur sequentially. Two PVCs in a row are called a pair (couplet), and three or more in a row are called nonsustained ventricular tachycardia.
40. Interpret the following rhythm:
a. Sinus rhythm with multifocal premature ventricular contractions
b. Sinus rhythm with unifocal premature ventricular contractions
c. Sinus rhythm with bigeminal premature ventricular contractions
d. Sinus rhythm with paired premature ventricular contractions (couplets) - D
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