Chapter 26 Management of Patients With Dysrhythmias and

Conduction Problems

1. The nurse is caring for a patient who has had an ECG. The nurse notes 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 physician that the patient is experiencing a new onset of dysrhythmia.

Ans: A

Feedback:

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.

2. The nurse is analyzing a rhythm strip. What component of the ECG corresponds to the
resting state of the patients heart?

A) P wave

B) T wave

C) U wave

D) QRS complex

Ans: B
 Feedback:

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.

3. The nursing educator is presenting a case study of an adult patient 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

Ans: C

Feedback:

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

4. An adult patient 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.

Ans: C

Feedback:
 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.

5. The nurse is writing a plan of care for a patient with a cardiac dysrhythmia. What would be
the most appropriate goal for the patient?

A) Maintain a resting heart rate below 70 bpm.

B) Maintain adequate control of chest pain.

C) Maintain adequate cardiac output.

D) Maintain normal cardiac structure.

Ans: C

Feedback:

For patient safety, the most appropriate goal is to maintain cardiac output to prevent
worsening complications as a result of decreased cardiac output. A resting rate of less
than 70 bpm is not appropriate for every patient. Chest pain is more closely associated
with acute coronary syndrome than with dysrhythmias. Nursing actions cannot normally
influence the physical structure of the heart.

6. A patient has returned to the cardiac care unit after having a permanent pacemaker
implantation. For which potential complication should the nurse most closely assess this
patient?

A) Chest pain

B) Bleeding at the implantation site

C) Malignant hyperthermia

D) Bradycardia

Ans: B
 Feedback:

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.

7. A patient 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

Ans: A

Feedback:

The identification of VVI indicates ventricular paced, ventricular sensed, inhibited.

8. The nurse is caring for an adult patient who has gone into ventricular fibrillation. When
assisting with defibrillating the patient, what must the nurse do?

A) Maintain firm contact between paddles and patient 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.

Ans: A

Feedback:
 When defibrillating an adult patient, the nurse should maintain good contact between the
paddles and the patients 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.

9. A patient who is a candidate for an implantable cardioverter defibrillator (ICD) asks the nurse
about the purpose of this device. What would be the nurses 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

Ans: A

Feedback:

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.

10. A nurse is providing health education to a patient scheduled for cryoablation therapy. The
nurse should describe what aspect of this treatment?

A) Peeling away the area of endocardium responsible for the dysrhythmia

B) Using electrical shocks directly to the endocarduim to eliminate the source of

dysrhythmia

C) Using high-frequency sound waves to eliminate the source of dysrhythmia

D) Using a cooled probe to eliminate the source of dysrhythmia

Ans: D

Feedback:
 Cryoablation therapy involves using a cooled probe to create a small scar on the
endocardium to eliminate the source of the dysrhythmias. Endocardium resection involves
peeling away a specified area of the endocardium. Electrical ablation involves using
shocks to eliminate the area causing the dysrhythmias. Radio frequency ablation uses
high-frequency sound waves to destroy the area causing the dysrhythmias.

11. The nurse is caring for a patient who has just had an implantable cardioverter defibrillator
(ICD) placed. What is the priority area for the nurses assessment?

A) Assessing the patients activity level

B) Facilitating transthoracic echocardiography

C) Vigilant monitoring of the patients ECG

D) Close monitoring of the patients peripheral perfusion

Ans: C

Feedback:

After a permanent electronic device (pacemaker or ICD) is inserted, the patients heart rate
and rhythm are monitored by ECG. This is a priority over peripheral circulation and
activity. Echocardiography is not indicated.

12. During a patients care conference, the team is discussing whether the patient is a candidate
for cardiac conduction surgery. What would be the most important criterion for a patient to have
this surgery?

A) Angina pectoris not responsive to other treatments

B) Decreased activity tolerance related to decreased cardiac output

C) Atrial and ventricular tachycardias not responsive to other treatments

D) Ventricular fibrillation not responsive to other treatments

Ans: C
 Feedback:

Cardiac conduction surgery is considered in patients who do not respond to medications

and antitachycardia pacing. Angina, reduced activity tolerance, and ventricular fibrillation
are not criteria.

13. A nurse is caring for a patient who is exhibiting ventricular tachycardia (VT). Because the
patient is pulseless, the nurse should prepare for what intervention?

A) Defibrillation

B) ECG monitoring

C) Implantation of a cardioverter defibrillator

D) Angioplasty

Ans: A

Feedback:

Any type of VT in a patient 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.

14. A patient 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 Cardizem
are given. The nurse caring for the patient understands that the main goal of treatment is
what?

A) Decrease SA node conduction

B) Control ventricular heart rate

C) Improve oxygenation

D) Maintain anticoagulation
Ans: B

Feedback:

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.

15. The nurse and the other members of the team are caring for a patient who converted to
ventricular fibrillation (VF). The patient was defibrillated unsuccessfully and the patient
remains in VF. According to national standards, 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

Ans: A

Feedback:

Epinephrine should be administered as soon as possible after the first unsuccessful

defibrillation and then every 3 to 5 minutes. Antiarrhythmic medications such as
amiodarone and licocaine are given if ventricular dysrhythmia persists.

16. The nurse is planning discharge teaching for a patient with a newly inserted permanent
pacemaker. What is the priority teaching point for this patient?

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 high-voltage electrical generators.

D) Avoid walking through store and library antitheft devices.

Ans: C

Feedback:

High-output electrical generators can reprogram pacemakers and should be avoided.

Recent pacemaker technology allows patients 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 patients 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.

17. A patient is brought to the ED and determined to be experiencing symptomatic sinus

bradycardia. The nurse caring for this patient 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.

Ans: A

Feedback:

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.

18. An ECG has been ordered for a newly admitted patient. What should the nurse do prior to
electrode placement?

A) Clean the skin with providone-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.

Ans: D

Feedback:

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.

19. The nurse is caring for a patient who has just undergone catheter ablation therapy. The
nurse in the stepdown unit should prioritize what assessment?

A) Cardiac monitoring

B) Monitoring the implanted device signal

C) Pain assessment

D) Monitoring the patients level of consciousness (LOC)

Ans: A

Feedback:

Following catheter ablation therapy, the patient 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.

20. The ED nurse is caring for a patient 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 patient at the time shock is delivered.

C) Continue to ventilate the patient via endotracheal tube during the procedure.

D) Allow at least 3 minutes between shocks.

Ans: B

Feedback:

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
patients skin to prevent leaking. Second, ensure that no one is in contact with the patient
or with anything that is touching the patient when the defibrillator is discharged, to
minimize the chance that electrical current will be conducted to anyone other than the
patient. Ventilation should be stopped during defibrillation.

21. A group of nurses are participating in orientation to a telemetry unit. What should the staff
educator tell this class about ST segments?

A) They are the part of an ECG that reflects systole.

B) They are the part of an ECG used to calculate ventricular rate and rhythm.

C) They are the part of an ECG that reflects the time from ventricular depolarization
through repolarization.

D) They are the part of an ECG that represents early ventricular repolarization.

Ans: D

Feedback:

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.
22. The nurse is providing care to a patient who has just undergone an electrophysiologic (EP)
study. The patient states that she is nervous about things going wrong during the
procedure. What is the nurses best response?

A) This is basically a risk-free procedure.

B) Thousands of patients 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.

Ans: D

Feedback:

Patients who are to undergo an EP study may be anxious about the procedure and its
outcome. A detailed discussion involving the patient, the family, and the
electrophysiologist usually occurs to ensure that the patient can give informed consent
and to reduce the patients 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 patients anxiety.
Characterizing EP as a step toward good health does not directly address the patients
anxiety.

23. New nurses on the telemetry unit have been paired with preceptors. One new nurse asks

her preceptor to explain depolarization. What would be the best answer by the preceptor? A)

Depolarization is the mechanical contraction of the heart muscles.

B) Depolarization is the electrical stimulation of the heart muscles.

C) Depolarization is the electrical relaxation of the heart muscles.

D) Depolarization is the mechanical relaxation of the heart muscles.

Ans: B

Feedback:
 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.

24. A cardiac care nurse is aware of factors that result in positive chronotropy. These factors
would affect a patients cardiac function in what way?

A) Exacerbating an existing dysrhythmia

B) Initiating a new dysrhythmia

C) Resolving ventricular tachycardia

D) Increasing the heart rate

Ans: D

Feedback:

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

25. The nurse is caring for a patient with refractory atrial fibrillation who underwent the
maze procedure several months ago. The nurse reviews the result of the patients most
recent cardiac imaging, which notes the presence of scarring on the atria. How should the
nurse best respond to 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 patient for pacemaker implantation.

Ans: B

Feedback:
 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.

26. A patient is scheduled for catheter ablation therapy. When describing this procedure to the
patients family, the nurse should address what aspect of the treatment?

A) Resetting of the hearts contractility

B) Destruction of specific cardiac cells

C) Correction of structural cardiac abnormalities

D) Clearance of partially occluded coronary arteries

Ans: B

Feedback:

Catheter ablation destroys specific cells that are the cause or central conduction route of a
tachydysrhythmia. It does not reset the hearts contractility and it does not address
structural or vascular abnormalities.

27. A patient has undergone diagnostic testing and received a diagnosis of sinus bradycardia
attributable to sinus node dysfunction. When planning this patients care, what nursing
diagnosis is most appropriate?

A) Acute pain

B) Risk for unilateral neglect

C) Risk for activity intolerance

D) Risk for fluid volume excess

Ans: C
 Feedback:

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.

28. The nurse is caring for a patient on telemetry. The patients ECG shows a shortened PR
interval, slurring of the initial QRS deflection, and prolonged QRS duration. What does this
ECG show?

A) Sinus bradycardia

B) Myocardial infarction

C) Lupus-like syndrome

D) Wolf-Parkinson-White (WPW) syndrome

Ans: D

Feedback:

In WPW syndrome there is a shortened PR interval, slurring (called a delta wave) of the
initial QRS deflection, and prolonged QRS duration. These characteristics are not typical
of the other listed cardiac anomalies.

29. A patient 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 nurses
responsibility in the care of the patients 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

Ans: A
 Feedback:

Monitoring for pacemaker malfunctioning and battery failure is a nursing responsibility. The
other listed actions are physician responsibilities.

30. The nurse caring for a patient whose sudden onset of sinus bradycardia is not responding
adequately to atropine. What might be the treatment of choice for this patient?

A) Implanted pacemaker

B) Trancutaneous pacemaker

C) ICD

D) Asynchronous defibrillator

Ans: B

Feedback:

If a patient suddenly develops a 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.

31. The nurse is caring for a patient 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

Ans: C
 Feedback:

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.

32. Following cardiac resuscitation, a patient has been placed in a state of mild hypothermia
before being transferred to the cardiac intensive care unit. The nurses assessment reveals
that the patient is experiencing neuromuscular paralysis. How should the nurse best
respond? A) Administer hypertonic IV solution.

B) Administer a bolus of warned normal saline.

C) Reassess the patient in 15 minutes.

D) Document this as an expected assessment finding.

Ans: D

Feedback:

The nurse caring for a patient with hypothermia (passive or induced) needs to monitor for
appropriate level of cooling, sedation, and neuromuscular paralysis to prevent seizures;
myoclonus; and shivering.

Neuromuscular paralysis is an expected finding and does not necessitate further

interventions.

33. The nurse is caring for a patient who has had a biventricular pacemaker implanted. When
planning the patients care, the nurse should recognize what goal of this intervention?

A) Resynchronization

B) Defibrillation

C) Angioplasty
D) Ablation

Ans: A

Feedback:

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.

34. When planning the care of a patient 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

Ans: B

Feedback:

For patients 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.

35. The nurse is assessing a patient who had a pacemaker implanted 4 weeks ago. During the
patients most recent follow-up appointment, the nurse identifies data that suggest the
patient 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

Ans: D

Feedback:

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 patients challenges.

36. The nurse is caring for a patient who is in the recovery room following the implantation of an
ICD. The patient has developed ventricular tachycardia (VT). What should the nurse assess and
document?

A) ECG to compare time of onset of VT and onset of devices shock

B) ECG so physician can see what type of dysrhythmia the patient has

C) Patients level of consciousness (LOC) at the time of the dysrhythmia

D) Patients activity at time of dysrhythmia

Ans: A

Feedback:

If the patient 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 devices shock or antitachycardia pacing. This is a priority over LOC or activity at the
time of onset.

37. 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 patients 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.

Ans: B

Feedback:

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.

38. During a CPR class, a participant asks about the difference between cardioversion and
defibrillation. What would be the instructors 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.

Ans: B

Feedback:

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 patients 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.

39. A patient is admitted to the cardiac care unit for an electrophysiology (EP) study. What

goal should guide the planning and execution of the patients care? A) Ablate the area

causing the dysrhythmia.

B) Freeze hypersensitive cells.

C) Diagnose the dysrhythmia.

D) Determine the nursing plan of care.

Ans: C

Feedback:

A patient may undergo an EP study in which electrodes are placed inside the heart to
obtain an intracardiac ECG. This is used not only to diagnose the dysrhythmia but also to
determine the most effective treatment plan. However, because an EP study is invasive, it
is performed in the hospital and may require that the patient be admitted.

40. A patient calls his cardiologists office and talks to the nurse. He is concerned because he
feels he is being defibrillated too often. The nurse tells the patient to come to the office to
be evaluated because the nurse knows that the most frequent complication of ICD therapy
is what?

A) Infection

B) Failure to capture

C) Premature battery depletion

D) Oversensing of dysrhythmias

Ans: D

Feedback:

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.