1. A nurse is assessing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats per minute. The nurse assesses the cardiac rhythm as:
A. Normal sinus rhythm
B. Sinus bra...
DYSRYTHMIA NURSING STUDENT STUDY BLOG NCLEX
1. A nurse is assessing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats per minute. The nurse assesses the cardiac rhythm as:
A. Normal sinus rhythm
B. Sinus bradycardia
C. Sick sinus syndrome
D. First-degree heart block. - correct answer 1. measurements are normal, measuring 0.12 to 0.20 second and 0.4 to 0.10 second, respectively.
2 A nurse notices frequent artifact on the ECG monitor for a client whose leads are connected by cable to a console at the bedside. The nurse examines the client to determine the cause. Which of the following items is unlikely to be responsible for the artifact?
1. Frequent movement of the client
2. Tightly secured cable connections
3. Leads applied over hairy areas
4. Leads applied to the limbs - correct answer 2. Motion artifact, or "noise," can be caused by frequent client movement, electrode placement on limbs, and insufficient adhesion to the skin, such as placing electrodes over hairy areas of the skin. Electrode placement over bony prominences also should be avoided. Signal interference can also occur with electrode removal and cable disconnection.
3. A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but over 100. The nurse determines that the client is experiencing:
1. Premature ventricular contractions
2. Ventricular tachycardia
3. Ventricular fibrillation
4. Sinus tachycardia - correct answer 2. Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (usually greater than 0.14 second), and a rate between 100 and
250 impulses per minute. The rhythm is usually regular.
4. A nurse is viewing the cardiac monitor in a client's room and notes that the client has just gone into ventricular tachycardia. The client is awake and alert and has good skin color. The nurse would prepare to do which of the following?
1. Immediately defibrillate
2. Prepare for pacemaker insertion
3. Administer amiodarone (Cordarone) intravenously
4. Administer epinephrine (Adrenaline) intravenously - correct answer 3. First-line treatment of ventricular tachycardia in a client who is hemodynamically stable is the use of anti-dysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm (cardioversion is recommended for stable ventricular tachycardia). Defibrillation is used with pulseless ventricular tachycardia. Epinephrine would stimulate and already excitable ventricle and is contraindicated.
5. A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs the client to do which of the following, if prescribed, during an episode of ventricular tachycardia?
1. Breathe deeply, regularly, and easily.
2. Inhale deeply and cough forcefully every 1 to 3 seconds.
3. Lie down flat in bed
4. Remove any metal jewelry - correct answer 2. Cough cardiopulmonary resuscitation (CPR) sometimes is used in the client with unstable ventricular tachycardia. The nurse tells the client to
use cough CPR, if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds. Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented.
6. A client is having frequent premature ventricular contractions. A nurse would place priority on assessment of which of the following items?
1. Blood pressure and peripheral perfusion
2. Sensation of palpitations
3. Causative factors such as caffeine
4. Precipitating factors such as infection - correct answer 1. Premature ventricular contractions can cause hemodynamic compromise. The shortened ventricular filling time with the ectopic beats leads to decreased stroke volume and, if frequent enough, to decreased cardiac output. The client may be asymptomatic or may feel palpations. PVCs can be caused by cardiac disorders
or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by the intake of caffeine, alcohol, or nicotine.
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