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Chapter 26

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
Ans: A
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
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
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
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
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
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
The identification of VVI indicates ventricular paced, ventricular sensed,
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
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
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
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
D) Using a cooled probe to eliminate the source of dysrhythmia
Ans: D
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
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
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
A) Defibrillation
B) ECG monitoring
C) Implantation of a cardioverter defibrillator
D) Angioplasty
Ans: A
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
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
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
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
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
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
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
D) Gently abrade the skin by rubbing the electrode sites with dry gauze or
Ans: D
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 step-down 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
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
D) Allow at least 3 minutes between shocks.
Ans: B
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
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
Ans: D
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
D) The whole team will be monitoring you very closely for the entire
Ans: D
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
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
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
D) Prepare the patient for pacemaker implantation.
Ans: B
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
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
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
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
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
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
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
D) Asynchronous defibrillator
Ans: B
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
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
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
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
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
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
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
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
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
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
A) Ablate the area causing the dysrhythmia.
B) Freeze hypersensitive cells.
C) Diagnose the dysrhythmia.
D) Determine the nursing plan of care.
Ans: C
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
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.