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The nurse is caring for a patient who has a normal cardiac rhythm and a heart rate of 72 beats/minute, except that the P-R interval is 0.24 seconds. Which of the following actions should the nurse implement?
- A. Notify the patient's health care provider immediately.
- B. Administer atropine per agency bradycardia protocol.
- C. Prepare the patient for temporary pacemaker insertion.
- D. Document the finding and continue to monitor the patient.
Correct Answer: D
Rationale: First-degree atrioventricular (AV) block is asymptomatic and requires ongoing monitoring because it may progress to more serious forms of heart block. The rate is normal, so there is no indication that atropine is needed. Immediate notification of the health care provider about an asymptomatic rhythm is not necessary.
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Which of the following information will the nurse include when teaching a patient who is scheduled to have a permanent pacemaker inserted for treatment of chronic atrial fibrillation with slow ventricular response?
- A. The pacemaker prevents or minimizes ventricular irritability.
- B. The pacemaker paces the atria at rates up to 500 impulses/minute.
- C. The pacemaker discharges if ventricular fibrillation and cardiac arrest occur.
- D. The pacemaker stimulates a heartbeat if the patient's heart rate drops too low.
Correct Answer: D
Rationale: The permanent pacemaker will discharge when the ventricular rate drops below the set rate. The pacemaker will not decrease ventricular irritability or discharge if the patient develops ventricular fibrillation. Since the patient has a slow ventricular rate, overdrive pacing will not be used.
The nurse has received change-of-shift report about the following patients on the telemetry unit. Which of the following patients should the nurse see first?
- A. A patient with atrial fibrillation, rate 88, who has a new order for warfarin
- B. A patient with type 1 second-degree atrioventricular (AV) block, rate 60, who is dizzy when ambulating
- C. A patient who is in a sinus rhythm, rate 98, after having electrical cardioversion 2 hours ago
- D. A patient whose implantable cardioverter-defibrillator (ICD) fired three times today who has a dose of amiodarone due
Correct Answer: D
Rationale: The frequent firing of the ICD indicates that the patient's ventricles are very irritable, and the priority is to assess the patient and administer the amiodarone. The other patients may be seen after the amiodarone is administered.
The nurse is caring for a patient who is on the telemetry unit and develops atrial flutter, rate 150, with associated dyspnea and diaphoresis, with an oxygen saturation of 94%. Which of the following actions that are included in the hospital dysrhythmia protocol should the nurse take first?
- A. Obtain a 12-lead electrocardiogram (ECG).
- B. Give O2 via nasal cannula at 3-4 L/minute.
- C. Take the patient's blood pressure and respiratory rate.
- D. Notify the health care provider of the change in rhythm.
Correct Answer: B
Rationale: Since this patient has dyspnea in association with the new rhythm, the nurse's initial actions should be to ensure a patent airway and oxygen administration. The other actions also are important and should be implemented rapidly.
The nurse needs to estimate quickly the heart rate for a patient with a regular heart rhythm. Which of the following methods is best to use?
- A. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes
- B. Count the number of large squares in the R-R interval and divide by 100.
- C. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.
- D. Calculate the number of small squares between one QRS complex and the next and divide into 1500.
Correct Answer: C
Rationale: This is the quickest way to determine the ventricular rate for a patient with a regular rhythm. All the other methods are accurate, but take longer.
The nurse is providing instruction to a patient on the management of a new implantable cardioverter-defibrillator (ICD). Which of the following patient statements indicate that the teaching has been effective?
- A. It will be 6 weeks before I can take a bath or return to my usual activities.
- B. I will notify the airlines when I make a reservation that I have a pacemaker.
- C. I won't lift the arm on the pacemaker side up very high until I see the doctor.
- D. I must avoid cooking with a microwave oven or being near a microwave in use.
Correct Answer: C
Rationale: The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The patient should notify airport security about the presence of a pacemaker before going through the metal detector, but there is no need to notify the airlines when making a reservation. Microwave oven use does not affect the pacemaker. The insertion procedure involves minor surgery that will have a short recovery period.