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The nurse is caring for a patient whose cardiac monitor shows sinus rhythm, rate 60-70. The P-R interval is 0.18 seconds at 1:00 A.M., 0.20 seconds at 2:30 P.M., and 0.23 seconds at 4:00 P.M. Which of the following actions should the nurse take at this time?
- A. Prepare for possible temporary pacemaker insertion.
- B. Administer atropine sulphate 1 mg IV per agency protocol.
- C. Document the patient's rhythm and assess the patient's response to the rhythm.
- D. Hold the dose of metoprolol and call the health care provider.
Correct Answer: D
Rationale: The patient has progressive first-degree atrioventricular (AV) block, and the β-blocker should be held until discussing the medication with the health care provider. Documentation and assessment are appropriate but not fully adequate responses. The patient with first-degree AV block usually is asymptomatic, and a pacemaker is not indicated. Atropine is sometimes used for symptomatic bradycardia, but there is no indication that this patient is symptomatic.
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Which of the following actions by a new nurse who is caring for a patient who has just had an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more education about care of patients with ICDs?
- A. The nurse assists the patient to do active range-of-motion exercises for all extremities.
- B. The nurse assists the patient to fill out the application for obtaining a Medic Alert ID and bracelet.
- C. The nurse gives atenolol to the patient without consulting first with the health care provider.
- D. The nurse teaches the patient that sexual activity usually can be resumed once the surgical incision is healed.
Correct Answer: A
Rationale: The patient should avoid moving the arm on the ICD insertion site until healing has occurred in order to prevent displacement of the ICD leads. The other actions by the new nurse are appropriate for this patient.
The nurse is caring for a patient who was admitted with a myocardial infarction and experiences a 50-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute. Which of the following actions should the nurse take next?
- A. Notify the health care provider.
- B. Perform synchronized cardioversion.
- C. Administer the PRN IV lidocaine.
- D. Document the rhythm and monitor the patient.
Correct Answer: C
Rationale: The burst of sustained ventricular tachycardia indicates that the patient has significant ventricular irritability, and antidysrhythmic medication administration is needed to prevent further episodes and accelerate repolarization. The nurse should notify the health care provider after the medications are administered. Defibrillation is not indicated given that the patient is currently in a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation.
Which of the following laboratory results for a patient whose cardiac monitor shows multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider?
- A. Blood glucose 12.8 mmol/L
- B. Serum chloride 90 mmol/L
- C. Serum sodium 133 mmol/L
- D. Serum potassium 2.8 mmol/L
Correct Answer: D
Rationale: Electrolyte imbalances increase the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation; the health care provider will need to prescribe a potassium infusion to correct this hypokalemia. Although the other laboratory values also are abnormal, they are not likely to be the etiology of the patient's PVCs and do not require immediate correction.
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.
The nurse obtains a monitor strip on a patient who has had a myocardial infarction and makes the following analysis. P wave not apparent, ventricular rate 162, R-R interval regular, P-R interval not measurable, and QRS complex wide and distorted, QRS duration 0.18 second. Which of the following cardiac rhythms should the nurse interpret from these findings?
- A. Atrial fibrillation
- B. Sinus tachycardia
- C. Ventricular fibrillation
- D. Ventricular tachycardia
Correct Answer: D
Rationale: The absence of P waves, wide QRS, rate >150, and the regularity of the rhythm indicate ventricular tachycardia. Atrial fibrillation is grossly irregular, has a narrow QRS configuration, and has fibrillatory atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration.