ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 38 Questions
Question 1 of 5
The nurse is interpreting an ECG strip to determine whether there is a delay in impulse conduction above the ventricles. Which of the following components of an ECG strip should the nurse measure?
Correct Answer: B
Rationale: The P-R interval represents depolarization of the atria, atrioventricular (AV) node, bundle of His, bundle branches, and the Purkinje fibres. The QRS represents ventricular depolarization. The Q-T interval represents depolarization and repolarization of the entire conduction system.
Question 2 of 5
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?
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.
Question 3 of 5
A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of how many beats/minute?
Correct Answer: B
Rationale: If the sinoatrial (S
A) node fails to discharge, the atrioventricular (AV) node will automatically discharge at the normal rate of 40-60. The slower rates are typical of the bundle of His and the Purkinje system and may be seen with failure of both the SA and AV nodes to discharge. The normal SA node rate is 60-100 beats/minute.
Question 4 of 5
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?
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.
Question 5 of 5
The nurse notes that a patient's cardiac monitor shows that every other beat is earlier than expected, has no P wave, and has a QRS complex with a wide and bizarre shape. How should the nurse document the rhythm?
Correct Answer: B
Rationale: Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking. Pairs of wide QRS complexes are described as couplets. There is no indication that the premature ventricular contractions (PVCs) are multifocal or that the R-on-T phenomenon is occurring.