Appendices and index

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Practice makes perfect

1.You’re caring for a patient with a history of mitral valve prolapse. Based on your knowledge of the heart’s anatomy, you know that the mitral valve is located:

A.between the left atrium and left ventricle.

B.where the left ventricle meets the aorta.

C.between the right atrium and right ventricle.

D.between the right ventricle and pulmonary artery.

2.A 45-year-old patient is admitted to your floor for observation after undergoing cardiac catheterization. His test results reveal a blockage in the circumflex artery. The circumflex artery supplies oxygenated blood to which area of the heart?

A.Anterior wall of the left ventricle

B.Left atrium

C.Right bundle branch

D.Right ventricle

3.Which of the following choices is responsible for slowing heart rate?

A.Norepinephrine (Levophed)

B.Vagus nerve

C.Epinephrine

D.Isoproterenol (Isuprel)

4.Which cycle describes cardiac cells at rest?

A.Early repolarization

B.Polarization

C.Rapid depolarization

D.Absolute refractory period

5.A patient admitted with an acute myocardial infarction (MI) complains of chest pain. When you look at his ECG monitor, you note a heart rate of 35 beats/minute. Which area of his heart has taken over as the heart’s pacemaker?

A.Sinoatrial (SA) node

B.Atrioventricular (AV) node

C.Bundle of His

D.Purkinje fibers

6.Which lead on a cardiac monitor is equivalent to V1 on a

12-lead ECG?

A.Lead I

B.Lead MCL6

C.Lead aVF

D.Lead MCL1

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12.A 72-year-old patient calls you to his room because he’s experiencing substernal chest pain that radiates to his jaw. You record a rhythm strip and monitor his vital signs. Which portion of the patient’s ECG complex may become elevated or depressed indicating myocardial damage?

A.T wave

B.ST segment

C.QRS complex

D.P wave

13.A 76-year-old patient with heart failure is receiving furosemide (Lasix) 40 mg I.V. twice daily. When you look at his rhythm strip, you note prominent U waves. Which condition may have caused U waves to appear on your patient’s rhythm strip?

A.Hypokalemia

B.Hypocalcemia

C.Worsening heart failure

D.Pericarditis

14.An 80-year-old patient with a history of atrial fibrillation is admitted with digoxin toxicity. When you assess his rhythm strip using the 10-times method, you note that his heart rate is 40 beats/ minute. Based on this finding, you should:

A.check the patient’s pulse and correlate it with the heart rate on the rhythm strip.

B.recheck the heart rate on the rhythm strip using the sequence method.

C.record another rhythm strip and reassess the heart rate on the rhythm strip.

D.recheck the heart rate on the rhythm strip using the 1,500 method.

15.A patient with a history of paroxysmal atrial tachycardia develops digoxin toxicity. Because digoxin toxicity may cause prolongation of the PR interval, you must monitor his rhythm strip closely. What’s the duration of a normal PR interval?

A.0.06 to 0.10 second

B.0.12 to 0.20 second

C.0.24 to 0.30 second

D.0.36 to 0.44 second

16.A patient is admitted to your telemetry unit with a diagnosis of sick sinus syndrome. Which medication should you keep readily available to treat a symptomatic event?

A.Isoproterenol (Isuprel)

B.Verapamil (Calan)

C.Lidocaine

D.Atropine

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21.A patient diagnosed with heart failure is admitted to your telemetry unit. He complains of seeing yellow-green halos around visual images. He also states that he’s been nauseated and unable to eat for the past few days. Based on these findings you suspect:

A.digoxin toxicity.

B.atrial fibrillation.

C.worsening heart failure.

D.MI.

22.A patient returns to your unit after cardiac surgery. As you perform your assessment of the patient, you note that his cardiac monitor shows atrial fibrillation at a rate of 160 beats/minute. The patient suddenly begins complaining of chest pain. Based on these findings, what’s the best treatment?

A.Digoxin (Lanoxin) administration

B.Defibrillation

C.Cardioversion

D.Flecainide (Tambocor) administration

23.A 32-year-old patient with a history of Wolff-Parkinson- White (WPW) syndrome is admitted to your floor after gallbladder surgery. Which ECG characteristics are typical in a patient with WPW syndrome?

A.Prolonged PR interval and narrowed QRS complex

B.Prolonged PR interval and presence of a delta wave

C.Shortened PR interval and narrowed QRS complex

D.Widened QRS complex and presence of a delta wave

24.A 68-year-old patient with a history of heart failure is receiving digoxin (Lanoxin). At the beginning of your shift, you record the patient’s rhythm strip shown below. You interpret this rhythm as:

A.junctional tachycardia.

B.wandering pacemaker.

C.accelerated junctional rhythm.

D.sinus tachycardia.

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29. A patient with a low magnesium level develops an arrhythmia. You record the rhythm strip shown below and identify the arrhythmia as:

A.monomorphic ventricular tachycardia.

B.ventricular fibrillation.

C.paroxysmal supraventricular tachycardia.

D.torsades de pointes.

30.A patient with an acute anterior wall MI develops thirddegree heart block. His blood pressure is 78/44 mm Hg, and he’s complaining of dizziness. You should immediately administer atropine and:

A.follow with a dose of isoproterenol (Isuprel).

B.apply a transcutaneous pacemaker.

C.place the patient in Trendelenburg’s position.

D.prepare for synchronized cardioversion.

31.An 86-year-old patient is found in his apartment without heat on a cold winter day. He’s admitted to your unit with hypothermia. You begin cardiac monitoring, which displays the rhythm shown below. You document this strip as:

A.normal sinus rhythm with first-degree AV block.

B.type 1 second-degree AV block.

C.sinus tachycardia.

D.junctional tachycardia.

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35.When teaching a patient with a newly inserted permanent pacemaker, you should:

A.advise him to avoid computed tomography scans.

B.tell him that hiccups are normal for the first few days after pacemaker insertion.

C.instruct him to avoid tight clothing.

D.explain that magnetic resonance imaging scans are safe.

36.You’re caring for a 75-year-old patient who’s receiving oral procainamide to control supraventricular tachycardia. Before discharge, you should instruct the patient:

A.to avoid chewing the drug, which may cause him to get too much of the drug at once.

B.that lupus-like symptoms are normal and will cease 2 to 3 weeks after initiation of therapy.

C.that a bitter taste is common.

D.that he may crush the extended-release tablet if it’s difficult to swallow.

37.A patient returns to your floor from the postanesthesia care unit after undergoing a right lower lobectomy. When you begin cardiac monitoring, you note the rhythm strip shown below. Which drug will the practitioner most likely prescribe to rapidly convert this rhythm?

A.Propafenone (Rhythmol)

B.Tocainide (Tonocard)

C.Procainamide

D.Ibutilide (Corvert)

38. After receiving quinidine, you note that your patient develops a prolonged QT interval on his rhythm strip. You notify the practitioner immediately because you know that prolongation of the QT interval places the patient at risk for what?

A.Atrial fibrillation

B.Junctional tachycardia

C.Polymorphic ventricular tachycardia

D.Atrial flutter

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43.The practitioner orders a signal-averaged ECG for a patient who sustained an acute MI. Why is this test typically ordered?

A.To locate posterior wall damage

B.To identify whether the patient is at risk for sudden death from sustained ventricular tachycardia

C.To identify whether the patient has suffered damage to his right ventricle

D.To identify left bundle-branch block in an anterior wall MI

44.You’re caring for a patient with a history of angina who

calls you into his room because he’s experiencing chest pain. His admission orders included a 12-lead ECG with each episode of chest pain. You immediately retrieve the ECG machine. To ensure proper placement, where should you place lead V1?

A.Over the fourth intercostal space at the right sternal border

B.Over the fourth intercostal space at the left sternal border

C.Over the fifth intercostal space at the left anterior axillary line

D.Over the fifth intercostal space at the left midclavicular line

45.A 12-lead ECG is ordered for a 32-year-old patient who comes to the ED complaining of chest pain. You know that a 12lead ECG is necessary to assess conduction of the:

A.right ventricle.

B.right and left ventricles.

C.left ventricle.

D.right and left atria.

46.You’re caring for a 72-year-old patient admitted with unstable angina. He calls you into his room and complains of chest pain that he rates an 8 on a scale of 0 to 10 (10 being the worst). You immediately obtain a 12-lead ECG. Which ECG change would you expect with angina?

A.Pathologic Q wave

B.T-wave inversion

C.Widened QRS complex

D.Poor R wave progression

47.A patient’s 12-lead ECG reveals left axis deviation. When is left axis deviation considered normal?

A.In infants

B.In small children

C.In pregnant women

D.In healthy adults

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53. As part of a preoperative assessment, you begin preparation for a 12-lead ECG. Using the figure below, identify the area on the patient’s chest where you would place lead V1.

54. While interpreting the rhythm strip shown below for a patient who was just admitted to the telemetry unit, you document the PR interval as how many seconds?

_____________________________________ seconds

Answers

1.A. The bicuspid valve, commonly called the mitral valve is located between the left atrium and left ventricle.

2.B. The circumflex artery supplies oxygenated blood to the lateral walls of the ventricle, the left atrium, and the left posterior fasciculus of the left bundle branch.

3. B. The vagus nerve carries impulses that slow the heart rate and the conduction of impulses through the AV node and ventricles.

4.B. Polarization describes cardiac cells at rest.

5.D. If the Purkinje fibers take over as the heart’s pacemaker, impulses are typically discharged at a rate of 20 to 40 beats per minute.

6.D. Lead MCL1 is the equivalent to V1 on a 12-lead ECG.

7.A. The six limb leads—leads I, II, III, aVR, aVL, and aVF— provide information about the heart’s frontal plane.

8.A. Before initiating cardiac monitoring, you must first prepare the patient’s skin. Use a special rough patch on the back of the electrode, a dry washcloth, or a gauze pad to briskly rub each site until the skin reddens.

9.A. Electrical interference appears on the ECG as a baseline that’s thick and unreadable. Electrical interference is caused by electrical power leakage. It may also occur due to interference from other equipment in the room or improperly grounded equipment.

10.B. The horizontal axis of the ECG strip represents time.

11.C. Using the 8-step method of rhythm strip interpretation, you should check the rhythm first and then calculate the rate. Next, evaluate the P wave, check out the PR interval and the QRS complex, examine the T wave, measure the QT interval and, finally, check for ectopic beats and other abnormalities.

12.B. A change in the ST segment may indicate myocardial damage. An ST segment may become either elevated or depressed.

13.A. A U wave isn’t present on every rhythm strip. A prominent U wave may be due to hypokalemia, hypercalcemia, or digoxin toxicity.

14.A. Although you can use the 10-times method, the 1,500 method, or the sequence method to determine heart rate, you shouldn’t rely on these methods. Always check a pulse to correlate it with the heart rate on the ECG.

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41.B. The 12 leads include three bipolar limb leads (I, II, and III),

three unipolar augmented limb leads (aVR, aVL, and aVF) and six unipolar precordial leads (V1, V2, V3, V4, V5, and V6).

42.D. Lead I views the lateral wall of the heart.

43.B. Signal-averaged ECG helps identify patients at risk for sudden death from sustained ventricular tachycardia. The test uses a computer to identify late electrical potentials that can’t be detected by a 12-lead ECG.

44.A. Lead V1 should be placed over the fourth intercostal space at the right sternal border.

45.C. A 12-lead ECG is used to assess left ventricular conduction activity. A right-sided ECG is necessary to assess right ventricular conduction activity.

46.B. Classic ECG changes associated with angina include a peaked T wave, flattened T wave, T-wave inversion, ST-segment depression with T-wave inversion, and ST-segment depression without T-wave inversion.

47.C. Left axis deviation is a normal finding in pregnant women. Right axis deviation is normal in infants and small children.

48.D. Unstable angina is more easily provoked and may occur while the patient is sleeping, causing him to awaken. It’s also unpredictable and tends to worsen over time. In stable angina, pain is triggered by exertion or stress and is commonly relieved by rest. Each episode follows a similar pattern.

49.A. The area of myocardial necrosis is called the zone of infarction. The ECG change associated with a necrotic area is a pathologic Q wave. The zone of injury shows up on an ECG as an elevated ST segment. The zone of ischemia is represented by T-wave inversion.

50.A. After you identify a bundle-branch block, examine lead V1, which lies to the right of the heart, and lead V6, which lies to the left of the heart. These leads will tell you if the block is in the right

or left bundle.

51.D. The rhythm strip reveals third-degree AV block. Characteristics of this arrhythmia include a regular atrial rhythm along with a regular but slow ventricular rhythm, an absence of a relationship between P waves and QRS complexes, and P and R waves that march across the strip in rhythm.