Question 1. When caring for a client with a biventricular pacemaker, which nursing action is
most likely to lead to serious complications?
1. Monitoring the client’s heart rate (HR) and blood pressure (BP)
2. Maintaining continuous cardiac monitoring
3. Placing defibrillation pads over the pacemaker
4. Monitoring the incision site of the client
Rationales
Option 1: To ensure that the pacemaker is functioning properly, the nurse should monitor
the client’s HR and BP as a small change in vital signs may lead to complications.
Option 2: To ensure detection of a rhythm change or pacer failure, the nurse should
maintain continuous cardiac monitoring.
Option 3: The nurse should not place the defibrillation pads over the pacemaker as it may increase
the client’s discomfort and can lead to serious complications.
Option 4: To prevent infections at the site, the nurse should monitor the incision site of
the internal pacemaker.
Course Topic: Dysrhythmias Concept(s): Nursing Cognitive Level: Application [Applying]
Client Need: Physiological Integrity: Basic Care and Comfort
Question 2. Which is true regarding treatments for ventricular fibrillation (VF)?
1. Provide light chest compressions at a rate of more than 120 bpm.
2. Switch compressors every 5 minutes.
3. Perform defibrillation within 2 to 3 minutes of onset of VF.
, 4. Stop chest compressions for no more than 5 minutes.
Rationales
Option 1:To get the best result, the chest compressions should be at least two inches deep in an adult
and fast, at a rate of at least of 100 bpm, but no more than 120 bpm.
Option 2:To limit fatigue and maintain continuous high quality cardiopulmonary resuscitation, compressors
should be switched every 2 minutes.
Option 3:To get the best survival result, defibrillation should be performed within 2 to 3 minutes of the onset
of VF.
Option 4:To prevent further complications, chest compressions should not be stopped for longer than 10
seconds. It should only be stopped when applying external defibrillation pads and when discharging the
electrical impulse from the defibrillator.
Course Topic: DysrhythmiasConcept(s): NursingCognitive Level: Application [Applying]
Client Need: Physiological Integrity: Basic Care and Comfort
Question 3. Which describes unifocal premature ventricular contractions (PVCs)?
1. It refers to PVCs that occur every other beat.
2. It refers to PVCs that are falling after every third beat.
3. It refers to two PVCs in a row.
4. It refers to PVCs that are coming from one ventricular pacemaker cell.
Rationales
Option 1:
When PVCs occur every other beat, it is known as bigeminy.
Option 2:
When PVCs fall after every third beat, it is known as trigeminy.
Option 3:
When two PVCs occur in a row, it is known as couplet.
Option 4:
Unifocal PVCs are triggered from one ventricular pacemaker cell.
Course Topic: Dysrhythmias Concept(s): Nursing
Cognitive Level: Knowledge [Remembering]
Client Need: Physiological Integrity: Basic Care and Comfort
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