# NCLEX-RN & EKG / ECG — Cardiac Rhythms, Dysrhythmias, Pacemakers & ACLS Nursing Interventions

> Essential EKG strip interpretation and NCLEX cardiac care: sinus rhythms, atrial fibrillation/flutter, ventricular tachycardia/fibrillation, AV heart blocks, pacemaker spike evaluation, and ACLS algorithms.

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- **Level:** basic
- **Languages:** en → en
- **Total Cards:** 32

## Flashcards (32 Cards)

| # | Front (Term / Prompt) | Back (Definition / Answer) | Example | Multiple-Choice Options |
| :--- | :--- | :--- | :--- | :--- |
| 1 | What is the dosing protocol for Amiodarone in adult pulseless VT and VF cardiac arrest? | First dose: 300 mg IV/IO push administered after the third defibrillation shock during CPR. Second dose: 150 mg IV/IO push administered after the next shock cycle if VF/pVT persists (alternative drug: Lidocaine 1–1.5 mg/kg initial dose). |  |  |
| 2 | What are the indications for Defibrillation and what safety command must the nurse vocalize? | Indications: Pulseless Ventricular Tachycardia (pVT) and Ventricular Fibrillation (VF). Safety: The nurse must look visually from top to bottom of the bed and loudly command 'CLEAR!' to ensure nobody is touching the client, bed, or connected equipment before pressing the shock discharge buttons. |  |  |
| 3 | What are the proper anatomical positions for applying external defibrillation / cardioversion pads? | Anterolateral (most common): One pad placed on right upper anterior chest below clavicle, second pad placed lateral to left nipple in mid-axillary line. Anteroposterior (alternative): One pad over anterior left precordium, second pad on back beneath left scapula (preferred in pediatric or hairy chests). |  |  |
| 4 | What is the ACLS protocol for Asystole and why must defibrillation NEVER be performed? | EKG shows complete absence of ventricular electrical activity (flat line). Confirm in 2 leads and check connections. Protocol: High-quality CPR, Epinephrine 1 mg IV/IO every 3–5 minutes, advanced airway, and identify reversible causes (Hs & Ts). Defibrillation is contraindicated because there is no electrical activity to depolarize. |  |  |
| 5 | What is Torsades de Pointes, what causes it, and what is the emergency treatment of choice? | Polymorphic ventricular tachycardia characterized by QRS complexes twisting around the isoelectric baseline ('twisting of the points'). Etiology: Prolonged QT interval (congenital, hypokalemia, hypomagnesemia, QT-prolonging drugs). Emergency treatment: IV Magnesium Sulfate (1–2 g diluted over 5–15 minutes) and defibrillation if pulseless. |  |  |
| 6 | What EKG criteria define a STEMI (ST-Segment Elevation Myocardial Infarction) and what is the target reperfusion window? | New ST elevation at the J-point in >= 2 contiguous leads: >= 1 mm (0.1 mV) in all leads other than V2–V3. Indicates transmural acute myocardial necrosis. Reperfusion window: Door-to-balloon time for Percutaneous Coronary Intervention (PCI) <= 90 minutes; or Door-to-needle time for fibrinolytic therapy <= 30 minutes if PCI unavailable. |  |  |
| 7 | What are Premature Ventricular Contractions (PVCs) and what patterns indicate impending malignant dysrhythmias? | Early, wide, distorted QRS complexes (> 0.12 s) followed by a full compensatory pause. Warning signs: > 6 PVCs/minute, multifocal PVCs (different shapes), couplets or triplets (runs of VT), and R-on-T phenomenon (PVC falling on vulnerable T wave of preceding beat triggering VF). |  |  |
| 8 | What is the dosing, concentration, and administration schedule of Epinephrine in adult ACLS cardiac arrest? | 1 mg of 1:10,000 solution (0.1 mg/mL) administered IV or IO rapid push, followed immediately by a 20 mL normal saline flush and extremity elevation. Repeated every 3 to 5 minutes throughout active cardiac resuscitation. |  |  |
| 9 | What are the EKG criteria and nursing management for Sinus Tachycardia? | Rate > 100 bpm (usually 101–150 bpm) with regular sinus P waves preceding every normal QRS. Nursing priority is identifying and treating underlying cause: pain, hypovolemia/dehydration, fever, sepsis, anxiety, hypoxia, caffeine, or blood loss (not primary antiarrhythmic medication). |  |  |
| 10 | What is the critical technical step when preparing to deliver Synchronized Cardioversion? | The 'SYNC' button on the defibrillator must be depressed. This programs the machine to sense the patient's intrinsic R wave and discharge the electrical shock precisely on the peak of the R wave, preventing the shock from falling on the vulnerable T wave (avoiding R-on-T ventricular fibrillation). |  |  |
| 11 | What are the EKG characteristics of First-Degree Atrioventricular (AV) Block? | Constant, prolonged PR interval > 0.20 seconds (greater than one large box or 5 small boxes) with every P wave followed by a QRS complex. Rhythm is regular and rate is usually normal. It is typically asymptomatic and requires routine observation. |  |  |
| 12 | What do pacemaker spikes look like on an EKG for atrial, ventricular, and dual-chamber pacing? | Atrial pacing: Sharp vertical spike immediately preceding the P wave. Ventricular pacing: Sharp vertical spike immediately preceding a widened, distorted QRS complex. Dual-chamber (AV sequential) pacing: Two vertical spikes, one preceding the P wave and the second preceding the QRS complex. |  |  |
| 13 | What defines Third-Degree (Complete) Heart Block on an EKG and what is its definitive treatment? | Complete AV dissociation: Atria and ventricles beat independently of each other. P waves march out regularly at their own rate (60–100 bpm) and QRS complexes march out regularly at a slower intrinsic ventricular or junctional rate (20–40 bpm). PR intervals are completely variable. Definitive treatment: Permanent Pacemaker. |  |  |
| 14 | What are the EKG characteristics and classic atrial rate for Atrial Flutter? | Sawtooth or picket-fence baseline ('F' waves) best seen in leads II, III, and aVF, regular or variable ventricular response, atrial rate typically 250–350 bpm (ventricular rate often ~150 bpm with 2:1 conduction). Managed with rate control, anticoagulation, and catheter ablation. |  |  |
| 15 | How do you distinguish Failure to Pace, Failure to Capture, and Failure to Sense in pacemaker telemetry? | Failure to Pace: Absence of expected pacer spike when heart rate drops below programmed minimum. Failure to Capture: Pacer spike is present but not followed by a cardiac depolarization (no P wave or no QRS). Failure to Sense: Pacer fires randomly throughout cardiac cycle without detecting intrinsic rhythm (spikes on T waves). |  |  |
| 16 | How do Hypercalcemia and Hypocalcemia affect the QT interval on an EKG? | Hypercalcemia (> 10.5 mg/dL): Shortened ST segment and shortened QT interval. Hypocalcemia (< 8.5 mg/dL): Prolonged ST segment and prolonged QT interval (predisposing to Torsades de Pointes and ventricular dysrhythmias). |  |  |
| 17 | What is the immediate ACLS protocol for Ventricular Fibrillation (VF) and Pulseless Ventricular Tachycardia (pVT)? | 1. Call for help and start CPR immediately; 2. Defibrillate as soon as shock available (biphasic 120–200 J); 3. Resume CPR immediately for 2 minutes without checking rhythm; 4. IV/IO access; 5. Epinephrine 1 mg IV/IO every 3–5 min after 2nd shock; 6. Amiodarone 300 mg bolus after 3rd shock (second dose 150 mg). |  |  |
| 18 | What is Pulseless Electrical Activity (PEA) and what are the reversible causes (Hs and Ts)? | Organized electrical rhythm on cardiac monitor but absent mechanical myocardial contraction and no palpable pulse. Hs: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia. Ts: Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis pulmonary (PE), Thrombosis coronary (ACS). |  |  |
| 19 | What are the hallmark EKG characteristics, clinical risks, and nursing goals for Atrial Fibrillation (A-Fib)? | EKG: Irregularly irregular ventricular rhythm, absence of distinct P waves (chaotic fibrillatory 'f' waves), variable ventricular rate. Major risk: Mural thrombus in left atrial appendage causing thromboembolic stroke. Management: Rate control (Beta-blockers, Diltiazem), anticoagulation (Warfarin, DOACs), or cardioversion. |  |  |
| 20 | What is Supraventricular Tachycardia (SVT) and what is the step-by-step acute management sequence? | Rapid, regular rhythm (rate 150–220 bpm) with narrow QRS complexes and hidden P waves. Sequence: 1. Vagal maneuvers (Valsalva, modified Valsalva leg-raise, ice to face); 2. IV Adenosine (6 mg rapid IV push followed by immediate 20 mL saline flush; repeat with 12 mg if unsuccessful); 3. Synchronized cardioversion if unstable. |  |  |
| 21 | What are the AHA CPR quality parameters for adult chest compressions? | Compression rate: 100–120 compressions/minute; Compression depth: At least 2 inches (5 cm) but no more than 2.4 inches (6 cm); Allow complete chest recoil between compressions (avoid leaning); Minimize interruptions in compressions to < 10 seconds; Rotate compressors every 2 minutes (or every 5 cycles). |  |  |
| 22 | What are the diagnostic EKG criteria for Normal Sinus Rhythm (NSR)? | Heart rate: 60–100 beats/min; Rhythm: regular; P waves: upright, uniform, one preceding every QRS complex; PR interval: 0.12–0.20 seconds (3–5 small boxes); QRS complex duration: < 0.12 seconds (< 3 small boxes); ST segment: isoelectric. |  |  |
| 23 | What postoperative nursing discharge education is vital after permanent pacemaker implantation? | Immobilize the affected arm in a sling / do not raise elbow above shoulder level for 4–6 weeks to prevent lead dislodgement; keep incision clean and dry; carry pacemaker ID card; check pulse daily; keep cell phones >= 6 inches away (use opposite ear); inform airport security; avoid MRI scans unless device is MRI-conditional. |  |  |
| 24 | What are the EKG features and first-line pharmacological treatment for symptomatic Sinus Bradycardia? | Rate < 60 bpm, normal regular P-QRS-T morphology. Symptoms: hypotension, dizziness, diaphoresis, syncope, chest pain. First-line drug: Atropine 1 mg IV push every 3–5 minutes (max 3 mg). If refractory, prepare transcutaneous pacing (TCP) or continuous infusions of Dopamine or Epinephrine. |  |  |
| 25 | What client education is essential for a client with an Implantable Cardioverter-Defibrillator (ICD)? | If the ICD delivers a single shock and client feels fine: Sit down, rest, and notify the cardiologist immediately. If the ICD delivers multiple shocks or client experiences chest pain, dizziness, or syncope: Call 911 immediately. Family members must learn CPR. Avoid contact sports and large electromagnetic fields. |  |  |
| 26 | What sequential EKG changes occur as serum potassium increases in Hyperkalemia? | 1. Mild (5.5–6.5 mEq/L): Tall, narrow, peaked, symmetrical T waves ('tented T waves'); 2. Moderate (6.5–7.5 mEq/L): Prolonged PR interval, flattened or lost P waves; 3. Severe (> 7.5–8.0 mEq/L): Widened QRS complex blending into T wave, forming a lethal 'sine wave' pattern, leading to asystole or VF. |  |  |
| 27 | What are the hallmark EKG changes associated with Hypokalemia (< 3.5 mEq/L)? | Flattened or inverted T waves, ST-segment depression, and prominent U waves (a positive deflection following the T wave, especially noticeable in leads V2–V4), increasing risk for ventricular dysrhythmias and digitalis toxicity. |  |  |
| 28 | How do you differentiate Ventricular Tachycardia (VT) with a pulse from Pulseless VT? | Both show wide, bizarre QRS complexes (> 0.12 s) at rates 100–250 bpm without P waves. VT with pulse: Assess hemodynamic stability; if stable give IV antiarrhythmics (Amiodarone 150 mg IV over 10 min); if unstable (hypotension, altered LOC) perform Synchronized Cardioversion. Pulseless VT: Treat identically to VF with immediate Defibrillation and CPR. |  |  |
| 29 | What is Targeted Temperature Management (TTM / Therapeutic Hypothermia) post-cardiac arrest? | Inducing hypothermia (target 32°C to 36°C) for at least 24 hours in comatose adult patients with return of spontaneous circulation (ROSC) after cardiac arrest. Rationale: Reduces cerebral metabolic rate, suppresses neurotoxic cascades, decreases intracranial pressure, and preserves neurological function. |  |  |
| 30 | What do ST-segment depression and T-wave inversion signify on an EKG? | Myocardial ischemia or Non-ST Elevation Myocardial Infarction (NSTEMI). ST depression may also represent reciprocal changes facing a transmural STEMI in the opposite myocardial wall, or digitalis effect ('scooped' ST segment). |  |  |
| 31 | What are the EKG features of Second-Degree AV Block Type II (Mobitz II) and its clinical danger? | Constant, normal or prolonged PR intervals with intermittent, non-conducted P waves resulting in suddenly dropped QRS complexes without prior PR prolongation. Danger: High risk of progressing suddenly to complete Third-Degree AV block or cardiac arrest; requires temporary and permanent pacemaker implantation. |  |  |
| 32 | What are the hallmark EKG changes in Second-Degree AV Block Type I (Mobitz I / Wenckebach)? | Progressive PR interval prolongation from beat to beat until a QRS complex is dropped ('longer, longer, longer, drop, then you have a Wenckebach'). The cycle then repeats. Usually benign, caused by AV node ischemia or medications (beta-blockers, digoxin). |  |  |

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