1. The Limb Leads lie in the ________ plane.
A. Transverse
B. Frontal
C. Axial
D. Inferior
2. The Precordial Leads lie in the _______plane.
A. Transverse
B. Frontal
C. Axial
D. Inferior
3. In the precordial leads the transition point for the R wave progression in a normal EKG
is most likely found:
A. Between leads V1 and V2.
B. Among leads V2, V3, V4, V5.
C. Between leads V5 and V6
D. Among leads aVR, aVL, and aVF.
E. Between leads II and III
4. If the Precordial Leads are placed correctly, then which of the statements is incorrect?
* remember anatomic location
A. Leads V1 and V2 are over the right heart.
B. Leads V3 and V4 are over the interventricular septum
C. Leads V5 and V6 are over the left ventricle
D. Leads V4, V5 and V6 are placed within the fourth intercostals space
5. The normal range of the PR- Interval is:
A. 1-2 small boxes on the EKG
B. 2- 4 small boxes on the EKG
C. 2- 5 small boxes on the EKG
D. 3 small boxes to one large box on the EKG
E. 3 large boxes to 5 large boxes on the EKG
6. Which of the following is NOT true regarding the frontal leads I, II, III?
A. Lead I is positive in the left arm with respect to the right arm
B. Lead II is positive in the left foot with respect to the right arm
C. Lead III is positive in the left foot with respect to the left arm
D. Lead II is positive in the right arm with respect to the left arm
1
The following questions 7-11 are matching questions and the answers may be used
more than once or not at all!!!
A. Duration of ventricular depolarization and repolarization
B. Junction of S and T wave
C. Duration of ventricular depolarization
D. Time onset from atrial depolarization to ventricular depolarization
E. Repolarization of the ventricles
7.
8.
9.
10.
11.
_D____PR Interval
_C___QRS complex
_B___ J point
_E___ST segment and T wave
_A___QT interval
12. True / False
If clinically indicated, treatment of supraventricular tachycardia (SVT) consists of IV
adenosine and vagal maneuvers.
A. True
B. False
13. True / False
In a patient presenting with atrial fibrillation, immediate restoration to normal sinus
rhythm is always the appropriate treatment.
A. True
B. False
14. An OMS III presents a patient and states that the R to R interval is ONE large box in
its duration. What is the atrial rate of the patient?
A. 300 BPM
B. 150 BPM
C. 100 BPM
D. 75 BPM
E. Unknown
2
15. Which of the above rhythm strips above represents Atrial Fibrillation, A or B?
A
Case History Question 16 – 75 year old male presents to the Emergency Department
stating that he has passed out 2 times this morning after standing up. BP 130 /80
Respiratory rate – 12, Pulse oximetry – 98 % room air.
16. Which answer which best describes the above rhythm?
A. Narrow complex bradycardia
B. Normal sinus rhythm with aberrant conduction
C. Accelerated idioventricular rhythm
D. Ventricular tachycardia
E. Indioventricular Accelerando Mundo
17. The above 75 y.o. male becomes unresponsive. You note a very weak femoral pulse
which is bradycardic. Based on 2005 AHA ACLS guidelines, which of the following
would be a reasonable intervention at this time.
A. Transcuntaneous pacing
B. Atropine
C. Epinephrine
D. Dopamine
E. All of the above
3
18. Despite your intervention, the patient becomes pulseless. Based on this patient’s
presentation, which of the following answers is the least likely cause of pulseless arrest?
A. Coronary Thrombosis
B. Hypoxia
C. Hyperkalemia
D. Tension pneumothorax
E. Hypovolemia
19. The nurse states that the patient is “capturing”. Which of the following answers best
explains what she means by this statement?
A. External pacing of patient with symptomatic sinus bradycardia.
B. Calculating the QT interval using Bazett’s equation
C. Re- Entry of the electrical signal into the atria in the WPW
D. Depolarization of the myocardium following the pacer spike
20. Which of the answers below best represents this rhythm?
.
FYI – disregard the numbers
A. 3 rd Degree AV block
B. 1 st Degree AV block
C. Mobitz type 1, 2nd Degree AV block or Wenckebach
D. Mobitz type 2, 2nd Degree AV block
E. Marked sinus arrhythmia
Match the following answers with the appropriate questions. Questions 21-24.
Answers may be used once or more than once or not at all!
A. 0 degrees to 90 degrees
B. 90 degrees to 180 degrees
C. 180 degrees to 270 degrees
D. 0 degrees to – (neg) 90 degrees
21 Left axis deviation =__D____.
22. Right axis deviation =__B___.
23. Normal axis =__A___.
24. Severe right axis deviation =_C___.
4
For Questions 25 - 29, please choose the following answers to complete the
statements below.
A. Constant
B. Irregular
C. None of the above
25. In First Degree AV block, the PR interval is __A___.
26. In Sinus Arrhythmia, the PR interval is ___A____.
27. In Atrial Fibrillation, the PR interval is ___C____.
28. In Complete (Third Degree AV Block) Heart Block, the PR interval is __B___.
29. In Second Degree AV Block, Mobitz II, the conducted PR interval is __A____.
Note the above tracing is for question #30
30. When viewing the above tracing ask your self the following questions. Are the P
waves regular and are they associated with the QRS complexes? Which answer best
describes this rhythm?
A. Sinus arrhythmia with slow ventricular response
B. 1St Degree AV Block
C. Mobitz 1, 2nd Degree Type1 Block
D. 3 rd Degree AV Block (Complete Heart Block)
E. Mobitz 2, 2nd Degree AV Block,
31. True / False
2nd AV Block (Mobitz II) is considered a more serious life threatening block than
Wenckebach, because it is sometimes followed by complete heart block ( 3rd AV Block )
A. True
B. False
C. The question is irrelevant
5
32. Which of the following answers best describes the above tracing?
A. The ventricular rate is less than 60 BPM
B. The QRS complex is wide (duration >0.12 ms)
C. The P waves are disassociated from the QRS complexes
D. This tracing represents 3 rd degree AV Block
E All of the above
33. A 39 year old celebrity reported to have been drinking double shots of alcohol and
taking methadone is found by EMS in her Florida hotel room unresponsive. You are an
OMS III on EM rotation, you palpate no pulse. Pupils are mid, fixed and dilated. Which
sequence is recommended by 2005 AHA ACLS guidelines?
A. Chest compressions, defibrillation, vasopressor medication
B. Pronounce the patient dead, claim to be the father of her children
C. Defibrillation, vasopressor medication
D. Epinephrine, vasopressin, magnesium and amiodarone
34 “R on T phenomena” refers to a time when an electrical stimulus can strike the latter
portion of the T- wave in the”vulnerable period” (when the ventricles are hypersensitive)
this might trigger ________ and possible sudden death.
A. Ventricular Tachycardia
B. Atrial Fibrillation
C. MAT (multiatrial tachycardia)
D. Atrial Flutter
6
Questions 35 – 37
35. Which of the following answers best describes the rate, rhythm and axis?
A. Sinus bradycardia @50 bpm, normal axis
B. Normal sinus rhythm @60 bpm, left axis
C. Normal sinus rhythm@ 75 bpm, normal axis
D. Normal sinus rhythm @60 bpm, normal axis
36. Which of the following best describes the QRS morphology?
A. Wide complex QRS with R-R’in V1
B. Narrow complex QRS with R-R’in V6
C. Wide complex QRS with R-R’ in V6
D. Wide complex QRS with rabbit ears in V1
37. True / False
A 75 year old male presents with a sudden onset of substernal chest pain radiating to his
L arm and neck which started 2 hours ago. The nurse shows you an EKG from one week
ago which is a NSR @ 75, normal axis and normal intervals. You quickly compare it to
the above EKG. Should this be considered an ACUTE myocardial infarction?
A. True
B. False
7
Question 38 – 40
38. Which of the following best describes the rate, rhythm and axis?
A. Sinus tachycardia@ 130 bpm, normal axis
B. Atrial Fibrillation @130 bpm, L axis
C. Atrial Fibrillation @130 bpm, R axis
D. Atrial Fibrillation @130 bpm, normal axis
39. The patient is a 30 year old binge alcohol drinker. He is awake and alert and not
complaining of chest pain. Based on the 2005 AHA ACLS guidelines, which would be
the most appropriate intervention to control the heart rate?
A. immediate synchronized cardioversion
B. Precordial thump
C. Beta Blocker or Diltiazem IV
D. Atropine IV
E. 4 chewed 81 mg Asprin
40. Which of the following answers best describes the QRST morphology?
A. Narrow complex QRS
B. Wide complex QRS
C. Wide complex QRS with ST segment elevation in III and aVF
D. Narrow complex QRS with ST segment elevation in III and aVF
8
Questions 41 – 43
41 When describing a completed purely inferior transmural myocardial infarction one
expects Q waves in which lead(s)?
A. Lead II
B. Lead III
C. Lead aVF
D. All of the above
E. None of the above
42. 54 year old male with hypertension, diabetes, and hyperlipidemia present to the EM
stating that he has a crushing pressure across his chest. The pain started 2 hours ago. He
appears pale, diaphoretic and short of breath. Which of the following intervention is the
best combination for this patient?
A. O2, IV, moniter, asprin, nitroglycerin and beta blocker
B. IV, O2, cardiac moniter, nitoglycerin and morphine
C. Immediate thrombolytics (no additional questions are required)
D. IV, atropine, transcutaneous pacing, nitroglycerin
E. Precordial thump
43. This infarction pattern represents which coronary artery?
A. Left main
B. Left anterior descending
C. Left circumflex
D. Obtuse marginal
E. Right coronary artery
9
Questions 44- 45
44. Which answer best describes this EKG?
A. NSR @81, Right axis, RBBB, 2nd Degree type I AV block
B. NSR @ 81, Right axis, LBBB, 1st degree AV block
C. NSR @81, Left axis, LBBB, 1st degree AV block
D. NSR @81, Right axis, RBBB, 1st degree AV block
45 Which of the following clinical scenarios could explain this EKG?
A. Left ventricular hypertrophy
B. Pulmonary embolism
C. Hyperkalemia
D. Hypothermia
E. None of the above
46. To conclude that a normal sinus rhythm is present you must see:
A. QRS complexes
B. Heart rate from 60 to 100
C. P waves preceding each QRS complex
D. all of the above
E. None of the above
10
Questions 47 -48
47. 64 year female states that’s she has had intermittent chest pain, shortness of breath and
sweating for the last 3 days lasting approx. 30 minutes. She denies prior history of myocardial
infarction. Which answer best describes this EKG?
A. NSR @ 64, R axis and anterior / lateral wall myocardial infarction
B. NSR @64, L axis and anterior / lateral wall myocardial infarction
C. NSR @64, R axis and anterior /lateral wall ischemia
D. NSR @64, L axis and anterior /lateral wall ischemia
E. None of the above
48. Which coronary artery is most likely involved?
A. Obtuse marginal
B. Right
C. Left circumflex
D. Left anterior descending
E. Unknown
49. To correct for the effect of heart rate on the QT interval you must divide the measured QT
interval by:
A. The square root of the QRS complex
B. The square root of the PR interval
C. The square root of pie
D. The square root of the R-R interval
11
50. What is the condition that is associated with tachyarrythmias, shortened PR interval and a
Delta wave that may produce intermittent symptoms in otherwise young healthy individuals?
A. Marfans Syndrome
B. Wolff – Parkinson – White (WPW)
C. Left Posterior Fasicular block
D. Paroxysmmal Supraventricular Tachycardia
12
Answers:
1. B
2. A
3. B
4. D
5. D
6. D
7. D
8. C
9. B
10. E
11. A
12. A
13. B
14. E
15. A
16. C
17. E
18. D
19. D
20. C
21. D
22. B
23. A
24. C
25. A
26. A
27. C
28. B
29. A
30. D
31. A
32. E
33. A
34. A
35. D
36. C
37. A
38. D
39. C
40. D
41. D
42. B
43. E
44. D
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45. B
46. D
47. D
48. E
49. D
50. B
Question
Answer
IF there is a Pwave, the rhythm
will be one of
theses Sinus
Rhythms:
Sinus Rhythm: Normal Sinus Rhythm, Sinus
Bradycardia or Sinus Tachycardia
If you do not have
a P-wave the
Ventricular
rhythm is:
Determine the
Rate:
60-100 (NSR or AJR)<60 (SB, or JR)> 100
(ST or JT)
PR Interval = <.12
(less than 3 little
= Junctional Rhythm, nextlook at rate
boxes)
PR Interval = .
12-.20 = (3 to 5
little boxes)
= Sinus Rhythm, Sinus Brady, Sinus Tach
PR Interval = >.20 1st degree heart block. Type of rhythnm
=
with 1st degree heart block
No P-wave=
Ventricular Tachacardia, ideoventricular,
Atrial flutter, Fixed conduction (...!...!...!)
Regular QRS =
0.06-0.10
Super Ventricular
Tachycardia
<3 little boxes
When do you
cardiovert
When you have a pulse
When do you
Defibulate
When you have no pulse
What drug(s) do
Epinephrine, and atropine
14
you use for
Asystole
The drug used to
Chemicaly
Cardiovert SVT is
Adenosine
Fear, Deficient knowledgeIneffective cardiac
tissue perfusion, Decreased cardiac output,
Nursing Diagnosis Impaired gas exchange, Risk for imbalanced
related to CABG
fluid volume, Disturbed sensory perception,
Acute pain, Ineffective tissue perfusion,
Ineffective thermoregulation
CVP normal
value:Wedge
pressure:PAP
CVP:0-4 Wedge pressure:8-15 PAP 20-30/515
Massive left sided heart failure, full of fluid,
pink frothy secretions, Treatment: diuretics
Pulmonary Edema
(lasix first line)If pt has renal failure then
(nitroglycerin and morphine)
Irregular Rhythms
A-flutter, Sinus Arrhythmia, 2 degree or 3
degree heart block, A-fib
Narrowing pulse
pressure would be
Tamponade, also massive JVD
seen in which
patient
Pacemaker
Information
required on Chart
Model of pacemaker, type of generator,
date and time of insertion, location of pulse
generator, stimulation threshold, Pacer
settings (eg, rate, energy output,
sensitivity, and duration of interval between
atrial and ventricular impulses)
Endocarditis
Infective Risk
factors
Risk factors: heart valve prosthesis, hx of
heart disease (mitral valve prolapse),
chronic dibilitatin disease, IV drug abuse
and immunosuppression
Pericarditis
Friction rub. notched T wave, S/S: fever,
positional chest discomfort, nonspecific ST-
15
segment elevation, elevated ESR
erythrocyte sedimentation rate, retrosternal
pain that worsens during supine positioning,
pulsus paradoxus
hypokalemia wave
U uaves after the T
form changes
hyperkalemia
Tall QRS complexes
hypomagnesium
Torsades de pointes
Medications to
treat ventricular
dysrhythmias
Lidocaine, Beta blockers, amiodarone (drug
of choice for v-tac)
JVD, Dependent Edema, right upper gastric
Right Heart Failure
pain(Right heart handles systemic blood
(chronic condition)
return)
Left Heart Failure
Bibasilar fine crackles, dyspnea,
tachycardia, S3 and S4 heartsounds,fatigue,
hemoptysis, non-productive cough, cool
pale skin, PMI displaces toward the left
anterior axillary line
Inferior wall
myocardial
Infarction
T-wave inversion:inadequate blood
supplyST-segment elevation:injury
prolonged ischemiaPathologic Q waves Are
all signs of tissue hypoxia
Digoxin
Hold if apical pulse is less than 60 bpm.
Digitalis Toxicity = vision changes (halos),
dysrhythmia, anorexia, nausea, vomiting,
headache, and malaise. Increases force of
myocardial contraction and decreases HR.
A-fib
Warfarin to prevent clots and decrease risk
of stroke, Digoxin to control HR
12 Lead EKG
ST elevation indicates immediate
myocardial injury. ST depressions indicate
myocardial ischemia. Q wave forms several
days after a myocardial infarction, U wave is
a sign of hypokalemia.
Laxix Furosemide
IV push: give at a rate of 20 mg/min or less.
16
Rapid injection can cause hearing loss as a
result of ototoxicity.Normal daily dose: 40
mg. loop diuretic
Nitroglycerin
Reduces oxygen consumption to devrease
ischemia and relieve pain. Vasodialator
mainly in veins and reduces blood return to
heart and preload is reduced. May cause a
significant drop in cardiac output and B/P if
pt is hypovolemic at higher doses.
Calcium Channel
Blockers
Slows heartrate and decreases strength of
contraction which decreases workload of
heart. Relaxes blood vessels decreasing BP
and increases coronary artery perfusion
Rhumatic Fever
Caused by strep
S/S of Infective
Endocarditis
Osler's nodes (red, painful nodules on the
fingers and toes) splinter hemorrhages,
fever, diaphoresis, hoint pain, weakness,
abdominal pain, new murmur, Janeway's
lesions (small, hemorrhagic areas on
fingers, toes, ears, and nose)
Myocarditis S/S
Flu-like symptoms.fatigue, dyspnea,
palpitations, and occasional discofort in the
chest and upper abdomen. My develop
dysrhythmias, or ST-T wave changes.
Systolic murmur, gallop rhtyhm,
ACE Inhibitors
promote vasodilation and diuresis by
decreasing afterload and preload.
Dobutamine
left ventricular dysfunction. increases
cardiac contractility. at high doses, it also
increases HR and incidence of ectopic beats
and tachydysrhythmias. take care in pt with
a-fib.
CK-MB earliest
4-8 hours, peaks 12-24 hrs, and returns to
increase, peak and
normal 1-3 weeks
return to normal
Troponin earliest
3-4 hours, peaks in 4-24 hrs and returns to
17
increase, peak and
normal 1-3 weeks
return to normal
Labs for Heart
failure
BUN, TSH, CBC, BNP
Mitral stenosis:
Rhythms, S/S
S/S: dyspnea, progressive fatigue,
hemoptysis, paroxysmal nocturnal dyspnea,
chough, wheeze, repeated respiratory
infections. Dysrhythmias like A-fib. Tests
Doppler echocardiography.
Aortic
Regurgitation:
Cause
Caused by inflammatory lesions that
deformt he leaflets of the aortic valve. also
infective or rheumatic endocarditis,
congenital abnormalities, diseases such as
syphilis, dissecting aneurysm, blunt chest
trauma, or valve replacement.
Forceful heartbeats in head and neck,
arterial pulsations that are visible or
Aortic
palpable at the carotid or temporal arteries.
Regurgitation: S/S Exertional dyspnea, fatigure, progressive s/s
of left ventricular failure includie breathing
difficulties, orthopnea, PND.
take long term anticoagulant therapy,
Valve replacement
freequent follow up appointsments and
teaching: pre and
blood lab studies. mak need to take aspirin,
post
precribed medication teaching,
Cardiac
Tamponade S/S
Life threatening need stat interventions. S/S
fullness within the chest, substantial or ill
defined pain. sob, massive JVD, falling
systolic blood pressure, narrowing pulse
pressure, rising venous pressure (increased
JVD) and distant heart sounds
Cardiac
Tamponade
treatment
pericardiocentesis, pericardiotomy
(pericardial window)
CABG:
70% occlusion (60% if in the Left main).
artery must me patent beyond the
occlusion. Use greater saphenous vein,
18
lesser saphenous, chephalic and basilic
veins.
19
20