TRAC

Telemetry Recognition
&
Application Course
2
 TRAC Course
Course GOAL
• Recognize cardiac rhythm and apply its significances to patient’s clinical condition.

Worksheet with Each Scenario

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________
PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

How to Complete the Scenario Worksheet

Assess Section
• ECG analysis and interpretation
• Key Clinical Findings
o Patient’s history and clinical findings that may be significant in relation to the rhythm and clinical
condition.
Risk Level Section
• The likelihood the patient’s condition will decompensate or become a life-threatening situation.
Intervene Section
• Nursing Actions
• Examples of actions the nurse may take based on the situation:
o Determine Code Status
o Assess LOC/Mental Status
o Obtain VS
o Ask the patient if they are having CP, SOB, lightheadedness, or dizziness
o Auscultate lung fields
o Does the patient have a working IV access?
• Additional actions (i.e., 12 Lead, NTG SL, cough/bear down, review MAR)
• Does the situation warrant provider notification?
o Activation of the RRT, Code blue, STEMI alert, Call APPs or providers
• Anticipated Orders
o Interventions that the provider will most likely order.
Evaluate
• What to monitor post-intervention.
• Post-interventions that would be ordered (i.e., VF arrest – amiodarone gtt, repeat labs).
• Prepare to transfer to another level of care or to a procedural area.

3
 Lead Placement
Proper lead placement is a very important step in cardiac monitoring. Using this diagram of
a chest, mark where each of the leads (by color) should be applied.

W = White B = Black R = Red G = Green BR = Brown

4
 Scenario 1
A 70-year-old female presents to ED with chief complaint of dyspnea at rest. Exam revealed labored
respirations at 32 bpm, crackles and inspiratory wheezes throughout lung fields, SR with an occasional PAC
and a systolic murmur. PMH of heart failure, mitral regurgitation, hypertension, type II diabetes, and
chronic renal insufficiency. ED nurse reports patient received 40 mg furosemide IV times 2 with a
moderate diuresis and was transitioned from BiPAP to 6 liters/min per NC during her 12-hour ED stay.
Drawn in the ED BUN 13
Sodium 140 Creatinine 1.62
Potassium 4.8 Glucose 198
Chloride 107 HBG 13.2
Bicarbonate 23 HCT 41.2

Admission Vitals BP: 145/80 mmHg HR: 95 bpm RR: 32 bpm T: 98.9 SpO2: 92% on 6 l/min per NC

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

5
 Scenario 2
A 55-year-old obese male who drives a semi for a living was admitted for chest pain which was relieved
with NTG SL and had no ECG changes on the 12 Lead ECG. Troponins, CBC, and CMP are pending. PMH
includes hypertension, hyperlipidemia, and 1 ppd X 30-year smoking history. He is resting comfortably on
2 liters per NC and #18 saline lock in his left forearm. He denies chest pain and SOB on admission to the
unit.

• PCN and Viagra allergies

• Code Status: Full
• BP: 150/87
• ST at 104 bpm with no ectopy
• RR: 26 bpm and unlabored
• T: 99.5°
• SpO2: 93%
As you walk into the patient’s room to complete your admission assessment, he screams out “I’m going to
die” while clutching his chest, and then becomes unresponsive. The monitor displays the below rhythm:

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________
Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

6
 Scenario 3
A 25-year-old female in graduate school finishing her thesis that is due in 1 week presents to ED with chest
pain and palpitations. Lab results are WNL. Troponins are flat and 12 lead ECG showed SR with no
ischemic changes. She has NKDA, no past medical history, and takes a multivitamin and vitamin C daily.
She is being admitted for observation. The ED nurse reports she had no episodes of palpations, remained
in SR with occasional PACs, and has stable vital signs. On admission, you note she has #20 saline lock IV in
the right hand and is on room air. She denies chest pains, SOB, and palpitations.
Several hours later the cardiac monitor alarm is activated, and the below rhythm is noted.

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

7
 Scenario 4
A 39-year-old male with a PMH of HIV, gallstones, HTN, alcoholic abuse, and tobacco abuse is admitted for
generalized seizures and UTI. He reports they occurred after he took a “pain pill” a friend gave him and
were witnessed by his family. Since admission he has had no seizure activity; however, he is fidgety and
constantly getting in and out bed. He is asking the nurse if he can go outside and smoke.

• Allergies: Azithromycin
• Code Status: Full
• BP 90/50 mm Hg
• RR: 23 bpm
• T: 99.6° PO
• SpO2: 93% on RA
• #20 saline lock in L Thumb
• Several episodes of N/V on the previous shift
• PO Intake 200 ml for the past 24 hours
The monitor displays the below rhythm:

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

8
 Scenario 5
You’re caring for a 71-year-old African American male who is admitted for a STEMI and had an emergency
cardiac catheterization with a drug-eluting stent (DES) to the RCA placed 6 hours ago. PMH includes type 2
diabetes, hypertension, CHF, CAD, hyperlipidemia, DES to LAD 3 years ago and episodes of atrial
fibrillation. Home medications are Lipitor, Coreg, Plavix, Lisinopril, and Lasix.
• Allergies: Adhesive Tape and Zofran
• Code Status: Full
• Denies chest pain, SOB, and nausea
• BP: 124/63 mm Hg
• Sinus Bradycardia 56 bpm with a rare PVC
• RR: 16 bpm unlabored and lungs clear to auscultation
• T: 100.1°
• SpO2: 98% on 4 liters per NC
• Normal Saline at 75 ml/hour via #20 angio IV right forearm
• CBC & BMP results WNL

During your shift assessment you note the below rhythm.

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

9
 Scenario 6
You are caring for a 22-year-old female who is in her first trimester of pregnancy. She was admitted for
pyelonephritis and has a PMH of asthma, mitral valve prolapse, and migraines. Current medications:
prenatal vitamin daily, Tylenol 650 mg q 6 hours prn for pain, and albuterol rescue inhaler prn.

• Allergies: NKDA, grass, pet dander

• Code Status: Full
• #20 Saline Lock in the right hand
• Denies pain, cramping, SOB, nausea at present
• BP 110/62 mm Hg
• RR: 22 bpm
• T: 100.9°
• SpO2 98% on RA
• CMP & CBC WNL
The monitor displays the below rhythm:

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

10
 Scenario 7
You’re caring for 43-year-old female with a history of bipolar affective disorder, community acquired
pneumonia, hyperlipidemia, and 25-year smoking history. She is admitted for respiratory difficulties
secondary to pneumonia. Home medications include ASA, Lipitor, and Seroquel XR.

• Allergies: Amoxicillin
• BP: 148/82
• Sinus Rhythm 96 bpm with PACS & rare PVCs
• RR: 32 bpm and labored
• T: 100.9°
• SpO2: 92% per 4 liters per oxymizer
• D5.45 at 100 ml/hour per right IJ CVC
• Albuterol every 4 hours & prn
• WBC 25,000
• Potassium 4.8
• Magnesium 2.5
• Levofloxacin 750 mg IVPB every 24 hours

You are preparing to administer 2200 antibiotic IVPB. Several nurses come to the room because the
monitor alarm was activated.

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

11
 Scenario 8
A 72-year-old Africa American female with a history of frequent COPD exacerbations requiring
hospitalization, home oxygen at 3 liters/min per NC, type 2 DM, HTN, and chronic renal insufficiency was
admitted for severe sepsis secondary to community acquired pneumonia. She initially was admitted to
ICU and on the ventilator for 5 days and then was extubated to 50% high flow oxygen yesterday. You
receive the following report from the ICU nurse:

• Allergy: PCN
• Code Status: DNRCC-A with no intubation
• Awakens to verbal stimuli & is oriented to person and place
• Nasotracheal suctioning every 6 hours & prn
• Right IJ triple lumen CVC
• Left small bore feeding tube with Impact Peptide 1.5 at 50 ml/hr
• BP: 140/76 mm Hg
• SR to ST with occasional PAC & unifocal PVCs
• RR: 30 bpm unlabored via high flow oxygen at 50%
• T: 100.0° Oral
• SpO2: 89-92%
You are settling the patient in and note the following rhythm on the monitor.

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________
PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

12
 Scenario 9
A 68-year-old male with a PMH of CAD, CABG X 3 five years ago, type 2 DM, HTN, atrial fibrillation,
cardiomyopathy, and tobacco abuse is admitted for syncope. Current medications include metoprolol 50
mg PO twice a day, Lipitor 80 mg every night, ASA 81 mg daily, lisinopril 20 mg daily, warfarin 5 mg daily,
metformin 500 mg twice a day and Amlodipine 10 mg daily.

• Allergies: NKDA
• Code Status: Full
• Alert & oriented X 4
• Ambulatory with minimal assistance
• #18 saline lock Right AC
• Sinus Rhythm 65 bpm with occasional PVC
• BP: 150/82 mm Hg
• RR: 26 bpm unlabored and symmetrical
• T: 98.5° Oral
• SpO2 95% on 2 liters per NC
• Denies chest pain, SOB, lightheadedness, or dizziness
Several hours into your shift the patient puts on his call light. Upon entering the room, you note the
patient is standing at the bedside trying to urinate and he tells you “He does not feel right and is going to
pass out.” The monitor displays the below rhythm.

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

13
 Scenario 10
A 75-year-old male with PMH of atrial fibrillation, non-ischemic cardiomyopathy, HFrEF (Heart Failure with
Reduced Ejection Fraction), HTN, hyperlipidemia, sick sinus syndrome, and colon cancer is admitted for
lethargy, generalized weakness, nausea, and vomiting.

• Allergies: Lisinopril (Angioedema)

• Code Status: DNRCC-A
• Responses to verbal/tactile stimuli, oriented to person, and follows commands
• NS at 100 ml/hr via #18 angio Left forearm
• BP: 100/74 mm Hg
• RR: 24 bpm easy and full & lungs clear to auscultation
• Atrial Fibrillation at 110 bpm without ectopy
• T: 97.6° Oral
• SpO2: 93% on RA
During your shift assessment, you note the following rhythm on the monitor.

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

14
 Scenario 11
A 56-year-old male with a PMH of COPD, ventricular tachycardia, non-ischemic cardiomyopathy, and
tobacco abuse. He is admitted for community acquired pneumonia. Current medications are lisinopril 20
mg PO daily, ASA 81 mg PO daily, amiodarone 400 mg PO daily, and albuterol rescue inhaler.

• Allergies: Lorazepam (Feels out of it after taking)

• Code Status: Full
• #18 saline lock Left hand
• BP: 123/67 mm Hg
• RR: 28 bpm labored with productive cough
• T: 101.5° Oral
• SpO2: 92% on 6 liters per NC
The following rhythm is on the monitor.

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________
Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

15
 Scenario 12
A 69-year-old male with a PMH of atrial fibrillation, CAD, CHF, chronic kidney disease, HTN,
hypothyroidism, and sudden cardiac death 3 months ago requiring an ICD placement. He is admitted for
ICD discharging several times in the past 6 hours.

• Allergies: NKDA
• Code Status: Full
• Alert & oriented X 4 & ambulates easily
• #20 saline lock Left Forearm
• BP: 130/56 mm Hg
• Atrial Fibrillation at 75 bpm without ectopy
• RR: 20 bpm easy & full
• T: 97.2 ° Oral
• SpO2: 97% on RA
You are charting your shift assessment and hear the monitor alarm. The monitor displays the below
rhythm.

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

16
 Scenario 13
An 82-year-old male with PMH of MI, HTN, HBV (Hepatitis B Virus), colon and prostate cancer,
hypothyroidism, CABG X 2 10 years ago, colectomy, and a spinal fusion. He presents to the ED with
complains of RUQ abdominal pain for 2 weeks and has been unable to eat because it makes the pain
worse. He reports intermittent fevers and chills during that time.

• Allergies: ASA
• Code Status: Full
• NPO
• Alert & oriented times 4 and follows commands
• Denies Chest pain & SOB
• BP: 160/90 mm Hg
• Sinus Rhythm 90 bpm
• RR: 30 bpm regular and shallow
• T: 99.9° Oral
• SpO2: 96% on 2 liters per NC
• D5.45 NaCl at 150 ml/hour via #18 angio Right AC

You are admitting him to your unit and the below rhythm is displayed on the monitor.

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

17
 Scenario 14
A 59-year-old female with a PMH of HTN, CAD, hyperlipidemia, depression, GERD, morbid obesity, and
tobacco abuse was admitted to your unit following an elective hernia repair. Surgery and PACU recovery
were without incident. She is now POD#1 and wants to use the bathroom. The PSA assists her to the
bedside commode. The PSA yells for help because the patient became unresponsive when trying to have a
bowel movement. You go to room and find the patient is alert and laughing with the PSA about “Trying to go out
like Elvis.”

You go to the central monitor to review her ECG alarms and find the following rhythm.

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________
Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

18
 Scenario 15
A 61-year-old female with PMH of bipolar disorder, type 1 DM, hyperlipidemia, CAD, and COPD. She
cannot remember what procedures and surgeries she had in the past and tells the doctor to look at her
chart. She is admitted for nephrolithiasis.

• Allergies: Lithium
• Code Status: Full
• Awake and moaning in pain and is reluctant to move
• LR at 100 ml/hour via # 20 angio right hand
• SpO2: 92% and does not want to wear the oxygen
You are admitting her to your unit and note the below rhythm.

Several hours later in your shift that cardiac monitor displays this rhythm.

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

19
 Scenario 16
You are caring for 80-year-old African American female with a PMH of breast cancer, chronic diastolic
heart failure, CKD, type 2 DM, HTN, CAD, and COPD. She had a heart stent placed 5 years ago due to a
heart attack and is on home O2 at 2 liters/min per NC. She presents to the ED with worsening peripheral
edema and 21-pound increase in weight over the past week. She is admitted for acute on chronic diastolic
heart failure and pneumonia. Current medications are allopurinol, carvedilol, aspirin, Lipitor, torsemide,
glimepiride, and spironolactone.
She has been on your unit for several days. During your shift assessment, she tells you that her heart feels
like it is missing a beat occasionally and it feels weird when it happens. You tell her to call if it happens
again. The PSA tells you the patient needs you now.
The monitor shows the below rhythm.

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

20
 Scenario 17
You are caring for 65-year-old female who was admitted for infected AV fistula and placement of
temporary hemodialysis catheter. She has refused the catheter for past several days and all testing. Her
most recent lab results are over 5 days old when she last received outpatient dialysis. She tells you that
she wants to go home now and is done with hospitals and doctors.

• Allergies: Sulfa
• Code Status: Full
• Alert and Oriented
• Atrial fibrillation at 80 bpm that is controlled with Cardizem PO
• BP 170/90 bpm
• RR: 26 bpm unlabored and full
• SpO2: 94% on RA
While talking to her, the monitor shows the following rhythm.

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________
PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

21
 Scenario 18
A 62-year-old female presents with blurry vision, weakness, and balance issues for the past week . PMH
includes HTN, alcohol abuse, and tobacco abuse. She is admitted for left cerebellar brain mass and
hyponatremia.

• Allergies: NKDA
• Code Status: Full
• Alert & oriented times 4 & follows command
• Denies chest pain, SOB, or N/V
• BP: 170/90 mm Hg
• RR: 16 bpm unlabored and full
• SpO2: 96% on RA
• #18 saline lock to Left forearm.
• CBC with WNL
• Na+ 129 & K+ 3.4
Monitor shows the below rhythm:

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________
Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

22
 Scenario 19
An 85-year-old female with a PMH of HTN and hyperlipidemia. She is regularly active on her small farm
and has been living independently with no problems. She reports that she has been having “blackout”
spells 2 to 3 times a day and then finds herself on the floor or slumped over in the chair for the past week.
Denies any injuries when she has fallen. She is admitted to the hospital for syncope. Current medications
are valsartan, aspirin, and Lipitor.

• Allergies: PCN & Sulfa

• Alert & oriented times 4, follows commands and has steady gait without assistance.
• #18 saline lock Right forearm
• 12 Lead ECG showed Sinus Rhythm 82 bpm with rare PVCs & PACs
• CBC & CMP with WNL
While receiving bedside report, the patient tells you, “I just blackout for a moment.” A nurse quickly
enters the room with ECG strip of 4 second pause followed by the below rhythm.

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

23
 Scenario 20
A 24-year-old physically fit male with no past medical history is admitted for a left open femur fracture
secondary to a motorcycle crash. He is admitted to the unit s/p left femur ORIF. Vital signs were stable in
the PACU. He received a total 1 mg Dilaudid IVP in PACU 4 hours ago and has required no additional pain
medication. He only takes a multivitamin daily and is a strict vegetarian. He is upset that he cannot
compete in the Boston marathon. He finally qualified after trying for several years.

• Allergies: Dust, Hay & grass & NKDA.

• Code Status: Full
• LR at 100 ml/hr via #16 Left AC
• Current Medications: Cefazolin 1 gm IVPB every 8 X 24 hours, Tylenol q4 hours for mild pain, and
Percocet PO q4 hours for moderate to severe pain
• Post-Op Labs WNL
• Room air
The monitor alarm is activated, and the below rhythm is displayed.

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

24
 Scenario 21
A 55-year-old female with PMH of metastatic bladder cancer status post tumor removal and
chemotherapy in the past 6 months, left ureteral obstruction requiring ureteral stent 1 month ago,
neurogenic bladder, PE, atrial fibrillation, and pacemaker placement 3 years ago. She is admitted for
generalized weakness and lightheadedness.

• Allergies: Bactrim
• Code Status: Full
• Alert & oriented times 4 and moves all extremities to command
• NS at 50 ml/hour per Right PICC
• BP 110/60 mm Hg
• Ventricular Paced & Captured Rhythm 75 bpm
• RR: 14 bpm easy and full
• T: 98.7° Oral
• SpO2: 95% on RA
She calls for the nurse and tells them something is not right. The monitor displays the below rhythm.

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________
PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

25
 Scenario 22
A 45 year-old obese male with a PMH of hyperlipidemia and type 2 DM is admitted for intermittent chest
pain for 2 weeks especially when lifting heavy boxes or raking the leaves in the yard, which was relieved
with rest. Denies tobacco, alcohol, and recreational drug use. 12 lead ECG showed non-specific ST
changes. Chest pain was revealed with NTG SL X 2.

• Allergies: NKDA
• Code Status: Full
• Alert & Orient times 4
• Denies chest pain, SOB, and N/V
• BP: 155/79 mm Hg
• RR: 24 bpm easy
• SpO2: 95% on 2 liters per NC
• CBC & CMP WNL
• Troponins: 1st set not indicative of ACS
Several hours after admission the monitor shows the below rhythm.

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

26
 Scenario 23
You are caring for a 24-year-old quadriplegic male with a tracheostomy. PMH includes a cervical spinal
cord injury secondary to a diving accident 4 months ago. He is admitted for SOB due to pneumonia.
• Allergies: NKDA
• Code Status: Full
• Alert & communicates by mouthing words
• BP 114/67 mm Hg
• RR: 28 bpm labored and noisy
• SpO2: 89% on 40% trach mask
• Left PICC
• Urinary Catheter
While tracheal suctioning the patient, you note the following rhythm on the monitor.

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

27
 Scenario 24
A 58-year-old male is admitted for STEMI and received a drug-eluting stent to LAD 4 hours ago. PMH
includes morbid obesity, asthma, hyperlipidemia, type 2 DM, and ulcerative colitis.
• Allergies: Tylenol
• Code Status: Full
• Vital signs stable
• Denies chest pain and SOB
• CBC & CMP
• Groin site without complications
Upon entering the patient’s room, the monitor displays the below rhythm:

As you are going to call the cardiologist, a nurse yells for you to get back to the room now. The monitor displays the
below rhythm upon your arrival.

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________
PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

28
 Scenario 25
A 72-year-old male with a PMH of AVR 5 years ago and required a permanent pacemaker for complete
heart block, CHF, and HTN. He is admitted for respiratory distress secondary to CHF exacerbation. He was
placed on 50% FiO2 via BiPAP and received 40 mg furosemide IVP.

• Allergies: Lipitor
• Code Status: Full
• Alert & oriented times 4
• RR: 35 bpm labored and using accessory muscles. Coarse crackles throughout lung fields.
• BP: 130/61 mm Hg
• SpO2: 93%
• #20 saline lock Right hand
The following rhythm is on the monitor.

Assess
Rhythm: ____________________ Rate:______________________ P to QRS Ratio: ___________________

PR Interval: ______________________ QRS Duration:_____________________ QT interval:____________

ECG Interpretation:_______________________________________________________________________

Key Clinical Findings: _____________________________________________________________________

Risk Level: NONE LOW MEDIUM HIGH

Intervene
Nursing Actions: ________________________________________________________________________

Anticipated Orders: ______________________________________________________________________

Evaluate
Next Steps: _____________________________________________________________________________

29