CSLB General Building (B) — All Questions

A technician measures the distance from the beginning of the P wave to the beginning of the QRS complex on a strip and counts four small boxes. What is the PR interval, and is it normal?

• a.0.04 second, which is shorter than normal
• b.0.08 second, which is normal
• c.0.16 second, which is normal✓
• d.0.40 second, which is longer than normal

Each small box equals 0.04 second at the standard paper speed of 25 mm/sec, so four small boxes equal 0.16 second. The normal PR interval is 0.12 to 0.20 second, so 0.16 second falls in range. The 0.04 and 0.08 answers miscount the boxes, and 0.40 second would require ten small boxes and would indicate a first-degree AV block.

What is the normal duration of the QRS complex in an adult?

• a.Less than 0.12 second✓
• b.0.12 to 0.20 second
• c.0.20 to 0.36 second
• d.Greater than 0.44 second

A normal QRS is under 0.12 second (fewer than three small boxes) because the ventricles depolarize rapidly through the bundle branches and Purkinje fibers. The 0.12 to 0.20 second range describes the PR interval, not the QRS. Values of 0.20 second or more suggest a bundle branch block or a beat that started in the ventricles, and 0.44 second is a QT-interval reference, not a QRS value.

Using the 300 method on a regular rhythm, a technician counts four large boxes between two consecutive R waves. What is the heart rate?

• a.60 beats per minute
• b.75 beats per minute✓
• c.100 beats per minute
• d.150 beats per minute

The 300 method divides 300 by the number of large boxes between R waves, so 300 divided by 4 equals 75 beats per minute. Sixty would require five large boxes, 100 would require three, and 150 would require two. The method only works when the rhythm is regular, because it assumes every R-R interval is the same.

A patient has an irregular rhythm. The technician counts 11 QRS complexes in a six-second strip. What is the approximate heart rate?

• a.11 beats per minute
• b.22 beats per minute
• c.66 beats per minute
• d.110 beats per minute✓

The six-second method multiplies the number of QRS complexes in six seconds by 10, giving 11 times 10, or about 110 beats per minute. This estimate is the preferred method for irregular rhythms because the 300 and 1500 methods assume equal R-R intervals. Multiplying by 2 or 6 instead of 10 gives the wrong scaling, since six seconds is one tenth of a minute.

What electrical event does the P wave represent on an EKG tracing?

• a.Ventricular repolarization
• b.Ventricular depolarization
• c.Atrial depolarization✓
• d.Atrial repolarization

The P wave is the small rounded deflection produced when the impulse from the SA node spreads across both atria and depolarizes them, which triggers atrial contraction. Ventricular depolarization produces the QRS complex, and ventricular repolarization produces the T wave. Atrial repolarization does occur, but it is buried inside the much larger QRS complex and is not normally visible.

A technician is explaining a tracing to a student and points to the rounded wave that follows each QRS complex. What does this wave represent?

• a.Repolarization of the ventricles✓
• b.Depolarization of the ventricles
• c.Conduction delay at the AV node
• d.Contraction of the atria

The T wave follows the QRS and represents ventricular repolarization, the recovery phase in which the ventricular cells return to their resting electrical state. Ventricular depolarization is the QRS itself. The AV node delay is represented by the flat segment within the PR interval, and atrial contraction follows the P wave.

Using the 1500 method, a technician counts 20 small boxes between two consecutive R waves on a regular strip. What is the heart rate?

• a.50 beats per minute
• b.75 beats per minute✓
• c.100 beats per minute
• d.300 beats per minute

The 1500 method divides 1500 by the number of small boxes between R waves: 1500 divided by 20 equals 75 beats per minute. The number 1500 is used because there are 1500 small boxes in one minute at 25 mm/sec. This method is the most precise of the calculation methods, but like the 300 method it requires a regular rhythm.

Which set of findings meets the criteria for normal sinus rhythm?

• a.Rate 110, regular, one upright P wave per QRS, PR 0.16 second
• b.Rate 80, irregular, P waves absent, QRS 0.08 second
• c.Rate 50, regular, inverted P waves, PR 0.10 second
• d.Rate 80, regular, one upright P wave before every QRS, PR 0.16 second, QRS 0.08 second✓

Normal sinus rhythm requires a rate of 60 to 100, a regular rhythm, one upright P wave in front of every QRS, a PR interval of 0.12 to 0.20 second, and a QRS under 0.12 second. A rate of 110 is sinus tachycardia, absent P waves with an irregular rhythm suggests atrial fibrillation, and a rate of 50 with inverted P waves and a short PR points to a junctional rhythm.

A sleeping athlete on telemetry shows a regular rhythm at 52 beats per minute with an upright P wave before each narrow QRS and a PR interval of 0.16 second. How should this rhythm be identified?

• a.Normal sinus rhythm
• b.Junctional escape rhythm
• c.Sinus bradycardia✓
• d.Second-degree AV block

Every measurement is normal except the rate, which is below 60, so the rhythm is sinus bradycardia. Normal sinus rhythm requires a rate of at least 60. A junctional escape rhythm would show absent or inverted P waves, and a second-degree AV block would show P waves that are not all followed by a QRS complex.

A patient with a fever of 103 degrees Fahrenheit has a regular rhythm at 124 beats per minute with an upright P wave before every narrow QRS. What is this rhythm?

• a.Sinus tachycardia✓
• b.Supraventricular tachycardia
• c.Atrial flutter
• d.Ventricular tachycardia

Sinus tachycardia is a sinus rhythm faster than 100 beats per minute, and it is a normal response to fever, pain, exercise, anxiety, or dehydration. Supraventricular tachycardia is usually faster than 150 and the P waves are hidden. Atrial flutter shows sawtooth flutter waves, and ventricular tachycardia produces wide QRS complexes with no P waves.

A pediatric strip shows upright P waves before every narrow QRS, a PR interval of 0.14 second, and R-R intervals that shorten with inhalation and lengthen with exhalation. What is this rhythm?

• a.Atrial fibrillation
• b.Sinus arrhythmia✓
• c.Wandering atrial pacemaker
• d.Second-degree AV block, Mobitz I

Sinus arrhythmia is a sinus rhythm whose only abnormality is an irregularity that varies with the breathing cycle, and it is a normal finding in children and young adults. Atrial fibrillation would have no identifiable P waves and an irregularly irregular rhythm. Wandering atrial pacemaker shows at least three different P wave shapes, and Mobitz I shows progressively lengthening PR intervals with a dropped QRS.

A strip shows no identifiable P waves, a wavy chaotic baseline, narrow QRS complexes, and R-R intervals that vary from beat to beat with no pattern. What is this rhythm?

• a.Sinus arrhythmia
• b.Atrial flutter
• c.Ventricular fibrillation
• d.Atrial fibrillation✓

Atrial fibrillation is described as irregularly irregular with no discernible P waves and a fibrillatory baseline, while the QRS stays narrow because conduction below the AV node is normal. Sinus arrhythmia still has clear P waves. Atrial flutter has organized sawtooth waves, and ventricular fibrillation has no QRS complexes at all.

A monitor strip shows a sawtooth baseline with regular atrial waves at about 300 per minute and a QRS after every fourth sawtooth wave. What is this rhythm?

• a.Atrial fibrillation
• b.Sinus tachycardia with artifact
• c.Atrial flutter with 4:1 conduction✓
• d.Third-degree AV block

Atrial flutter produces uniform sawtooth flutter waves, classically at 250 to 350 per minute, and the AV node blocks most of them so that only every second, third, or fourth impulse reaches the ventricles. Atrial fibrillation has a chaotic rather than uniform baseline. Sinus tachycardia has discrete P waves, and third-degree block shows normal P waves that are completely unrelated to the QRS complexes.

An otherwise regular sinus strip contains one early beat with a P wave shaped differently from the others, followed by a normal narrow QRS and then a pause. What is the early beat?

• a.Premature atrial contraction✓
• b.Premature ventricular contraction
• c.Premature junctional contraction
• d.Escape beat

A premature atrial contraction arrives early and comes from an irritable site in the atria, so its P wave looks different from the sinus P waves but the QRS remains narrow because conduction to the ventricles is normal. A premature ventricular contraction would be wide and bizarre with no P wave. A junctional premature beat has an inverted or absent P wave, and an escape beat arrives late rather than early.

A patient reports sudden palpitations. The strip shows a perfectly regular narrow-complex rhythm at 180 beats per minute with P waves that cannot be identified. What is the most likely rhythm?

• a.Sinus tachycardia
• b.Supraventricular tachycardia✓
• c.Ventricular tachycardia
• d.Accelerated junctional rhythm

Supraventricular tachycardia is a regular narrow-complex rhythm, usually 150 to 250 beats per minute, in which the P waves are buried in the preceding T waves and cannot be seen. Sinus tachycardia usually stays under 160 and has visible P waves that speed up gradually. Ventricular tachycardia has wide QRS complexes, and an accelerated junctional rhythm runs about 60 to 100.

A strip shows a regular rhythm at 45 beats per minute with narrow QRS complexes and inverted P waves appearing immediately after each QRS. What is this rhythm?

• a.Sinus bradycardia
• b.Idioventricular rhythm
• c.First-degree AV block
• d.Junctional escape rhythm✓

When the junction takes over as pacemaker, the atria depolarize backward, so the P wave is inverted and may fall before, during, or after the QRS; at 40 to 60 beats per minute this is a junctional escape rhythm. Sinus bradycardia has upright P waves before the QRS. An idioventricular rhythm has wide QRS complexes at 20 to 40, and first-degree AV block has upright P waves with a long PR interval.

What is the inherent rate range of the AV junction when it functions as the heart's pacemaker?

• a.100 to 150 beats per minute
• b.60 to 100 beats per minute
• c.40 to 60 beats per minute✓
• d.20 to 40 beats per minute

The AV junction fires at an inherent rate of 40 to 60 beats per minute and takes over when the SA node fails or slows. The SA node is the primary pacemaker at 60 to 100, and the ventricular Purkinje network is the last-resort pacemaker at 20 to 40. A junctional rhythm faster than 60 is called accelerated junctional, and above 100 it is junctional tachycardia.

A sinus rhythm strip contains a single early beat that is wide and bizarre, has no preceding P wave, and has a T wave that points opposite to the QRS. What is the beat?

• a.Premature ventricular contraction✓
• b.Premature atrial contraction
• c.Paced beat
• d.Artifact

A premature ventricular contraction originates below the bundle of His, so the impulse travels cell to cell rather than through the fast conduction system, producing a wide bizarre QRS with no preceding P wave and opposite T wave polarity. A premature atrial contraction stays narrow. A paced beat is preceded by a sharp pacer spike, and artifact does not interrupt the underlying R-R cycle in this way.

A monitor alarms and the strip shows a regular wide-complex rhythm at 170 beats per minute with no visible P waves. The patient is unresponsive. What rhythm is displayed?

• a.Supraventricular tachycardia
• b.Ventricular tachycardia✓
• c.Atrial flutter
• d.Sinus tachycardia with a bundle branch block

Ventricular tachycardia is three or more consecutive PVCs at a rate above 100, appearing as a regular run of wide, uniform complexes without P waves, and it is a lethal rhythm when the patient has no pulse. Supraventricular tachycardia is narrow. Atrial flutter shows sawtooth waves, and while a rate-related bundle branch block can widen a sinus tachycardia, an unresponsive patient with this tracing must be treated as ventricular tachycardia and help summoned at once.

A telemetry strip suddenly shows chaotic, irregular waves of varying height with no identifiable P waves, QRS complexes, or T waves. What should the technician do first?

• a.Reposition the electrodes and print a new strip
• b.Chart the finding and continue monitoring
• c.Ask the patient to lie still and stop talking
• d.Immediately check the patient and call for emergency help✓

That description is ventricular fibrillation, a lethal rhythm in which the ventricles quiver and produce no cardiac output, so the technician must verify the patient at the bedside and activate the emergency response without delay. Documenting and waiting wastes the minutes that determine survival. Repositioning electrodes or asking the patient to hold still is the response to suspected artifact, and artifact is ruled out the moment the patient is found unresponsive and pulseless.

A monitor shows a nearly flat line with no waveforms in two different leads and the patient is unresponsive with no pulse. What is this rhythm?

• a.Ventricular fibrillation
• b.Idioventricular rhythm
• c.Asystole✓
• d.Loose lead artifact

Asystole is the absence of all electrical activity, appearing as a flat or nearly flat line, and it must be confirmed in more than one lead before it is accepted as true. Ventricular fibrillation still shows chaotic deflections, and an idioventricular rhythm shows wide slow complexes. A loose lead can mimic a flat line, which is exactly why the finding is confirmed in a second lead and at the bedside.

A strip shows wide QRS complexes at a regular rate of 32 beats per minute with no P waves. What is this rhythm called?

• a.Idioventricular rhythm✓
• b.Junctional escape rhythm
• c.Sinus bradycardia
• d.Agonal artifact

When the ventricles become the pacemaker of last resort, they fire at their inherent rate of 20 to 40 beats per minute and produce wide complexes without P waves, which is an idioventricular rhythm. A junctional escape rhythm runs 40 to 60 with narrow complexes. Sinus bradycardia has upright P waves and narrow QRS complexes, and this tracing is an organized rhythm rather than artifact.

A regular strip at 68 beats per minute has one upright P wave before every narrow QRS, and every PR interval measures 0.28 second. What is this rhythm?

• a.Normal sinus rhythm
• b.Sinus rhythm with a first-degree AV block✓
• c.Second-degree AV block, Mobitz II
• d.Third-degree AV block

A PR interval that is constant but longer than 0.20 second defines first-degree AV block, in which every impulse still reaches the ventricles but is delayed. Normal sinus rhythm requires a PR of 0.12 to 0.20 second. Mobitz II drops beats without lengthening the PR, and third-degree block shows no consistent relationship between P waves and QRS complexes at all.

A strip shows PR intervals of 0.18, 0.24, 0.32 second, then a P wave with no QRS after it, and the pattern repeats. What is this rhythm?

• a.First-degree AV block
• b.Second-degree AV block, Mobitz II
• c.Third-degree AV block
• d.Second-degree AV block, Mobitz I (Wenckebach)✓

Mobitz I, also called Wenckebach, shows the PR interval getting progressively longer until one P wave is not conducted and a QRS is dropped, then the cycle starts over. First-degree block never drops a beat. Mobitz II drops beats while the conducted PR intervals stay constant, and third-degree block has P waves and QRS complexes that march independently.

A strip shows a constant PR interval of 0.20 second on conducted beats, but every third P wave is suddenly not followed by a QRS complex. What is this rhythm?

• a.Second-degree AV block, Mobitz I
• b.Sinus arrhythmia
• c.Second-degree AV block, Mobitz II✓
• d.Premature atrial contractions that are not conducted

Mobitz II is identified by dropped QRS complexes with no warning and PR intervals that remain constant on the beats that do conduct. Mobitz I would show the PR lengthening before the drop. Sinus arrhythmia never drops a QRS, and non-conducted premature atrial contractions arrive early with abnormal P waves rather than on schedule.

A strip shows a regular ventricular rhythm at 40 beats per minute with wide QRS complexes, regular P waves at 80 per minute, and no consistent relationship between the P waves and the QRS complexes. What is this rhythm?

• a.Second-degree AV block, Mobitz I
• b.Third-degree (complete) AV block✓
• c.Sinus bradycardia with premature atrial contractions
• d.Junctional escape rhythm

In third-degree AV block nothing crosses the AV node, so the atria and ventricles beat independently: the P-P interval is regular, the R-R interval is regular, and the PR interval constantly changes. Mobitz I still conducts most beats with a lengthening PR. Sinus bradycardia keeps one P wave tied to each QRS, and a pure junctional escape rhythm would not show a separate faster atrial rate marching through the tracing.

A strip shows a sharp, narrow vertical spike immediately before each wide QRS complex at a regular rate of 70. What does this indicate?

• a.A ventricular paced rhythm✓
• b.Sixty-cycle AC interference
• c.A premature ventricular contraction pattern
• d.Somatic tremor artifact

A pacemaker spike is a thin vertical line marking the electrical impulse delivered by the device; a spike followed by a wide QRS indicates ventricular capture. AC interference appears as a uniform fuzzy band across the whole tracing rather than a single spike per beat. Premature ventricular contractions occur early and irregularly without spikes, and somatic tremor causes erratic jagged baseline movement.

A monitor alarms for ventricular fibrillation, but the technician finds the patient sitting up, alert, and brushing her teeth, and a regular narrow-complex rhythm is visible between the chaotic sections. What is the most likely explanation?

• a.Intermittent true ventricular fibrillation
• b.Third-degree AV block
• c.Pacemaker malfunction
• d.Muscle movement artifact✓

An alert, talking patient cannot be in ventricular fibrillation, and the presence of underlying normal complexes marching through the chaos identifies the tracing as motion artifact. True ventricular fibrillation has no organized QRS complexes anywhere and produces immediate unresponsiveness. AV block and pacemaker failure both produce organized, measurable patterns rather than chaotic noise tied to the patient's activity.

Which group of rhythms is considered immediately life-threatening and requires the technician to summon help right away?

• a.Sinus bradycardia, sinus tachycardia, and sinus arrhythmia
• b.First-degree AV block, atrial flutter, and premature atrial contractions
• c.Ventricular fibrillation, pulseless ventricular tachycardia, and asystole✓
• d.Junctional rhythm, wandering atrial pacemaker, and paced rhythm

Ventricular fibrillation, pulseless ventricular tachycardia, and asystole produce no effective cardiac output, so survival depends on immediate recognition and activation of the emergency response. The sinus rhythms in the first choice are common and often benign. First-degree block, flutter, and premature atrial beats need reporting but not emergency action, and junctional or paced rhythms usually maintain perfusion.

What does the QT interval measure on an EKG tracing?

• a.The time for the atria to depolarize and repolarize
• b.The total time for ventricular depolarization and repolarization✓
• c.The delay of the impulse at the AV node
• d.The time between two consecutive R waves

The QT interval is measured from the start of the QRS complex to the end of the T wave and represents the full cycle of ventricular depolarization and recovery; it normally occupies less than half of the R-R interval and generally measures under about 0.44 second at normal rates. Atrial activity is represented by the P wave. The AV nodal delay lies inside the PR interval, and the R-R interval measures rate and regularity.

A strip shows a normal sinus beat followed by a wide bizarre beat, then another sinus beat followed by another wide bizarre beat, repeating throughout the strip. What is this pattern called?

• a.Ventricular bigeminy✓
• b.Ventricular trigeminy
• c.A couplet
• d.Ventricular tachycardia

Bigeminy means every other beat is a premature ventricular contraction, alternating one normal beat and one PVC. Trigeminy is a PVC every third beat. A couplet is two PVCs in a row, and three or more consecutive PVCs at a rate above 100 constitute ventricular tachycardia.

Which premature ventricular contraction pattern is considered most dangerous because it can trigger ventricular tachycardia or fibrillation?

• a.A unifocal PVC that is late in the cycle
• b.An interpolated PVC between two normal beats
• c.A PVC followed by a full compensatory pause
• d.A PVC that lands on the T wave of the preceding beat✓

A PVC falling on the T wave, called the R-on-T phenomenon, arrives during the vulnerable relative refractory period of repolarization and can precipitate ventricular tachycardia or fibrillation. Unifocal PVCs that arrive later in the cycle are the least worrisome type. An interpolated PVC does not disturb the underlying rhythm, and a compensatory pause is a normal feature of most PVCs rather than a warning sign.

An otherwise normal sinus strip contains one early narrow beat with an inverted P wave right in front of it and a PR interval of 0.08 second. What is this beat?

• a.Premature atrial contraction
• b.Premature ventricular contraction
• c.Premature junctional contraction✓
• d.Sinus escape beat

A premature junctional contraction comes from the AV junction, so the atria depolarize retrograde and produce an inverted P wave with a short PR of less than 0.12 second, while the QRS stays narrow. A premature atrial contraction has an upright though differently shaped P wave with a normal PR. A PVC is wide with no P wave, and an escape beat comes late, not early.

What is the correct way to determine whether a ventricular rhythm is regular?

• a.Compare the height of each R wave across the strip
• b.Measure the R-to-R intervals across the strip and see whether they are equal✓
• c.Count the number of P waves in six seconds
• d.Compare each PR interval to 0.20 second

Ventricular regularity is judged by marching out the R-to-R intervals with calipers or paper and checking whether they stay the same; atrial regularity is judged the same way using P-to-P intervals. R wave height reflects voltage and lead placement, not regularity. Counting P waves gives the atrial rate, and measuring PR intervals evaluates AV conduction.

On standard EKG paper running at 25 mm/sec, how far apart are the vertical time markers printed at the top of the strip used for the six-second method?

• a.Three seconds apart, so two intervals equal six seconds✓
• b.One second apart, so six intervals equal six seconds
• c.Six seconds apart, so one interval equals six seconds
• d.Half a second apart, so twelve intervals equal six seconds

EKG paper is marked at three-second intervals, which equals 15 large boxes, so a six-second strip spans two marked intervals or 30 large boxes. Each large box is 0.20 second and each small box is 0.04 second at the standard 25 mm/sec speed. The other spacings do not correspond to how standard EKG paper is printed.

Where is the V1 electrode placed for a 12-lead EKG?

• a.Fifth intercostal space, left midclavicular line
• b.Fourth intercostal space, left sternal border
• c.Fifth intercostal space, right sternal border
• d.Fourth intercostal space, right sternal border✓

V1 sits in the fourth intercostal space at the right sternal border, and it is located by walking down from the sternal angle to the second rib, then counting the second, third, and fourth spaces. The fourth space at the left sternal border is V2. The fifth space at the left midclavicular line is V4, and there is no standard chest lead at the fifth space on the right sternal border.

A technician has correctly placed V1. Where does the V2 electrode go?

• a.Directly below V1 in the fifth intercostal space
• b.Midway between V1 and V4
• c.Fourth intercostal space, left sternal border✓
• d.Fifth intercostal space, left anterior axillary line

V2 is placed in the fourth intercostal space at the left sternal border, directly across the sternum from V1. The electrode placed midway between V2 and V4 is V3, and V3 is always positioned after V4 is located. The fifth space at the left anterior axillary line is V5.

Which chest electrode is placed in the fifth intercostal space at the left midclavicular line?

• a.V3
• b.V4✓
• c.V5
• d.V6

V4 is placed in the fifth intercostal space at the left midclavicular line, and it is located before V3 because V3 is defined as the midpoint between V2 and V4. V5 goes at the left anterior axillary line and V6 at the left midaxillary line, both level with V4 rather than following the rib spaces.

After placing V1, V2, and V4, where should the technician place V3?

• a.Midway between V2 and V4✓
• b.Midway between V1 and V2
• c.Directly below V2 in the fifth intercostal space
• d.At the left anterior axillary line level with V4

V3 is placed on a straight line halfway between V2 and V4, which is why V4 must be positioned first. Placing it between V1 and V2 would put it over the sternum. Dropping it straight down from V2 ignores the diagonal path of the chest wall, and the left anterior axillary line position is V5.

A technician is placing V5 on a 12-lead EKG. Which description is correct?

• a.Fifth intercostal space, left midaxillary line
• b.Sixth intercostal space, left anterior axillary line
• c.Fourth intercostal space, left anterior axillary line
• d.Left anterior axillary line, on the same horizontal level as V4✓

V5 is placed at the left anterior axillary line on the same horizontal plane as V4 rather than by counting rib spaces, because the chest wall curves and the horizontal alignment keeps V4, V5, and V6 comparable. The midaxillary line at that level is V6. Counting to the sixth space or the fourth space would place the electrode too low or too high.

Where is the V6 electrode placed?

• a.Left posterior axillary line, level with V4
• b.Sixth intercostal space, left midclavicular line
• c.Left midaxillary line, on the same horizontal level as V4 and V5✓
• d.Fifth intercostal space, right midaxillary line

V6 is placed at the left midaxillary line on the same horizontal plane as V4 and V5, completing the left lateral view of the heart. The posterior axillary line is used only for additional posterior leads such as V7. The right midaxillary line and the sixth space at the midclavicular line are not standard chest lead positions.

Where should the limb electrodes be placed for a standard 12-lead EKG?

• a.On the bony prominences of the wrists and ankles for the best signal
• b.On fleshy, non-muscular areas of the arms and lower legs, positioned symmetrically✓
• c.On the upper chest and abdomen for all four limb leads
• d.Anywhere convenient, since limb lead position does not affect the tracing

Limb electrodes belong on flat, fleshy areas of the arms and lower legs, placed symmetrically on the right and left, because bone conducts poorly and muscle bellies generate tremor artifact. Torso placement is acceptable only for continuous monitoring or when a limb is missing, and it must be documented because it alters the tracing. Limb position does affect amplitude and axis, so it is never arbitrary.

A 12-lead tracing shows an inverted P wave, inverted QRS, and inverted T wave in lead I, while the chest leads look normal. What is the most likely cause?

• a.The right arm and left arm electrodes are reversed✓
• b.The V1 and V2 electrodes are reversed
• c.The right leg electrode is loose
• d.The paper speed is set to 50 mm/sec

Reversing the right and left arm electrodes flips the polarity of lead I, producing a global inversion in that lead while the chest leads, which do not depend on arm placement, remain normal. Reversing V1 and V2 distorts only those chest leads. A loose right leg (ground) electrode causes baseline wander or noise rather than inversion, and a doubled paper speed stretches the complexes without inverting them.

A tracing shows a uniform, thick, fuzzy baseline with small spikes occurring exactly 60 times per second across all leads. What is the most likely cause?

• a.The patient is shivering
• b.The electrodes are dried out
• c.The patient is breathing deeply
• d.Electrical interference from nearby powered equipment✓

Sixty-cycle interference is alternating current picked up from nearby electrical devices, cords, or fluorescent lights, and it produces a perfectly regular fuzzy band at 60 hertz in the affected leads. Shivering produces irregular jagged somatic tremor rather than a uniform pattern. Deep breathing causes a slow wandering baseline, and dried electrodes produce erratic noise or a flat trace in one lead.

An anxious, cold patient produces a tracing with irregular jagged spikes that obscure the small waveforms. What artifact is this and what is the best first correction?

• a.Wandering baseline; ask the patient to hold his breath
• b.AC interference; unplug nearby equipment
• c.Somatic tremor; warm and reposition the patient so the limbs are supported and relaxed✓
• d.Loose electrode; reapply the chest leads

Somatic tremor is muscle-movement artifact from shivering, tension, or involuntary motion, and it is corrected by warming the patient, supporting the arms and legs on the bed, and coaching him to relax. Wandering baseline drifts up and down slowly with respiration. AC interference is a uniform 60-cycle band, and a loose electrode affects only the lead it belongs to.

A tracing shows the baseline slowly drifting up and down in a wave pattern that matches the patient's breathing. What should the technician check first?

• a.Whether the machine is set to 50 mm/sec
• b.Whether the electrodes are loose, dried out, or applied over lotion or oil✓
• c.Whether the arm and leg electrodes are reversed
• d.Whether the standardization is set to 20 mm/mV

A wandering baseline is usually caused by poor electrode contact from loose tabs, dried gel, body lotion, oils, or sweat, and it is also worsened by deep respiration or cable tension. The fix is to clean and dry the skin, apply fresh electrodes, and secure the lead wires. Paper speed and standardization change the size or spacing of the complexes, and lead reversal changes polarity rather than causing drift.

What does the standardization mark on an EKG tracing indicate when it is 10 mm tall?

• a.The machine is calibrated so that 1 millivolt produces a 10 millimeter deflection✓
• b.The paper is running at 10 millimeters per second
• c.The patient's voltage is 10 times normal
• d.Each large box represents 10 milliseconds

Standard calibration is 10 mm per millivolt, printed as a rectangular standardization mark two large boxes tall at the start of the tracing, so that amplitudes can be compared between machines and over time. Paper speed is a separate setting of 25 mm/sec. The mark says nothing about the patient's own voltage, and each large box represents 0.20 second, not 10 milliseconds.

At the standard paper speed, how much time does one small box represent, and what is that speed?

• a.0.20 second at 25 mm/sec
• b.0.04 second at 50 mm/sec
• c.0.10 second at 25 mm/sec
• d.0.04 second at 25 mm/sec✓

Standard EKG paper runs at 25 millimeters per second, so each 1 mm small box equals 0.04 second and each 5 mm large box equals 0.20 second. The 0.20 second value belongs to the large box, not the small one. A speed of 50 mm/sec is a special setting used to spread out very fast rhythms, and 0.10 second does not correspond to any standard box.

How much time and voltage does one large box on standard EKG paper represent?

• a.0.04 second and 1 millimeter of height
• b.0.10 second and 10 millimeters of height
• c.0.20 second and 5 millimeters of height✓
• d.0.50 second and 5 millimeters of height

A large box is five small boxes across and five tall, so it represents 0.20 second horizontally and 5 millimeters, or 0.5 millivolt, vertically at standard calibration. The 0.04 second and 1 millimeter values describe a small box. The 0.10 and 0.50 second values do not match standard paper, where five large boxes equal one second.

A patient has a hairy chest and oily skin. What is the correct skin preparation before applying chest electrodes?

• a.Apply the electrodes over the hair and press firmly
• b.Clip the hair at each site, cleanse the skin with alcohol, let it dry, and gently abrade with a dry gauze✓
• c.Shave the entire chest with a razor and apply lotion to soothe the skin
• d.Wipe the chest with a povidone-iodine swab and apply electrodes while still wet

Good skin prep means clipping excess hair only at the electrode sites, cleansing with alcohol to remove oils, allowing the skin to dry completely, and lightly abrading with dry gauze to reduce resistance. Applying electrodes over hair or wet skin causes poor contact and wandering baseline. Lotion insulates the skin, and full shaving with a razor is unnecessary and risks nicks that break the skin barrier.

A technician is setting up 5-lead telemetry monitoring. Which placement follows the standard color convention?

• a.White on the right shoulder, black on the left shoulder, green on the right lower abdomen, red on the left lower abdomen, brown on the chest✓
• b.White on the left shoulder, black on the right shoulder, red on the right lower abdomen, green on the left lower abdomen, brown on the chest
• c.All five electrodes across the upper chest in a row
• d.White and black on the legs, red and green on the arms, brown on the back

The standard 5-lead convention is white on the right upper chest, black on the left upper chest, green on the right lower chest or abdomen, red on the left lower chest or abdomen, and brown as the chest lead, remembered as white on right, smoke over fire, and clouds over grass. Swapping white and black reverses lead I. Clustering the electrodes together or moving them to the limbs destroys the intended vectors.

How many electrodes are applied for standard 3-lead cardiac monitoring, and what do they produce?

• a.Three electrodes producing all 12 leads
• b.Five electrodes producing leads I, II, and III
• c.Three electrodes producing leads I, II, and III✓
• d.Three electrodes producing leads V1 through V3

Three-lead monitoring uses three electrodes, usually right arm, left arm, and left leg positions, and generates the three bipolar limb leads I, II, and III, with lead II most often selected because it shows P waves well. Twelve leads require ten electrodes. Five-lead systems add a ground and a chest lead, and V1 through V3 are precordial leads that a 3-lead setup cannot produce.

The QRS complexes on a 12-lead tracing are so tall that they run off the paper and overlap the lead above. What is the appropriate action?

• a.Increase the paper speed to 50 mm/sec
• b.Change the standardization to half sensitivity (5 mm/mV) and document the change on the tracing✓
• c.Move the chest electrodes one intercostal space lower
• d.Reduce the gain until the complexes look like the patient's last EKG

When complexes are too tall to fit, the machine is switched to half standardization, so 1 millivolt produces a 5 millimeter deflection, and the change must be marked on the tracing so the physician can interpret amplitudes correctly. Increasing paper speed widens complexes but does not lower their height. Moving electrodes falsifies the anatomic view, and adjusting the gain to match a prior tracing is not an accepted practice.

A patient's heart rate is so fast that the complexes are crowded together and hard to measure. Which machine adjustment can help, and what must the technician remember?

• a.Reduce paper speed to 12.5 mm/sec; intervals will read the same
• b.Set standardization to 20 mm/mV; intervals will read the same
• c.Reduce paper speed to 10 mm/sec; intervals will double
• d.Increase paper speed to 50 mm/sec; each small box now equals 0.02 second and the change must be noted✓

Doubling the paper speed to 50 mm/sec spreads the complexes apart for easier measurement, but each small box then represents 0.02 second instead of 0.04 second, so the change must be documented or intervals will be misread. Slower speeds compress the tracing further. Standardization changes amplitude, not timing, and intervals never simply double without accounting for the new time scale.

What is the standard patient position for obtaining a resting 12-lead EKG?

• a.Supine with arms resting at the sides and legs uncrossed✓
• b.Sitting upright with the arms folded across the chest
• c.Standing with the arms extended
• d.Left lateral with the knees drawn up

The standard resting EKG is taken with the patient supine, arms relaxed at the sides, legs flat and uncrossed, so muscle tension and limb contact do not distort the tracing. Folded arms and crossed legs create somatic tremor and can bridge electrodes. Standing or lying on the side shifts the heart within the chest and changes the tracing, so any deviation must be documented.

A patient with severe shortness of breath cannot tolerate lying flat for a 12-lead EKG. What should the technician do?

• a.Refuse to perform the test until the patient can lie flat
• b.Lay the patient flat quickly and finish before symptoms worsen
• c.Raise the head of the bed to a semi-Fowler position, obtain the tracing, and document the position used✓
• d.Have the patient sit on the edge of the bed and hold the electrodes in place

Patient comfort and safety come first, so the head of the bed is raised to a tolerable semi-Fowler position, and the non-standard position is documented on the tracing because it can alter waveform amplitude and axis. Forcing a dyspneic patient flat risks harm. Refusing to test delays care, and holding electrodes by hand introduces motion artifact and unreliable contact.

A physician orders right-sided chest leads on a patient with a suspected right ventricular infarction. Which electrode position corresponds to V4R?

• a.Fourth intercostal space, left sternal border
• b.Fifth intercostal space, right midclavicular line✓
• c.Fifth intercostal space, left midaxillary line
• d.Second intercostal space, right sternal border

Right-sided leads mirror the standard positions across the chest, so V4R sits in the fifth intercostal space at the right midclavicular line and is the single most useful lead for right ventricular infarction. The fourth space at the left sternal border is standard V2. The left midaxillary position is V6, and the second space at the right sternal border is not a chest electrode site.

A patient has a right below-the-knee amputation. How should the technician place the limb electrodes?

• a.Omit the right leg electrode entirely and run a 9-lead tracing
• b.Place both leg electrodes on the intact left leg, several inches apart
• c.Place the right leg electrode on the right arm
• d.Place the right leg electrode on the right lower torso and place the left leg electrode symmetrically, then document the modification✓

When a limb is missing, the electrode is moved to the nearest torso location on the same side and the opposite limb electrode is moved to match, keeping the tracing symmetric, and the modification is documented for the interpreting physician. Omitting an electrode prevents the machine from producing a valid tracing. Doubling up on one leg or moving a leg lead to an arm distorts the frontal-plane leads.

When performing a 12-lead EKG on a female patient with large breast tissue, where should the V4 and V5 electrodes be placed?

• a.Under the breast, directly on the chest wall at the correct anatomic landmarks✓
• b.On top of the breast tissue at approximately the right level
• c.Above the breast to avoid touching it
• d.On the back, opposite the usual positions

Chest electrodes are placed beneath the breast on the chest wall at the true anatomic landmarks, because breast tissue between the electrode and the heart reduces voltage and distorts the tracing. Placing electrodes on top of or above the breast produces inaccurate amplitudes. Back placement is used only for special posterior leads. The patient's privacy is protected with draping throughout.

On a 12-lead tracing, leads I, II, and aVR are clean, but lead III alone shows an erratic, noisy trace. What is the most likely cause?

• a.The patient is having a myocardial infarction affecting only the inferior wall
• b.The paper speed is incorrect
• c.A single electrode or lead wire connection is loose or dried out✓
• d.Alternating current interference from the room lighting

Artifact confined to one lead points to a problem with a specific electrode or lead wire, since each limb lead uses a different combination of electrodes; the fix is to reapply that electrode and reseat the wire. A true infarction produces recognizable ST or Q wave changes across a group of leads rather than random noise. Paper speed errors and AC interference affect the entire tracing, not one lead.

A technician opens a package of disposable electrodes and finds the conductive gel is dry and crusted. What should be done?

• a.Moisten the electrodes with tap water and use them
• b.Discard the package and open fresh electrodes within their expiration date✓
• c.Add alcohol to the gel to soften it
• d.Use them anyway and increase the machine gain to compensate

Dried electrodes cannot conduct properly and cause wandering baseline and false readings, so they are discarded and replaced with fresh, unexpired electrodes stored in a sealed package. Water and alcohol are not substitutes for conductive gel and alcohol actually increases resistance once it dries. Increasing gain amplifies the artifact along with the signal and does not fix the contact problem.

A tracing shows steady 60-cycle interference. Which troubleshooting sequence is most appropriate?

• a.Increase the paper speed and reprint
• b.Apply new electrodes and ask the patient to breathe deeply
• c.Switch the machine to half standardization
• d.Unplug nearby electrical equipment, move the cables away from power cords, verify the ground electrode, and confirm the patient is not touching metal✓

Sixty-cycle interference comes from surrounding alternating current, so the corrections are environmental: turn off or unplug nearby devices, separate the patient cable from power cords, verify a good ground electrode, and keep the patient from contacting the bed rails or other metal. Paper speed and standardization changes alter the display without removing the noise, and deep breathing worsens baseline wander rather than fixing interference.

Before beginning a shift, a technician inspects the EKG machine. Which finding requires the machine be removed from service?

• a.A frayed patient cable with exposed wire✓
• b.A paper roll that is about half full
• c.A standardization mark measuring exactly 10 millimeters
• d.Electrode tabs stored in a sealed, unexpired package

A frayed cable with exposed conductor is an electrical hazard and a source of artifact, so the machine is tagged and removed from service until repaired. A half-full paper roll is simply replaced or monitored. A 10 millimeter standardization mark is the correct calibration, and sealed unexpired electrodes are exactly what should be stocked.

What is the inherent firing rate of the sinoatrial node in a healthy adult?

• a.20 to 40 beats per minute
• b.40 to 60 beats per minute
• c.60 to 100 beats per minute✓
• d.100 to 150 beats per minute

The SA node in the upper right atrium is the heart's primary pacemaker and fires 60 to 100 times per minute, which is why normal sinus rhythm is defined by that range. The AV junction fires at 40 to 60 as a backup, and the Purkinje network fires at 20 to 40 as the last resort. A rate of 100 to 150 is a tachycardia, not an inherent pacemaker rate.

A patient's SA node fails completely. Which structure normally takes over, and at what rate?

• a.The Purkinje fibers at 60 to 100 beats per minute
• b.The AV junction at 40 to 60 beats per minute✓
• c.The bundle branches at 100 to 120 beats per minute
• d.The atrial muscle at 20 to 40 beats per minute

The AV junction is the secondary pacemaker and assumes control at 40 to 60 beats per minute when the SA node fails, producing a junctional escape rhythm with absent or inverted P waves. The Purkinje network fires only at 20 to 40 and takes over if the junction also fails. Bundle branches conduct rather than pace at a fast rate, and general atrial muscle is not a designated escape pacemaker.

What is the inherent rate of the Purkinje fibers, and what does a rhythm at that rate look like?

• a.60 to 100 beats per minute with narrow complexes
• b.40 to 60 beats per minute with inverted P waves
• c.100 to 150 beats per minute with sawtooth waves
• d.20 to 40 beats per minute with wide QRS complexes and no P waves✓

The Purkinje network is the heart's pacemaker of last resort at 20 to 40 beats per minute, and because the impulse starts below the AV junction, the QRS is wide and no P waves precede it. The 60 to 100 range belongs to the SA node and produces narrow complexes with upright P waves. The 40 to 60 range with inverted P waves describes a junctional rhythm, and sawtooth waves indicate atrial flutter.

What is the correct order of the cardiac electrical conduction pathway?

• a.SA node, AV node, bundle of His, right and left bundle branches, Purkinje fibers✓
• b.AV node, SA node, Purkinje fibers, bundle of His, bundle branches
• c.SA node, bundle of His, AV node, Purkinje fibers, bundle branches
• d.Purkinje fibers, bundle branches, bundle of His, AV node, SA node

The impulse begins in the SA node, spreads across the atria to the AV node, passes through the bundle of His, splits into the right and left bundle branches, and ends in the Purkinje fibers that depolarize the ventricular muscle. Any sequence that starts at the AV node or the Purkinje fibers reverses normal physiology, and the bundle of His always lies below the AV node, never above it.

Why does the impulse pause briefly at the AV node, and how does that pause appear on the EKG?

• a.To let the ventricles repolarize; it appears as the T wave
• b.To let the coronary arteries fill; it appears as the QT interval
• c.To let the atria finish contracting and fill the ventricles; it appears as the flat segment of the PR interval✓
• d.To slow the SA node; it appears as the ST segment

The AV node delays the impulse about a tenth of a second so the atria can complete their contraction and top off ventricular filling before the ventricles fire, and that delay is the flat portion of the PR interval between the end of the P wave and the start of the QRS. The T wave represents ventricular repolarization. The ST segment is the interval between depolarization and repolarization of the ventricles, and the AV node does not regulate the SA node.

What is depolarization?

• a.The relaxation of cardiac muscle as it returns to its resting state
• b.The electrical discharge of cardiac cells that stimulates contraction✓
• c.The flow of blood into the coronary arteries
• d.The closing of the atrioventricular valves

Depolarization is the rapid electrical change across the cell membrane that triggers mechanical contraction, and it produces the P wave in the atria and the QRS complex in the ventricles. Relaxation and electrical recovery are repolarization. Coronary filling and valve closure are mechanical events of the cardiac cycle, not the electrical activity the EKG records.

A student asks why an EKG can look normal in a patient whose heart is not pumping effectively. What is the best explanation?

• a.The EKG measures blood pressure, not electrical activity
• b.The EKG only records the atria
• c.EKG machines are frequently inaccurate
• d.The EKG records electrical activity, and electrical activity can be present without effective mechanical contraction✓

An EKG records only the electrical events of the heart, so an organized rhythm can appear on the monitor while the heart produces no pulse, a situation known as pulseless electrical activity. This is exactly why the technician always confirms the patient's condition rather than treating the monitor. The EKG does not measure pressure or output, and it records both atrial and ventricular activity.

What is the correct path of blood through the heart, starting with deoxygenated blood returning from the body?

• a.Right atrium, tricuspid valve, right ventricle, pulmonic valve, lungs, left atrium, mitral valve, left ventricle, aorta✓
• b.Left atrium, mitral valve, left ventricle, lungs, right atrium, tricuspid valve, right ventricle, aorta
• c.Right atrium, mitral valve, right ventricle, aorta, lungs, left atrium, tricuspid valve, left ventricle
• d.Right ventricle, right atrium, lungs, left ventricle, left atrium, aorta

Deoxygenated blood enters the right atrium from the venae cavae, passes the tricuspid valve into the right ventricle, leaves through the pulmonic valve to the lungs, returns oxygenated to the left atrium, crosses the mitral valve into the left ventricle, and exits through the aortic valve to the body. The mitral valve is always on the left and the tricuspid on the right, and blood always flows atrium to ventricle, never the reverse.

Which valve separates the right atrium from the right ventricle?

• a.Mitral valve
• b.Aortic valve
• c.Tricuspid valve✓
• d.Pulmonic valve

The tricuspid valve, named for its three cusps, lies between the right atrium and right ventricle and prevents backflow during ventricular systole. The mitral valve is the corresponding atrioventricular valve on the left side. The pulmonic and aortic valves are semilunar valves that guard the exits from the right and left ventricles.

When does blood flow into the coronary arteries to supply the heart muscle itself?

• a.During ventricular systole, when pressure is highest
• b.During ventricular diastole, when the heart muscle is relaxed✓
• c.Only during atrial contraction
• d.Continuously and equally throughout the cardiac cycle

The coronary arteries branch from the base of the aorta and fill primarily during diastole, because during systole the contracting myocardium compresses the vessels running through it. This is one reason very fast heart rates, which shorten diastole, can provoke ischemia. Atrial contraction contributes to ventricular filling, not coronary perfusion, and coronary flow is distinctly phasic rather than constant.

How is cardiac output calculated?

• a.Systolic pressure minus diastolic pressure
• b.Heart rate divided by stroke volume
• c.Stroke volume multiplied by blood pressure
• d.Heart rate multiplied by stroke volume✓

Cardiac output equals heart rate times stroke volume, the amount of blood ejected by the left ventricle each beat, and it is normally about 4 to 8 liters per minute in an adult. Subtracting diastolic from systolic pressure gives pulse pressure. Dividing rate by stroke volume or multiplying stroke volume by blood pressure produces no meaningful physiologic measurement.

What happens during ventricular diastole?

• a.The ventricles relax and fill with blood✓
• b.The ventricles contract and eject blood
• c.The atrioventricular valves snap shut
• d.Blood is forced into the aorta and pulmonary artery

Diastole is the relaxation and filling phase, during which the atrioventricular valves are open and blood flows from the atria into the ventricles. Contraction and ejection define systole. The atrioventricular valves close at the start of systole, and blood enters the great vessels only when the ventricles contract.

A patient arrives with crushing chest pain radiating to the left jaw. The 12-lead shows ST segment elevation in leads II, III, and aVF. What does this pattern most likely represent?

• a.Normal early repolarization
• b.Atrial enlargement
• c.Pericardial friction
• d.An acute myocardial infarction involving the inferior wall✓

ST segment elevation in a group of anatomically related leads is the classic sign of acute myocardial injury, and leads II, III, and aVF look at the inferior wall of the left ventricle. The technician does not diagnose but must recognize the pattern and notify the nurse or physician immediately. Atrial enlargement changes the P wave, not the ST segment, and benign early repolarization does not appear with this presentation of severe radiating pain.

How does stable angina differ from a myocardial infarction?

• a.Angina causes permanent muscle death; an infarction does not
• b.Angina is temporary ischemia relieved by rest or nitroglycerin, while an infarction is prolonged blockage causing tissue death✓
• c.Angina always shows ST elevation; an infarction never does
• d.Angina occurs only at rest; an infarction occurs only with exertion

Angina is chest pain from temporary oxygen shortage in the myocardium, typically brought on by exertion and relieved within minutes by rest or nitroglycerin, and it may show transient ST depression or T wave inversion. A myocardial infarction is sustained occlusion that kills muscle tissue and often produces ST elevation and later Q waves. It is the infarction, not angina, that causes permanent damage.

A patient scheduled for an EKG has ankle swelling, shortness of breath when lying flat, and a history of congestive heart failure. What is happening physiologically?

• a.The coronary arteries are completely blocked
• b.The SA node has stopped firing
• c.The heart cannot pump effectively, so blood backs up into the lungs and peripheral tissues✓
• d.The electrical conduction system has been severed

In congestive heart failure the weakened ventricle cannot move the volume delivered to it, so fluid backs up behind the failing side, causing pulmonary congestion and orthopnea on the left and peripheral edema on the right. Complete coronary occlusion describes an infarction. SA node failure produces an escape rhythm, and a severed conduction system is not a mechanism of chronic heart failure.

Long-standing untreated hypertension most commonly produces which EKG-related change?

• a.Left ventricular hypertrophy with increased QRS voltage in the left-sided leads✓
• b.Absent P waves in every lead
• c.A shortened QT interval below 0.20 second
• d.Pacemaker spikes before each QRS

Chronic high blood pressure forces the left ventricle to work against increased resistance, so the muscle thickens and generates larger voltage, appearing as tall R waves in the left-sided leads and deep S waves in V1 and V2. Absent P waves indicate atrial fibrillation or a junctional rhythm. A QT under 0.20 second is not a hypertension finding, and pacemaker spikes come from an implanted device.

Which layer of the heart wall is the thick muscular layer responsible for contraction?

• a.Pericardium
• b.Endocardium
• c.Epicardium
• d.Myocardium✓

The myocardium is the middle, muscular layer whose contraction generates the pumping force, and it is the tissue damaged in a myocardial infarction. The endocardium is the thin inner lining in contact with the blood. The epicardium is the outer surface layer of the heart, and the pericardium is the surrounding sac.

Why is the left ventricle the thickest chamber of the heart?

• a.It holds the largest volume of blood
• b.It must generate enough pressure to pump blood through the entire systemic circulation✓
• c.It contains the SA node and needs extra muscle to protect it
• d.It receives blood directly from the venae cavae

The left ventricle pumps against the high resistance of the systemic circuit, so its wall is roughly three times thicker than the right ventricle, which only pumps to the nearby low-pressure lungs. Both ventricles eject about the same volume per beat, so volume is not the reason. The SA node sits in the right atrium, and the venae cavae empty into the right atrium.

Before performing an EKG on an inpatient, how should the technician identify the patient?

• a.Confirm the room and bed number on the order
• b.Call the patient's name and proceed if someone answers
• c.Use two patient identifiers, such as having the patient state name and date of birth and comparing them to the armband and order✓
• d.Ask the family member at the bedside to confirm who the patient is

Two patient identifiers, most commonly full name and date of birth verified against the armband and the order, are the accepted standard, and the patient states them rather than confirming a name read aloud. Room and bed numbers change and are never acceptable identifiers. Patients may answer to the wrong name when medicated or hard of hearing, and family confirmation does not replace the required two identifiers.The Joint Commission National Patient Safety Goal 01.01.01

An EKG technician looks up the chart of a coworker who was admitted overnight, out of concern for her wellbeing. Is this permitted?

• a.No, accessing records without a treatment, payment, or operations purpose violates patient privacy law✓
• b.Yes, because the technician is an employee of the facility
• c.Yes, as long as the technician does not tell anyone what she reads
• d.Yes, if the coworker is a personal friend

Federal privacy rules limit access to protected health information to what is necessary for a person's own job duties, so browsing a coworker's chart out of curiosity or concern is a reportable violation regardless of intent. Employment grants access only to the records needed for assigned care. Keeping the information secret does not cure the improper access, and a personal relationship is not a permitted purpose.HIPAA

Two technicians are discussing a patient's abnormal EKG in a crowded elevator. What is the problem?

• a.Nothing, as long as they do not use the patient's last name
• b.Nothing, because both are employees of the facility
• c.It is only a problem if a family member is present
• d.Protected health information is being disclosed where unauthorized people can overhear it✓

Discussing a patient where visitors and unrelated staff can overhear is an improper disclosure of protected health information, and clinical conversations belong in private areas. Omitting the last name does not protect a patient who can still be identified from context. Being coworkers permits discussion only when there is a treatment need and a private setting, and the violation exists whether or not a relative happens to be present.HIPAA

When must an EKG technician perform hand hygiene?

• a.Only after contact with blood or body fluids
• b.Before and after every patient contact, after removing gloves, and after contact with contaminated equipment✓
• c.Only at the beginning and end of the shift
• d.Only when the hands look visibly soiled

Hand hygiene is required before and after every patient contact, after glove removal, and after touching potentially contaminated surfaces or equipment, because gloves can have unseen defects and hands become contaminated during removal. Waiting for visible soil or for blood exposure ignores the routine transfer of organisms. Shift-based washing leaves every patient in between unprotected.CDC Guideline for Hand Hygiene in Health-Care Settings

A patient's chest has an open, draining wound near a chest electrode site. What does the bloodborne pathogens standard require of the technician?

• a.Nothing special, since EKG testing is noninvasive
• b.Apply the electrode directly over the wound to preserve accurate placement
• c.Treat blood and body fluids as infectious, wear appropriate personal protective equipment, and avoid placing the electrode on broken skin✓
• d.Refuse to perform the test and send the patient home

The bloodborne pathogens standard requires that all blood and other potentially infectious material be treated as infectious, so gloves and any other indicated protective equipment are worn and contaminated items are disposed of properly. Electrodes are never applied over broken or draining skin; the site is shifted slightly and the change documented. Noninvasive testing does not exempt the technician, and refusing care is not an option.OSHA 29 CFR 1910.1030

A patient asks the EKG technician, "Does this tracing mean I had a heart attack?" What is the appropriate response?

• a.Explain that the physician interprets the tracing and will discuss the results, and notify the nurse of the patient's question✓
• b.Tell the patient the tracing looks like an infarction
• c.Reassure the patient that the tracing looks completely normal
• d.Hand the tracing to the patient so he can read it himself

Interpreting and diagnosing are outside the EKG technician's scope of practice, so the correct answer refers the question to the provider while acknowledging the patient's concern and passing it on to the nurse. Offering either an abnormal or a reassuring interpretation exceeds the technician's role and may be wrong. Releasing the tracing directly to the patient bypasses the provider and the facility's record release process.

While attaching electrodes, the technician sees ventricular fibrillation appear on the screen and the patient becomes unresponsive. What is the first action?

• a.Finish the 12-lead so the physician has a complete record
• b.Document the time and rhythm in the chart
• c.Reposition the electrodes to rule out artifact
• d.Call for help and activate the facility's emergency response, then begin CPR according to training✓

Ventricular fibrillation in an unresponsive patient is a cardiac arrest, and survival depends on immediate activation of the emergency response and prompt CPR and defibrillation. Completing the test or charting first wastes critical minutes. Checking for artifact is appropriate only when the patient is awake and stable, which is not the case here.

During a treadmill stress test, the patient reports chest pain and the monitor shows new ST segment depression. What should the technician do?

• a.Increase the speed to complete the protocol stage
• b.Stop the test, notify the supervising physician or nurse immediately, and monitor the patient✓
• c.Tell the patient the pain is normal and continue
• d.Turn off the monitor so the patient does not become anxious

New chest pain or significant ST changes are recognized indications to terminate a stress test, and the supervising provider must be notified at once while the patient is monitored during recovery. Advancing the protocol increases myocardial oxygen demand and risk. Dismissing symptoms is unsafe, and turning off monitoring removes the very information needed to manage the event.

Which information must appear on every EKG tracing?

• a.The technician's home phone number and the machine serial number only
• b.The patient's diagnosis and insurance carrier
• c.The patient's full name and identifier, the date and time of the tracing, and the technician's identification✓
• d.The patient's next appointment date

A tracing is a legal part of the medical record and must identify the patient, the exact date and time it was taken, and the person who took it, along with any deviations such as altered electrode placement or non-standard settings. Diagnoses are supplied by the interpreting physician, not the technician. Insurance and appointment details belong elsewhere in the record, and personal contact information is never placed on a tracing.

What is appropriate routine maintenance for EKG equipment between patients?

• a.Wipe the machine, cables, and any reusable electrodes with an approved disinfectant, untangle and inspect the lead wires, and restock supplies✓
• b.Soak the entire patient cable in disinfectant solution
• c.Wrap the lead wires tightly around the machine to save space
• d.Clean the machine only when it appears visibly dirty

Between patients the machine surfaces, cables, and reusable components are wiped with a facility-approved disinfectant, wires are inspected for cracks and gently uncoiled, and supplies are restocked so the unit is ready. Immersing a patient cable damages the connectors and creates an electrical hazard. Wrapping wires tightly breaks the internal conductors and causes artifact, and waiting for visible soil ignores unseen contamination.

A patient is being fitted with a 24-hour Holter monitor. Which instruction is correct?

• a.Remove the electrodes at night and reapply them in the morning
• b.Avoid all physical activity so the recording stays clean
• c.Take the monitor off for showers and note the time
• d.Keep a diary of activities and symptoms with the times they occur, and do not get the monitor wet✓

The value of a Holter study comes from matching recorded rhythm changes to the patient's diary of activities and symptoms, so accurate timed entries are essential and the device must stay on and dry for the full recording period. Removing electrodes at night or for showers creates gaps in exactly the data being sought. Patients are told to follow their normal routine, not to avoid activity, because the goal is to capture everyday events.

What is the purpose of telemetry monitoring?

• a.To record a permanent 12-lead tracing once per shift
• b.To transmit a patient's cardiac rhythm continuously by radio signal to a central monitoring station✓
• c.To measure blood pressure automatically every fifteen minutes
• d.To record heart sounds for later review

Telemetry uses a small battery-powered transmitter worn by the patient to send the rhythm wirelessly to a central station, allowing continuous observation while the patient moves about the unit. A 12-lead EKG is a separate diagnostic test taken with a stationary machine. Blood pressure monitoring and heart sound recording use entirely different equipment.

Which instructions should a patient receive before a scheduled exercise stress test?

• a.Eat a large meal beforehand and drink coffee for energy
• b.Wear dress shoes and take all usual medications without mentioning them
• c.Avoid food, caffeine, and tobacco for the hours before the test as directed, wear comfortable clothing and walking shoes, and review current medications with the provider✓
• d.Stop all medications for one week before the test

Standard stress test preparation includes fasting and avoiding caffeine and tobacco for the period the facility specifies, wearing comfortable two-piece clothing and supportive walking shoes, and reviewing medications with the provider since drugs such as beta blockers affect the heart rate response. Eating heavily or drinking coffee alters the results. Dress shoes are unsafe on a treadmill, and patients never stop medications on their own.

An anxious patient is trembling and asks whether the EKG will shock her. What is the best response?

• a.Explain in simple terms that the machine only records the heart's own electrical signals and does not deliver any current, then help her get comfortable✓
• b.Tell her not to worry about it and start the test
• c.Explain the full electrical engineering of the machine in technical detail
• d.Have her sign the consent form and proceed without discussion

Clear, simple explanation reduces anxiety, and a relaxed patient also produces a tracing free of somatic tremor artifact, so communication is both a professional and a technical necessity. Dismissing the concern leaves the patient frightened and tense. Overly technical explanations confuse rather than reassure, and obtaining a signature without addressing the question is not informed cooperation.

A competent adult patient refuses to allow an ordered EKG. What should the technician do?

• a.Perform the test anyway because a physician ordered it
• b.Tell the patient he will be billed if he refuses
• c.Have a family member give permission instead
• d.Stop, respect the refusal, and notify the nurse or ordering provider and document what occurred✓

A competent adult has the right to refuse any procedure, and proceeding without consent could constitute battery, so the technician stops, reports the refusal to the nurse or provider, and documents it. A physician order does not override the patient's decision. Threatening the patient with charges is coercion, and a family member cannot consent for a competent adult.

A technician sustains a needlestick-free but bloody scratch from a broken bed rail while positioning a patient. What is the required response?

• a.Finish the EKG and mention it at the end of the shift
• b.Wash the area immediately, report the exposure incident to the supervisor at once, and follow the facility's post-exposure evaluation protocol✓
• c.Cover it with a glove and continue with all patients
• d.Document it in the patient's chart only

The bloodborne pathogens standard requires that exposure incidents be washed immediately and reported without delay so the employer can provide a confidential medical evaluation and any indicated post-exposure follow-up, which is time-sensitive. Delaying the report until the shift ends can forfeit protection. Covering the wound and continuing risks both the technician and patients, and an employee exposure belongs in an incident report, not the patient's chart.OSHA 29 CFR 1910.1030

A technician notices she wrote the wrong date on a completed paper EKG record. How should the correction be made?

• a.Erase the entry and write the correct date
• b.Cover the error with correction fluid and write over it
• c.Draw a single line through the error, write the correct information, and add her initials and the date of the correction✓
• d.Shred the record and print a new one without noting the change

Legal health records are corrected by drawing one line through the error so it remains readable, entering the correct information, and initialing and dating the change, which preserves an honest audit trail. Erasing or covering the entry destroys the original and looks like concealment. Destroying a record and silently replacing it is falsification of a medical record.

An outpatient's routine 12-lead shows a run of ventricular tachycardia, but the patient feels fine and asks to leave. What should the technician do?

• a.Keep the patient in the department and notify the physician or nurse immediately about the critical finding✓
• b.Give the patient the tracing and let him take it to his next appointment
• c.Repeat the tracing until a normal one is obtained, then release the patient
• d.Reassure the patient and let him leave, filing the tracing for review later

A critical finding such as ventricular tachycardia is reported to the provider immediately and the patient is kept under observation, because a symptom-free patient can deteriorate without warning. Filing the tracing for later review delays urgent care. Repeating the study until it looks normal conceals a real finding, and handing the tracing to the patient shifts a clinical responsibility onto him.

Which action best reflects professional behavior for an EKG technician?

• a.Posting an interesting anonymized rhythm strip on social media
• b.Telling a patient's spouse the results while the patient is in radiology
• c.Performing a lab draw because the unit is short staffed and the tech has watched it done
• d.Introducing herself by name and title, explaining the procedure, and performing only tasks within her training and scope✓

Professionalism means identifying yourself and your role, explaining what you will do, and working strictly within your training and scope of practice. Posting strips online risks re-identification and violates patient privacy even when names are removed. Sharing results with a spouse without authorization is an improper disclosure, and performing an untrained procedure exceeds scope regardless of staffing pressure.