BSMH ADVANCED ARRHYTHMIA ACTUAL
EXAM PREP 2026 ALL QUESTIONS AND
CORRECT DETAILED ANSWERS ALREADY A
GRADED WITH EXPERT FEEDBACK |NEW AND
REVISED
1. A patient presents with a regular narrow QRS tachycardia at 180 bpm. Carotid
sinus massage slows the rate transiently, then the tachycardia resumes. Which
arrhythmia is most likely?
A. Atrial fibrillation
B. Atrial flutter with variable block
C. Atrioventricular nodal reentrant tachycardia (AVNRT)
D. Monomorphic ventricular tachycardia
Rationale: AVNRT is a regular narrow-complex tachycardia often terminated or
transiently slowed by vagal maneuvers. Atrial fibrillation is irregular. Atrial
flutter with variable block is usually irregular when variable. VT is wide
complex.
2. Which ECG finding is most characteristic of hypothermia?
A. Prolonged QT interval
B. Osborne (J) wave
C. ST-segment elevation in V1-V4
D. T-wave inversion in all leads
Rationale: Osborne waves (positive deflection at the J point) are pathognomonic
for hypothermia. Prolonged QT may occur but is not specific.
3. A patient has a regular wide-complex tachycardia at 210 bpm, no palpable pulse,
and is unresponsive. The rhythm on the monitor is monomorphic wide QRS. What
is the priority action?
A. Administer adenosine 6 mg IV push
B. Defibrillate immediately at 120-200 J (biphasic)
C. Perform synchronized cardioversion at 50 J
,D. Give amiodarone 300 mg IV push
Rationale: Pulseless wide-complex tachycardia (VT) is a defibrillation priority.
Synchronized cardioversion is for unstable patients with a pulse. Adenosine is
for stable regular narrow-complex tachycardia.
4. Which statement best describes the ECG pattern of hyperkalemia?
A. Flattened T waves and prominent U waves
B. Peaked, narrow-based T waves, widened QRS, loss of P waves
C. ST-segment elevation with reciprocal depression
D. Shortened QT interval
Rationale: Early hyperkalemia → peaked T waves. Progressive → widened QRS,
PR prolongation, loss of P waves. Sine wave → cardiac arrest. Flattened T/U
waves are hypokalemia.
5. A patient with a permanent pacemaker has a pacing spike that falls on the T
wave of the previous beat. This is concerning for:
A. Normal pacemaker function
B. A potential R-on-T phenomenon that could induce ventricular fibrillation
C. Pacemaker failure to capture
D. Oversensing of the T wave
Rationale: Pacing spikes on the T wave (during the vulnerable period) can
trigger R-on-T VT/VF. This is often due to pacemaker malfunction or
misprogramming. Urgent evaluation is needed.
6. What is the ventricular rate in atrial flutter with 4:1 AV conduction?
A. 75-100 bpm (atrial rate 300)
B. 75-100 bpm (atrial rate 300) → 300/4 = 75 bpm
C. 150 bpm
D. 200 bpm
*Rationale: Atrial flutter typically has an atrial rate of 250-350 bpm (often ~300).
Conduction ratio determines ventricular rate. 4:1 yields ~75 bpm. 2:1 yields ~150
bpm.*
7. A patient with a history of heart failure has a new irregularly irregular rhythm
with no identifiable P waves and a ventricular rate of 140 bpm. Which medication
should the nurse anticipate for acute rate control?
A. Amiodarone 150 mg IV over 10 min
B. Diltiazem 0.25 mg/kg IV or metoprolol 5 mg IV
C. Digoxin 0.5 mg IV push
,D. Lidocaine 1.5 mg/kg IV push
Rationale: The rhythm is atrial fibrillation with rapid ventricular response. Rate
control with IV beta-blockers or nondihydropyridine calcium channel blockers is
first-line for stable patients without pre-excitation. Digoxin is second-line.
Amiodarone is for rhythm control or unstable patients.
8. Which lead is most useful for detecting posterior myocardial infarction?
A. Lead II
B. Lead V4
C. Lead V6
D. Leads V7, V8, V9
*Rationale: Posterior MI is diagnosed by ST depression in V1-V3 (mirror test) and
confirmed with ST elevation in posterior leads (V7-V9). True posterior leads are
essential for definitive diagnosis.*
9. A patient has a wide QRS tachycardia at 190 bpm, regular, with a history of
coronary artery disease and prior MI. The patient is stable with blood pressure
110/70 mmHg. What is the most appropriate next step?
A. Immediate synchronized cardioversion
B. Administer amiodarone 150 mg IV over 10 minutes
C. Give adenosine 6 mg rapid IV push
D. Start an epinephrine infusion
Rationale: Stable monomorphic VT (wide, regular, history of structural heart
disease) is treated with amiodarone or procainamide. Adenosine may be used for
diagnosis but can cause degeneration. Synchronized cardioversion is for
unstable patients.
10. Which ECG finding is most consistent with acute pericarditis?
A. ST-segment elevation in a single coronary distribution
B. Diffuse ST-segment elevation (concave up) with PR depression
C. Deep Q waves in leads II, III, aVF
D. ST-segment elevation in V1-V4 with reciprocal changes
Rationale: Pericarditis causes diffuse, concave-up ST elevation and PR
depression (atrial injury). Changes are not confined to a coronary territory. Q
waves indicate prior MI.
11. A patient’s telemetry shows a regular rhythm at 42 bpm, narrow QRS, and one
P wave before each QRS with a PR interval of 0.24 seconds. This is:
A. First-degree AV block with sinus bradycardia
, B. First-degree AV block with sinus bradycardia
C. Type I second-degree AV block (Wenckebach)
D. Type II second-degree AV block
*Rationale: Sinus bradycardia (rate <60) with PR >0.20 seconds = first-degree AV
block. The PR is constant, not progressively lengthening, ruling out Wenckebach.*
12. What is the earliest sign of digoxin toxicity on an ECG?
A. Ventricular tachycardia
B. Premature ventricular contractions (PVCs), often bigeminy
C. Atrial fibrillation with slow ventricular response
D. ST-segment sagging (reverse checkmark)
Rationale: The most common early ECG signs of digoxin toxicity are PVCs
(often bigeminy), along with nausea, visual changes. ST sagging is a therapeutic
effect, not toxicity. VT and heart block occur in severe toxicity.
13. A patient with a wide QRS tachycardia at 220 bpm is pulseless and
unresponsive. CPR is in progress. The rhythm is irregular wide complex. Which is
the appropriate shock energy?
A. 50 J synchronized
B. 200 J defibrillation (biphasic)
C. 360 J monophasic (but not synchronized) – defibrillation energy
D. 10 J defibrillation
*Rationale: Pulseless wide-complex tachycardia (VT/VF) is defibrillated with
maximum energy (120-200 J biphasic, 360 J monophasic). Synchronized mode is
not used in pulseless arrest. Irregular wide-complex tachycardia in pulseless arrest
is likely polymorphic VT/VF.*
14. Which of the following is a characteristic of torsades de pointes?
A. Regular wide-complex tachycardia with a rate of 180 bpm
B. Polymorphic ventricular tachycardia with twisting of the QRS axis around
the baseline
C. Sinus tachycardia with a prolonged QT
D. Atrial flutter with variable block
Rationale: Torsades de pointes is a polymorphic VT where the QRS amplitude
and axis twist. It is associated with prolonged QT (congenital or acquired).
Treatment includes magnesium sulfate and removal of QT-prolonging drugs.
15. A patient’s ECG shows a heart rate of 110 bpm, regular, narrow QRS, P waves
that are negative in leads II, III, aVF, and a short PR interval (0.10 sec). This is
EXAM PREP 2026 ALL QUESTIONS AND
CORRECT DETAILED ANSWERS ALREADY A
GRADED WITH EXPERT FEEDBACK |NEW AND
REVISED
1. A patient presents with a regular narrow QRS tachycardia at 180 bpm. Carotid
sinus massage slows the rate transiently, then the tachycardia resumes. Which
arrhythmia is most likely?
A. Atrial fibrillation
B. Atrial flutter with variable block
C. Atrioventricular nodal reentrant tachycardia (AVNRT)
D. Monomorphic ventricular tachycardia
Rationale: AVNRT is a regular narrow-complex tachycardia often terminated or
transiently slowed by vagal maneuvers. Atrial fibrillation is irregular. Atrial
flutter with variable block is usually irregular when variable. VT is wide
complex.
2. Which ECG finding is most characteristic of hypothermia?
A. Prolonged QT interval
B. Osborne (J) wave
C. ST-segment elevation in V1-V4
D. T-wave inversion in all leads
Rationale: Osborne waves (positive deflection at the J point) are pathognomonic
for hypothermia. Prolonged QT may occur but is not specific.
3. A patient has a regular wide-complex tachycardia at 210 bpm, no palpable pulse,
and is unresponsive. The rhythm on the monitor is monomorphic wide QRS. What
is the priority action?
A. Administer adenosine 6 mg IV push
B. Defibrillate immediately at 120-200 J (biphasic)
C. Perform synchronized cardioversion at 50 J
,D. Give amiodarone 300 mg IV push
Rationale: Pulseless wide-complex tachycardia (VT) is a defibrillation priority.
Synchronized cardioversion is for unstable patients with a pulse. Adenosine is
for stable regular narrow-complex tachycardia.
4. Which statement best describes the ECG pattern of hyperkalemia?
A. Flattened T waves and prominent U waves
B. Peaked, narrow-based T waves, widened QRS, loss of P waves
C. ST-segment elevation with reciprocal depression
D. Shortened QT interval
Rationale: Early hyperkalemia → peaked T waves. Progressive → widened QRS,
PR prolongation, loss of P waves. Sine wave → cardiac arrest. Flattened T/U
waves are hypokalemia.
5. A patient with a permanent pacemaker has a pacing spike that falls on the T
wave of the previous beat. This is concerning for:
A. Normal pacemaker function
B. A potential R-on-T phenomenon that could induce ventricular fibrillation
C. Pacemaker failure to capture
D. Oversensing of the T wave
Rationale: Pacing spikes on the T wave (during the vulnerable period) can
trigger R-on-T VT/VF. This is often due to pacemaker malfunction or
misprogramming. Urgent evaluation is needed.
6. What is the ventricular rate in atrial flutter with 4:1 AV conduction?
A. 75-100 bpm (atrial rate 300)
B. 75-100 bpm (atrial rate 300) → 300/4 = 75 bpm
C. 150 bpm
D. 200 bpm
*Rationale: Atrial flutter typically has an atrial rate of 250-350 bpm (often ~300).
Conduction ratio determines ventricular rate. 4:1 yields ~75 bpm. 2:1 yields ~150
bpm.*
7. A patient with a history of heart failure has a new irregularly irregular rhythm
with no identifiable P waves and a ventricular rate of 140 bpm. Which medication
should the nurse anticipate for acute rate control?
A. Amiodarone 150 mg IV over 10 min
B. Diltiazem 0.25 mg/kg IV or metoprolol 5 mg IV
C. Digoxin 0.5 mg IV push
,D. Lidocaine 1.5 mg/kg IV push
Rationale: The rhythm is atrial fibrillation with rapid ventricular response. Rate
control with IV beta-blockers or nondihydropyridine calcium channel blockers is
first-line for stable patients without pre-excitation. Digoxin is second-line.
Amiodarone is for rhythm control or unstable patients.
8. Which lead is most useful for detecting posterior myocardial infarction?
A. Lead II
B. Lead V4
C. Lead V6
D. Leads V7, V8, V9
*Rationale: Posterior MI is diagnosed by ST depression in V1-V3 (mirror test) and
confirmed with ST elevation in posterior leads (V7-V9). True posterior leads are
essential for definitive diagnosis.*
9. A patient has a wide QRS tachycardia at 190 bpm, regular, with a history of
coronary artery disease and prior MI. The patient is stable with blood pressure
110/70 mmHg. What is the most appropriate next step?
A. Immediate synchronized cardioversion
B. Administer amiodarone 150 mg IV over 10 minutes
C. Give adenosine 6 mg rapid IV push
D. Start an epinephrine infusion
Rationale: Stable monomorphic VT (wide, regular, history of structural heart
disease) is treated with amiodarone or procainamide. Adenosine may be used for
diagnosis but can cause degeneration. Synchronized cardioversion is for
unstable patients.
10. Which ECG finding is most consistent with acute pericarditis?
A. ST-segment elevation in a single coronary distribution
B. Diffuse ST-segment elevation (concave up) with PR depression
C. Deep Q waves in leads II, III, aVF
D. ST-segment elevation in V1-V4 with reciprocal changes
Rationale: Pericarditis causes diffuse, concave-up ST elevation and PR
depression (atrial injury). Changes are not confined to a coronary territory. Q
waves indicate prior MI.
11. A patient’s telemetry shows a regular rhythm at 42 bpm, narrow QRS, and one
P wave before each QRS with a PR interval of 0.24 seconds. This is:
A. First-degree AV block with sinus bradycardia
, B. First-degree AV block with sinus bradycardia
C. Type I second-degree AV block (Wenckebach)
D. Type II second-degree AV block
*Rationale: Sinus bradycardia (rate <60) with PR >0.20 seconds = first-degree AV
block. The PR is constant, not progressively lengthening, ruling out Wenckebach.*
12. What is the earliest sign of digoxin toxicity on an ECG?
A. Ventricular tachycardia
B. Premature ventricular contractions (PVCs), often bigeminy
C. Atrial fibrillation with slow ventricular response
D. ST-segment sagging (reverse checkmark)
Rationale: The most common early ECG signs of digoxin toxicity are PVCs
(often bigeminy), along with nausea, visual changes. ST sagging is a therapeutic
effect, not toxicity. VT and heart block occur in severe toxicity.
13. A patient with a wide QRS tachycardia at 220 bpm is pulseless and
unresponsive. CPR is in progress. The rhythm is irregular wide complex. Which is
the appropriate shock energy?
A. 50 J synchronized
B. 200 J defibrillation (biphasic)
C. 360 J monophasic (but not synchronized) – defibrillation energy
D. 10 J defibrillation
*Rationale: Pulseless wide-complex tachycardia (VT/VF) is defibrillated with
maximum energy (120-200 J biphasic, 360 J monophasic). Synchronized mode is
not used in pulseless arrest. Irregular wide-complex tachycardia in pulseless arrest
is likely polymorphic VT/VF.*
14. Which of the following is a characteristic of torsades de pointes?
A. Regular wide-complex tachycardia with a rate of 180 bpm
B. Polymorphic ventricular tachycardia with twisting of the QRS axis around
the baseline
C. Sinus tachycardia with a prolonged QT
D. Atrial flutter with variable block
Rationale: Torsades de pointes is a polymorphic VT where the QRS amplitude
and axis twist. It is associated with prolonged QT (congenital or acquired).
Treatment includes magnesium sulfate and removal of QT-prolonging drugs.
15. A patient’s ECG shows a heart rate of 110 bpm, regular, narrow QRS, P waves
that are negative in leads II, III, aVF, and a short PR interval (0.10 sec). This is
