RELIAS DYSRHYTHMIA- ADVANCED A
QUESTIONS
WITH COMPLETE SOLUTIONS 2026/2027
Comprehensive Advanced Dysrhythmia Examination | Advanced Dysrhythmia Interpretation & Cardiac
Monitoring Certification Preparation
Aligned with Relias Advanced Dysrhythmia Testing Standards, AHA Guidelines for Cardiac Monitoring,
ACLS Algorithms, and Advanced Electrocardiogram Interpretation Competencies (2026/2027 Edition)
100 Questions | 9 Sections | 25 Advanced Rhythm Strip Identifications | 15 Differential Diagnosis Items | 15 ACLS
Management Items | Complete Solutions & Rationales
Section 1: Cardiac Anatomy, Electrophysiology, & Conduction Q1 - Q10
Q1: Which sequence correctly describes the normal pathway of electrical impulse conduction through the
heart?
A. SA node → Bundle of His → AV node → bundle branches → Purkinje fibers
B. AV node → SA node → bundle branches → Bundle of His → Purkinje fibers
C. SA node → AV node → Bundle of His → bundle branches → Purkinje fibers [CORRECT]
D. AV node → Bundle of His → SA node → Purkinje fibers → bundle branches
Correct Answer: C
Rationale: Per Relias advanced dysrhythmia methodology, the impulse originates in the SA node (the
dominant pacemaker), spreads across the atria to the AV node, where it is deliberately delayed, then descends
through the Bundle of His, the right and left bundle branches, and finally the Purkinje fibers, which trigger
ventricular contraction. Options A, B, and D place the AV node before the SA node or route the impulse
through the His-Purkinje system in an anatomically impossible order, which would reverse atrial and
ventricular activation.
Q2: A monitor technician is reviewing pacemaker cell automaticity. Which set of intrinsic firing rates is
correct?
A. SA node 60-100/min; AV junction 40-60/min; ventricular Purkinje cells 20-40/min [CORRECT]
B. SA node 40-60/min; AV junction 60-100/min; ventricular Purkinje cells 20-40/min
C. SA node 100-150/min; AV junction 40-60/min; ventricular Purkinje cells 60-100/min
D. SA node 60-100/min; AV junction 20-40/min; ventricular Purkinje cells 40-60/min
Correct Answer: A
Rationale: Relias testing standards require memorization of the pacemaker hierarchy: SA node 60-100/min,
AV junction 40-60/min, and ventricular Purkinje cells 20-40/min. When a faster pacemaker fails, the next
slowest site escapes at its own intrinsic rate, which explains junctional and idioventricular escape rhythms.
Options B, C, and D transpose these rates and would lead to misidentification of the origin of an escape
rhythm on a rhythm strip.
Advanced Dysrhythmia Certification Examination | 2026/2027 Edition Page 1
,Relias Dysrhythmia - Advanced A | Complete Solutions 2026/2027
Q3: During phase 0 of the ventricular myocardial action potential, which ionic movement is responsible for
rapid depolarization?
A. Slow calcium influx through L-type channels
B. Potassium efflux through delayed rectifier channels
C. Chloride influx through ligand-gated channels
D. Rapid sodium influx through fast sodium channels [CORRECT]
Correct Answer: D
Rationale: In His-Purkinje and ventricular myocardial cells, phase 0 is produced by rapid sodium influx
through fast sodium channels, which corresponds to the QRS complex on the ECG. Slow calcium influx
(option A) generates phase 0 in SA and AV nodal tissue, not ventricular muscle, while potassium efflux
(option B) drives phase 3 repolarization. This sodium-versus-calcium distinction is a core Relias competency
because it explains why class I and class III antiarrhythmics behave differently in nodal versus ventricular
tissue.
Q4: Which phase of the cardiac action potential corresponds to ventricular repolarization represented by the T
wave?
A. Phase 1 (early rapid repolarization)
B. Phase 3 (terminal rapid repolarization) [CORRECT]
C. Phase 2 (plateau)
D. Phase 4 (resting membrane potential)
Correct Answer: B
Rationale: Phase 3 is produced by massive potassium efflux that restores the resting membrane potential, and
it maps to the T wave on the ECG, particularly the downslope. Phase 2, the plateau of balanced calcium influx
and potassium efflux, corresponds to the ST segment; phase 1 corresponds to the J point; and phase 4 is
electrical diastole. Relias links these phases to QT-prolonging risk: drugs or electrolyte disorders that delay
phase 3 lengthen the QT interval and predispose to torsades de pointes.
Q5: A stimulus delivered during which period will fail to generate any new action potential regardless of
stimulus strength?
A. Relative refractory period
B. Supernormal period
C. Absolute refractory period [CORRECT]
D. Diastolic resting period (phase 4)
Correct Answer: C
Rationale: During the absolute refractory period, which extends from the onset of the QRS to approximately
the peak of the T wave, sodium channels are completely inactivated, so no stimulus of any strength can
depolarize the cell. In the relative refractory period (downslope of the T wave) only a stronger-than-normal
stimulus excites the cell, and in the supernormal period an unusually weak stimulus may capture it, which is
arrhythmogenic. Relias emphasizes this timing map because it predicts when a premature beat can and cannot
propagate.
Advanced Dysrhythmia Certification Examination | 2026/2027 Edition Page 2
,Relias Dysrhythmia - Advanced A | Complete Solutions 2026/2027
Q6: A nurse notes a PVC falling on the downslope of the preceding T wave on the telemetry strip. Per Relias
advanced standards, why is this finding significant?
A. It can precipitate ventricular tachycardia or ventricular fibrillation (R-on-T phenomenon)
[CORRECT]
B. It confirms the presence of first-degree AV block
C. It indicates atrial irritability and impending atrial fibrillation
D. It is a benign finding that requires no continued monitoring
Correct Answer: A
Rationale: A PVC striking the vulnerable downslope of the T wave occurs during the relative refractory
period, when repolarization is heterogeneous, creating a reentry substrate that can degenerate into VT or VF.
The risk is amplified in acute ischemia and in patients with prolonged QT intervals. The event is purely
ventricular in origin, so the explanations involving AV block (option B) or atrial irritability (option C) are
physiologically unrelated.
Q7: What is the primary function of the AV node in the normal conduction system?
A. To generate impulses at 60-100/min as the dominant pacemaker
B. To conduct impulses at the fastest velocity in the heart
C. To serve as the ventricular backup pacemaker at 20-40/min
D. To delay conduction, allowing atrial contraction to complete ventricular filling [CORRECT]
Correct Answer: D
Rationale: The AV node intentionally slows impulse conduction by approximately 0.10 second, permitting
atrial contraction (the atrial kick) to complete ventricular filling and contribute up to about 30 percent of
stroke volume, a hemodynamic principle Relias stresses in every atrial and junctional rhythm discussion. The
SA node is the dominant 60-100/min pacemaker (option A), the Purkinje network conducts fastest (option B),
and ventricular cells provide only the last-resort 20-40/min pacemaker (option C).
Q8: Which portion of the conduction system has the fastest intrinsic conduction velocity?
A. AV node
B. Purkinje fiber network [CORRECT]
C. SA node
D. Atrial internodal pathways
Correct Answer: B
Rationale: Purkinje fibers conduct at roughly 1.5-4.0 m/s, the fastest in the heart, allowing near-simultaneous
ventricular depolarization and producing a narrow QRS under 0.12 second. The AV node is actually the
slowest conductor (about 0.02-0.05 m/s) because of its calcium-channel physiology, which is precisely why it
protects the ventricles from rapid atrial rates. Relias uses this contrast to explain why nodal rhythms stay
narrow while ventricular rhythms are wide.
Advanced Dysrhythmia Certification Examination | 2026/2027 Edition Page 3
, Relias Dysrhythmia - Advanced A | Complete Solutions 2026/2027
Q9: A patient is started on diltiazem for rate control. Which electrophysiologic effect should the nurse
anticipate on monitoring?
A. Prolonged QRS duration from slowed ventricular depolarization
B. Enhanced automaticity of the His-Purkinje system
C. Slowed conduction through the SA and AV nodes [CORRECT]
D. Shortened ventricular refractory periods
Correct Answer: C
Rationale: SA and AV nodal cells depend on slow calcium channels for phase 0 depolarization, so calcium
channel blockers such as diltiazem decrease nodal conduction velocity and automaticity, producing
bradycardia, PR prolongation, and possible AV block. Ventricular depolarization remains sodium-dependent,
so the QRS is unaffected (option A is wrong), and calcium channel blockers do not enhance His-Purkinje
automaticity or shorten ventricular refractoriness. This nodal selectivity is why diltiazem is useful for atrial
rate control but dangerous in pre-excited wide-complex rhythms.
Q10: During a rhythm strip review, the SA node suddenly fails to depolarize. A narrow-complex escape
rhythm at 45/min with retrograde P waves emerges. Which pacemaker site has assumed control?
A. AV junction [CORRECT]
B. SA node
C. Ventricular Purkinje fibers
D. Left bundle branch subendocardial cells
Correct Answer: A
Rationale: A rate of 45/min falls in the intrinsic AV junctional range of 40-60/min, and the narrow QRS with
retrograde (inverted in lead II) P waves reflects the junction taking over as the escape pacemaker. A
ventricular escape would run 20-40/min with a wide QRS (options C and D), and the SA node cannot rescue
itself because it has failed by definition (option B). Relias teaches that identifying the escape site immediately
determines urgency: junctional escape is relatively stable, ventricular escape demands pacing readiness.
Section 2: EKG Waveform Components, Intervals, & Q11 - Q20
Measurements
Q11: The P wave on the ECG represents which cardiac electrical event?
A. Ventricular depolarization
B. Atrial depolarization [CORRECT]
C. Atrial repolarization
D. Ventricular repolarization
Correct Answer: B
Rationale: The P wave records atrial muscle depolarization as the impulse spreads from the SA node across
both atria. Atrial repolarization is buried within the QRS complex and is never seen as a separate wave,
ventricular depolarization produces the QRS (option A), and ventricular repolarization produces the T wave
(option D). Relias waveform mapping requires this P-QRS-T attribution to be automatic before any rhythm
interpretation can begin.
Advanced Dysrhythmia Certification Examination | 2026/2027 Edition Page 4
QUESTIONS
WITH COMPLETE SOLUTIONS 2026/2027
Comprehensive Advanced Dysrhythmia Examination | Advanced Dysrhythmia Interpretation & Cardiac
Monitoring Certification Preparation
Aligned with Relias Advanced Dysrhythmia Testing Standards, AHA Guidelines for Cardiac Monitoring,
ACLS Algorithms, and Advanced Electrocardiogram Interpretation Competencies (2026/2027 Edition)
100 Questions | 9 Sections | 25 Advanced Rhythm Strip Identifications | 15 Differential Diagnosis Items | 15 ACLS
Management Items | Complete Solutions & Rationales
Section 1: Cardiac Anatomy, Electrophysiology, & Conduction Q1 - Q10
Q1: Which sequence correctly describes the normal pathway of electrical impulse conduction through the
heart?
A. SA node → Bundle of His → AV node → bundle branches → Purkinje fibers
B. AV node → SA node → bundle branches → Bundle of His → Purkinje fibers
C. SA node → AV node → Bundle of His → bundle branches → Purkinje fibers [CORRECT]
D. AV node → Bundle of His → SA node → Purkinje fibers → bundle branches
Correct Answer: C
Rationale: Per Relias advanced dysrhythmia methodology, the impulse originates in the SA node (the
dominant pacemaker), spreads across the atria to the AV node, where it is deliberately delayed, then descends
through the Bundle of His, the right and left bundle branches, and finally the Purkinje fibers, which trigger
ventricular contraction. Options A, B, and D place the AV node before the SA node or route the impulse
through the His-Purkinje system in an anatomically impossible order, which would reverse atrial and
ventricular activation.
Q2: A monitor technician is reviewing pacemaker cell automaticity. Which set of intrinsic firing rates is
correct?
A. SA node 60-100/min; AV junction 40-60/min; ventricular Purkinje cells 20-40/min [CORRECT]
B. SA node 40-60/min; AV junction 60-100/min; ventricular Purkinje cells 20-40/min
C. SA node 100-150/min; AV junction 40-60/min; ventricular Purkinje cells 60-100/min
D. SA node 60-100/min; AV junction 20-40/min; ventricular Purkinje cells 40-60/min
Correct Answer: A
Rationale: Relias testing standards require memorization of the pacemaker hierarchy: SA node 60-100/min,
AV junction 40-60/min, and ventricular Purkinje cells 20-40/min. When a faster pacemaker fails, the next
slowest site escapes at its own intrinsic rate, which explains junctional and idioventricular escape rhythms.
Options B, C, and D transpose these rates and would lead to misidentification of the origin of an escape
rhythm on a rhythm strip.
Advanced Dysrhythmia Certification Examination | 2026/2027 Edition Page 1
,Relias Dysrhythmia - Advanced A | Complete Solutions 2026/2027
Q3: During phase 0 of the ventricular myocardial action potential, which ionic movement is responsible for
rapid depolarization?
A. Slow calcium influx through L-type channels
B. Potassium efflux through delayed rectifier channels
C. Chloride influx through ligand-gated channels
D. Rapid sodium influx through fast sodium channels [CORRECT]
Correct Answer: D
Rationale: In His-Purkinje and ventricular myocardial cells, phase 0 is produced by rapid sodium influx
through fast sodium channels, which corresponds to the QRS complex on the ECG. Slow calcium influx
(option A) generates phase 0 in SA and AV nodal tissue, not ventricular muscle, while potassium efflux
(option B) drives phase 3 repolarization. This sodium-versus-calcium distinction is a core Relias competency
because it explains why class I and class III antiarrhythmics behave differently in nodal versus ventricular
tissue.
Q4: Which phase of the cardiac action potential corresponds to ventricular repolarization represented by the T
wave?
A. Phase 1 (early rapid repolarization)
B. Phase 3 (terminal rapid repolarization) [CORRECT]
C. Phase 2 (plateau)
D. Phase 4 (resting membrane potential)
Correct Answer: B
Rationale: Phase 3 is produced by massive potassium efflux that restores the resting membrane potential, and
it maps to the T wave on the ECG, particularly the downslope. Phase 2, the plateau of balanced calcium influx
and potassium efflux, corresponds to the ST segment; phase 1 corresponds to the J point; and phase 4 is
electrical diastole. Relias links these phases to QT-prolonging risk: drugs or electrolyte disorders that delay
phase 3 lengthen the QT interval and predispose to torsades de pointes.
Q5: A stimulus delivered during which period will fail to generate any new action potential regardless of
stimulus strength?
A. Relative refractory period
B. Supernormal period
C. Absolute refractory period [CORRECT]
D. Diastolic resting period (phase 4)
Correct Answer: C
Rationale: During the absolute refractory period, which extends from the onset of the QRS to approximately
the peak of the T wave, sodium channels are completely inactivated, so no stimulus of any strength can
depolarize the cell. In the relative refractory period (downslope of the T wave) only a stronger-than-normal
stimulus excites the cell, and in the supernormal period an unusually weak stimulus may capture it, which is
arrhythmogenic. Relias emphasizes this timing map because it predicts when a premature beat can and cannot
propagate.
Advanced Dysrhythmia Certification Examination | 2026/2027 Edition Page 2
,Relias Dysrhythmia - Advanced A | Complete Solutions 2026/2027
Q6: A nurse notes a PVC falling on the downslope of the preceding T wave on the telemetry strip. Per Relias
advanced standards, why is this finding significant?
A. It can precipitate ventricular tachycardia or ventricular fibrillation (R-on-T phenomenon)
[CORRECT]
B. It confirms the presence of first-degree AV block
C. It indicates atrial irritability and impending atrial fibrillation
D. It is a benign finding that requires no continued monitoring
Correct Answer: A
Rationale: A PVC striking the vulnerable downslope of the T wave occurs during the relative refractory
period, when repolarization is heterogeneous, creating a reentry substrate that can degenerate into VT or VF.
The risk is amplified in acute ischemia and in patients with prolonged QT intervals. The event is purely
ventricular in origin, so the explanations involving AV block (option B) or atrial irritability (option C) are
physiologically unrelated.
Q7: What is the primary function of the AV node in the normal conduction system?
A. To generate impulses at 60-100/min as the dominant pacemaker
B. To conduct impulses at the fastest velocity in the heart
C. To serve as the ventricular backup pacemaker at 20-40/min
D. To delay conduction, allowing atrial contraction to complete ventricular filling [CORRECT]
Correct Answer: D
Rationale: The AV node intentionally slows impulse conduction by approximately 0.10 second, permitting
atrial contraction (the atrial kick) to complete ventricular filling and contribute up to about 30 percent of
stroke volume, a hemodynamic principle Relias stresses in every atrial and junctional rhythm discussion. The
SA node is the dominant 60-100/min pacemaker (option A), the Purkinje network conducts fastest (option B),
and ventricular cells provide only the last-resort 20-40/min pacemaker (option C).
Q8: Which portion of the conduction system has the fastest intrinsic conduction velocity?
A. AV node
B. Purkinje fiber network [CORRECT]
C. SA node
D. Atrial internodal pathways
Correct Answer: B
Rationale: Purkinje fibers conduct at roughly 1.5-4.0 m/s, the fastest in the heart, allowing near-simultaneous
ventricular depolarization and producing a narrow QRS under 0.12 second. The AV node is actually the
slowest conductor (about 0.02-0.05 m/s) because of its calcium-channel physiology, which is precisely why it
protects the ventricles from rapid atrial rates. Relias uses this contrast to explain why nodal rhythms stay
narrow while ventricular rhythms are wide.
Advanced Dysrhythmia Certification Examination | 2026/2027 Edition Page 3
, Relias Dysrhythmia - Advanced A | Complete Solutions 2026/2027
Q9: A patient is started on diltiazem for rate control. Which electrophysiologic effect should the nurse
anticipate on monitoring?
A. Prolonged QRS duration from slowed ventricular depolarization
B. Enhanced automaticity of the His-Purkinje system
C. Slowed conduction through the SA and AV nodes [CORRECT]
D. Shortened ventricular refractory periods
Correct Answer: C
Rationale: SA and AV nodal cells depend on slow calcium channels for phase 0 depolarization, so calcium
channel blockers such as diltiazem decrease nodal conduction velocity and automaticity, producing
bradycardia, PR prolongation, and possible AV block. Ventricular depolarization remains sodium-dependent,
so the QRS is unaffected (option A is wrong), and calcium channel blockers do not enhance His-Purkinje
automaticity or shorten ventricular refractoriness. This nodal selectivity is why diltiazem is useful for atrial
rate control but dangerous in pre-excited wide-complex rhythms.
Q10: During a rhythm strip review, the SA node suddenly fails to depolarize. A narrow-complex escape
rhythm at 45/min with retrograde P waves emerges. Which pacemaker site has assumed control?
A. AV junction [CORRECT]
B. SA node
C. Ventricular Purkinje fibers
D. Left bundle branch subendocardial cells
Correct Answer: A
Rationale: A rate of 45/min falls in the intrinsic AV junctional range of 40-60/min, and the narrow QRS with
retrograde (inverted in lead II) P waves reflects the junction taking over as the escape pacemaker. A
ventricular escape would run 20-40/min with a wide QRS (options C and D), and the SA node cannot rescue
itself because it has failed by definition (option B). Relias teaches that identifying the escape site immediately
determines urgency: junctional escape is relatively stable, ventricular escape demands pacing readiness.
Section 2: EKG Waveform Components, Intervals, & Q11 - Q20
Measurements
Q11: The P wave on the ECG represents which cardiac electrical event?
A. Ventricular depolarization
B. Atrial depolarization [CORRECT]
C. Atrial repolarization
D. Ventricular repolarization
Correct Answer: B
Rationale: The P wave records atrial muscle depolarization as the impulse spreads from the SA node across
both atria. Atrial repolarization is buried within the QRS complex and is never seen as a separate wave,
ventricular depolarization produces the QRS (option A), and ventricular repolarization produces the T wave
(option D). Relias waveform mapping requires this P-QRS-T attribution to be automatic before any rhythm
interpretation can begin.
Advanced Dysrhythmia Certification Examination | 2026/2027 Edition Page 4
