PCCN questions
Medications commonly used in the treatment of heart failure include: A. ACE inhibitors, beta blockers B. calcium channel blockers C. nitrates D. calcium channel blockers and digoxin (Lanoxicaps)
A. ACE inhibitors, beta blockers The most effective and evidence-based practice treatment of heart failure is neurohormonal blockade. These medications include beta blockers and ACE inhibitors. They reduce preload and afterload as well as controlling heart rate and BP. Calcium channel blockers are not used in heart failure since they tend to increase the absorption of sodium and water. Nitrates are used for treatment in conjunction with other drugs. Beta blockers are ACE-I are the foundation of treatments. Digoxin is also used but only after the beta blockers and ACE-I are started.
The two major components that determine blood pressure are: A. systemic vascular resistance (SVR) (afterload) and cardiac output B. contractility and SVR (afterload) C. preload and SVR (afterload) D. contractility and SVR (afterload)
A. SVR (afterload) and cardiac output The equation for BP is: BP = SVR x cardiac output. BP is determined by resistance of the arterial bed and the cardiac output. If the SVR (afterload) is high and the cardiac output low, the patient may still have a normal BP. the pulse pressure will be lower, but this is a compensatory response by the heart to maintain BP. If the SVR (afterload) is low (as in early septic shock), the cardiac output is very high, thereby trying to support BP.
The primary cause of hypercapnia is: A. abnormal alveolar minute ventilation B. abnormal respiratory rhythm C. abnormal compliance D. abnormal oxygenation
A. abnormal alveolar minute ventilation Abnormal respiratory rhythm may cause a change in CO2, but this is not the primary cause of hypercapnia. Abnormal compliance, or stiff lung, usually causes changes in oxygenation. Abnormal oxygenation does not cause hypercapnia. The most common cause of hypercapnia is a change in either respiratory rate or tidal volume (alveolar minute ventilation).
A patient who is postoperative day 2 after a pancreatic resection for hemorrhagic pancreatitis is now complaining of acute shortness of breath with rales bilaterally and increasing oxygen requirements. This could be the beginning of: A. acute respiratory distress syndrome B. asthma C. postoperative pain syndrome D. gastric bleed
A. acute respiratory distress syndrome Any patient with an inflammatory disorder (such as postoperative abdominal surgery) can develop acute respiratory distress syndrome approximately 24-36 hrs post event. The signs and symptoms include acute shortness of breath, rales bilaterally, diffuse bilateral ground-glass appearance, or white-out, on chest x-ray and increased requirements for oxygen. Asthma would include wheezing. Postoperative pain would not likely cause rales. A gastric bleed would not cause rales.
Signs of venous peripheral vascular disease in the legs include: A. brown pigmentation at the ankles, warm legs, open area over the lateral malleolus B. normal color, severe pain, open sore at the end of the great toe C. shiny skin with no hair, pale extremities, pain with ambulation D. pitting edema, absent pulses, thick toenails, feet becoming cyanotic when dependent
A. brown pigmentation at the ankles, warm legs, open area over the lateral malleolus Arterial insufficiency Etiology: arteriosclerosis Risk factors: smoking, DM, HTN Pain: severe muscle ischemia, intermittent claudication, worse with exercise, pain at rest, muscle fatigue, cramping, numbness Vascular: decreased or absent pulses, pallor and rubor Skin changes: shiny, dry, nail changes, coolness Venous insufficiency Pain: minimal to moderate steady pain, aching Skin: thickening in tissues, dark, cyanotic, thickened and brown, with ulceration at sides of ankles (a medial malleolus classic), and legs are warm since there is normal arterial circulation
Which of the following indicates an active pleural air leak for a patient with a chest tube attached to a pleural drainage system? A. bubbling in the water-seal chamber B. bubbling in the suction control chamber C. fluctuation of water level in the water-seal chamber with respiration D. no fluctuation of water level in the water-seal chamber with respiration
A. bubbling in the water-seal chamber An active air leak is noticeable in the chest tube drainage system by the presence of bubbling in the water-seal chamber. Air bubbles result from a leakage of air from the lung parenchyma into the pleural space. If an air leak is present, the chest tube should not be removed or the leaking air will be trapped, resulting in a pneumothorax.
The most sensitive and one of the earliest indicators of changes in intracranial pressure in a patient who is unresponsive is: A. change in pulse pressure B. change in pupillary response C. blood glucose levels D. response of the cranial nerves
A. change in pulse pressure In patients who are unresponsive, the second physical assessment sign to change is the pulse pressure. The systolic pressure raises, the diastolic drops and the patient's heart rate slows. The triad of changes are change in mental status, pulse pressure widens and heart rate slows, then pupillary changes occur. Blood sugar levels may not change with changes in mental status or behavior; however, behavioral and mental status changes may be an early indicator of lowered blood serum glucose. Response of cranial nerves is incorrect.
Which type of condition can lead to a tension pneumothorax? A. closed pneumothorax B. open pneumothorax C. subcutaneous emphysema D. pneumomediastinum
A. closed pneumothorax The only way a tension pneumothorax can occur is within a closed chest wall. A tension pneumothorax denotes an opening in the pleural space where air is trapped inside the chest between the collapsed pleural wall and the chest wall. Eventually enough air will be trapped to push the mediastinum to the opposite wall, compressing the heart and causing vascular collapse and death.
A patient in the ED is now being admitted to telemetry bwith complaint of chest pain and has been judged to be a possible candidate for therapy with alteplase (Activase). Which of the following is not considered a contraindication for the use of this medication? A. current antibiotic use B. recent abdominal surgery C. recent gastrointestinal bleed D. recent intracranial bleed
A. current antibiotic use Use of antibiotics is not a contraindication for the use of alteplase. All the other answers -- recent abdominal surgery, recent gastrointestinal bleeding and a recent intracranial bleed -- are contraindications for the use of any fibrinolytic.
A patient with an anterior-wall STEMI is in cardiogenic shock. What would be the hemodynamic profile assessment? A. decreased cardiac index, increased preload, increased afterload B. decreased cardiac index, decreased preload, increased afterload C. decreased cardiac index, decreased preload, decreased afterload D. increased cardiac index, decreased preload, decreased afterload
A. decreased cardiac index, increased preload, increased afterload In a patient with cardiogenic shock, both preload and afterload are increased due to severe vasoconstriction on both the venous and arterial side. Arterial vasoconstriction increases afterload and therefore lowers cardiac index. Because the ventricle is failing and contractility is also low, the left ventricular pressures increase and cause blood to increase in the pulmonary bed, resulting in increased right ventricular pressures and preload. In heart failure, there is an increase in preload and afterload with a decrease in cardiac index and contractility. The other answers are incorrect.
Coronary artery perfusion is dependent upon: A. diastolic pressure B. systolic pressure C. afterload D. systemic vascular resistance (SVR)
A. diastolic pressure Diastolic pressure in the aortic root is higher than left ventricular end-diastolic pressure (LVEDP), the pressure exerted on the ventricular muscle at the end of diastole when the ventricle is full. This enables blood to flow from a higher pressure through open arteries to a lower pressure, a pressure gradient known as coronary artery prefusion pressure. As diastolic pressure drops, there is a decrease in coronary artery blood flow. Coronary artery perfusion is not affected by systolic pressure, afterload or SVR, but they all increase the demand of oxygen in the heart.
Which of the following vasodilators primarily dilates coronary arteries and is used to treat angina and supraventricular tachycardia? A. diltiazem (Cardizem) B. captopril (Capoten) C. nitroglycerin D. sodium nitroprusside (Nipride)
A. diltiazem Diltiazem is an excellent vasodilator (classified as a non-dihydropyridine calcium channel blocker) with the property to dilate the coronary arteries and to treat supraventricular tachycardia. It is also a selective coronary vasodilator. It dilates coronary vessels better than it does systemic vascular beds. It is also used to decrease heart rate and treat supraventricular arrhythmias, inculding SVT. Captopril, an ACE-I, is also a vasodilator but has no affect on coronary circulation. Nitroglycerin, a well known coronary artery dilator, and nitroprusside, an excellent arterial and venous vasodilator, have no affect on SVT.
Two months after an ischemic stroke, a patient has difficulty understanding and producing language in speaking, reading and writing but can understand gestures, pictures and diagrams. This type of aphasia is: A. global B. transient C. Broca's D. Wernicke's
A. global The term aphasia is the loss of the ability to use and/or understand written or spoken language. Global aphasia is characterized by difficulty understanding gestures, pictures and diagrams. transient aphasia is short-lasting, and often related to transient ischemic episodes. Broca's aphasia is characterized by the ability to understand, but difficult producing, language. Wernicke's aphasia is characterized by difficulty understanding language but with the ability to understand gestures and produce language.
Positive inotropic agents are used to: A. improve cardiac output and tissue perfusion B. decrease water loss through the kidneys C. increase heart rate D. vasodilate vessels
A. improve cardiac output and tissue perfusion The term "inotropic" refers to affecting the force of myocardial contraction. Improvement of cardiac muscle contraction leads to improved cardiac output and tissue perfusion.
The patient goals for acute respiratory failure include: A. improve oxygenation greater than 60 mmHg B. allow for CO2 elevation greater than 60 mmHg C. allow respiratory rates greater than 35 to lower CO2 D. medicate the patient with anti-anxiety medications to lower respiratory rate
A. improve oxygenation greater than 60 mmHg In most patients with acute respiratory failure, the goal is to maintain the most normal ABG possible; however, since many patients may not be able to attain that, the physician may ask for permissive hypoxia or allow for the PaO2 to be lower than normal or above 60 mm Hg. A goal for the patient would be to maintain or allow for slight increase in CO2; not to allow CO2 elevation above 60 mm Hg. An adult with a respiratory rate greater than 35 is in need of intubation and is working extremely hard to maintain gas exchange. This patient will not be able to tolerate this rate for long. The diaphragm requires more oxygen as the rate increases and will tire.
When assessing cardiac output in a normal heart, a decrease in heart rate should cause the stroke volume to: A. increase B. decrease C. remain the same D. vary
A. increase In the normal heart with normal volume, a decrease in the heart rate should increase stroke volume. With a decrease in heart rate, the filling time of the ventricle increases and thereby should improve cardiac output and stroke volume. The other answers are incorrect.
Which of the following are measures that would improve the cerebral perfusion pressure (CPP)? A. increase mean arterial pressure (MAP) B. decrease MAP C. decrease the heart rate D. all of the above
A. increase mean arterial pressure (MAP) CPP is determined by MAP and intracranial pressure (ICP). By improving MAP, the CPP will increase. Lowering the ICP would also increase CPP. Heart rate does not affect CPP.
The major early signs and symptoms of acute respiratory failure include: A. increased respiratory rate, tachycardia, change in mental status B. no change in respiratory rate, tachycardia C. complaint of shortness of breath D. there are no early signs of respiratory failure
A. increased respiratory rate, tachycardia, change in mental status The patient with respiratory failure will have increased respiratory rate (due to either hypoxemia or acidosis), tachycardia (stress response) and change in mental status (decreases in oxygen will effect mental status as well as acidosis, if that is present). A complaint of shortness of breath is very subjective and may not reveal the patient's clinical status.
A patient with pulmonary edema has impaired diffusion due to: A. increased thickness of the alveolar capillary membrane B. retaining CO2 C. an elevated body temperature associated with pulmonary edema D. low barometric pressure
A. increased thickness of the alveolar capillary membrane With increasing left ventricular pressures, blood moves back into the left atrium, then to the pulmonary veins. When the pressure in the pulmonary veins increases, capillary function decreases, and fluid then shifts to the interstitial space, causing interstitial edema, thereby, increasing the thickness of the space oxygen must travel. When left ventricular pressures increase, the fluid then shifts to the alveolar space, causing pulmonary edema. This fluid acts as a deterrent to oxygen diffusion. Retention of CO2 does not impair diffusion. An elevated body temperature associated with pulmonary edema is not causing a diffusion abnormality; increased temperature shifts the oxyhemoglobin curve to the right, more quickly releasing oxygen to the tissues. Low barometric pressure has no effect on diffusion of gases in the lung.
Epinephrine is indicated as the first-line drug for any pulseless condition because it has the following actions: A. inotropic and selectively shunts blood to brain and heart B. converts ventricular fibrillation to sinus rhythm C. slows the heart rate and improves contractility D. causes decreased contractility,
A. inotropic and selectively shunts blood to brain and heart Epinephrine is a pure catecholamine that increases contractility and causes vasoconstriction that shunts blood to the heart, brain, and diaphragm. According to ACLS, it is the drug of choice for any pulseless arrest. Epinephrine does not convert VF to any rhythm, slow heart rates or cause decreased contractility.
The most appropriate first-line drug for treatment of a seizure is: A. lorazepam (Ativan) B. midazolam (Versed) C. phenytoin (Dilantin) D. phenobarbital
A. lorazepam (Ativan) According to ACLS, the first-line drug for the emergent treatment of seizure activity is lorazepam. Although midazolam is a sedative, it is not a first-line drug for seizure activity. Although phenytoin and phenobarbital are both frequently used in the suppression of seizures, they are not considered first-line drugs.
The layer of the arterial vessel wall responsible for changes in the diameter of the artery is the: A. media B. intima C. externa D. adventitia
A. media The media layer of the arterial wall contains vascular smooth muscle cells and is responsible for arterial tone. Vasoactive substances released in response to the sympathetic nervous system and/or the renin-angiotensin system determine arterial tone. Intima, externa and adventitia are incorrect.
A patient presents with pulmonary edema characterized by tachycardia, hypertension and cough with frothy sputum. What initial treatments are most common? A. oxygen, nitroglycerin, loop diuretics, and morphine B. oxygen, thiazide diuretics, and ACE inhibitors C. oxygen and thiazide diuretics D. oxygen, morphine, and calcium channel blockers
A. oxygen, nitroglycerin, loop diuretics, and morphine The first line drugs of choice for acute pulmonary edema are oxygen, loop diuretics such as furosemide (Lasix), nitroglycerin (preload reducer and increased myocardial blood flow), and morphine (vasodilator to reduce preload, decrease pain and anxiety; pain and anxiety increase the oxygen needs of the myocardium). Thiazide diuretics, ACE inhibitors and calcium channel blockers are not used as first line drugs in treatment of pulmonary edema.
When interpreting an arterial blood gas, which of the following is one of the most important aspects for developing a treatment plan? A. pH B. arterial oxygenation C. venous oxygenation D. arterial bicarbonate
A. pH The pH is most important since it establishes whether the patient is compensating. It also directs the action of the caregiver. If the pH is acidotic, that may be an indication for intubation. If the pH is alkalotic, the patient may require intubation or other means of support to improve oxygen delivery. Arterial oxygenation may be assessed using the pulse oximetry. Venous oxygenation is a good tool for the assessment of oxygen consumption, but not delivery. Arterial bicarbonate is a way to measure metabolic characteristics.
One major complication of pulmonary embolus is: A. pulmonary infarction B. gastrointestinal infarction C. liver failure D. leg edema
A. pulmonary infarction A pulmonary embolus is a venous embolus originating most commonly from a DVT from the leg. This travels into the pulmonary artery and occludes a small pulmonary artery. Distal to the occlusion, there will be no further circulation and infarction may occur in a segment of the lung; the size of infarct is dependent on the size of the embolus. Liver and gastrointestinal infarctions are not related to pulmonary emboli. Leg edema is not a complication of pulmonary emboli, but may result from DVT.
The primary goal in treatment of acute respiratory distress syndrome (ARDS) is to: A. restore oxygenation B. restore blood pressure C. restore temperature regulation D. restore normal respiratory rate
A. restore oxygenation Remember, with questions like this, the question asks. "What is the primary goal in treatment?". With all patients. the nurse would control blood pressure, temperature, and respiratory rate. The primary goal in ARDS is to restore oxygenation since this is the major derangement.
A patient is admitted to your floor with the following arterial blood gas. pH 7.55 CO2 28 PaO2 88 HCO3 26 What is the interpretation? A. respiratory acidosis B. compensated metabolic alkalosis C. non-compensated respiratory alkalosis D. metabolic alkalosis
C. non-compensated respiratory alkalosis The patient has a rapid respiratory rate with low CO2. The pH is alkalotic (a pH grater than 7.45), the PaO2 is within the normal range, and the bicarbonate is normal. Since the pH is abnormal, this ABG shows non-compensated changes.
The jugular venous pulse is particularly valuable for assessing: A. right atrial function B. left atrial function C. right ventricular function D. left ventricular function
A. right atrial function The jugular venous pulse is an excellent tool to assess the right ventricle. The right atrium is filled by the superior vena cava; the jugular comes off the SVC. The jugular vein will have increased pulsations when the right atrium is overloaded or overfilled. With acute right ventricular failure, the patient will have jugular venous distention. With prolonged right ventricular failure, the patient may exhibit JVD, but only when the right artria is involved.
An atrial septal defect is characterized by: A. shunting of blood returning from the lungs through the left atrium back to the right atrium and then returns to the pulmonary circulation B. left to right shunt, increased pulmonary hypertension and right-sided heart failure C. right ventricular hypertrophy from increased pressure in the right ventricle and decreased pulmonary flow D. Left ventricular wall hypertrophy
A. shunting of blood returning from the lungs through the left atrium back to the right atrium and then returns to the pulmonary circulation An arterial septal defect (ASD) allows blood from the left atrium (due to higher pressure gradient in the left atrium) to return to the right atrium and then the right ventricle before returning to the lungs. This causes a shunting of oxygenated blood to go through the pulmonary circulation again. This may cause pulmonary congestion. A ventricular septal defect (VSD) causes blood to cross from the left ventricle to the right ventricle, causing pulmonary hypertension and right ventricular failure. The other answers are incorrect.
A patient is admitted with decompensated heart failure. The patient is receiving furosemide (Lasix), digoxin (Lanoxin), metoprolol (Lopressor) and lisinopril (Zestril) at home. What drug can be added to reduce preload? A. spironolactone (Aldactone) b. verapamil (Calan) c. dabigatran etexilate (Pradaza) d. No other drugs are essential
A. spironolactone (Aldactone) When the heart failure patient continues to have volume overload on appropriate medications, an aldosterone inhibitor such as spironolactone or eplerenone (Inspera) should be added. Aldosterone inhibition will decrease sodium reabsorption from the kidneys and therefore decrease intravascular volume. The nurse would carefully monitor potassium since aldosterone blockers are potassium-sparing diuretics. Remember not to use verapamil in heart failure; it will increase sodium and water retention. Dabigatran etexilate is an anticoagulant used only for non-vascular atrial fibrillation.
Symptoms of acute endocarditis of the mitral valve cause: A. symptoms similar to heart failure B. severe chest pain mimicking STEMI C. Claudication-type pain D. pain that is relieved by sitting up
A. symptoms similar to heart failure Symptoms of acute endocarditis are very similar to heart failure. The mitral valve with infection may become incompetent and cause increased pulmonary pressures just like left ventricular heart failure. The pateint will need heart failure treatment as well as antibiotics. Claudication-type pain is caused by ischemia to the lower extremities. Pain relieved by sitting up is usually pericarditis in nature.
When listening to heart sounds, S1 signifies which of the following? A. the beginning of ventricular systole B. the beginning of ventricular diastole C. the propulsion of blood into a non-compliant ventricle D. the blood going in the wrong direction
A. the beginning of ventricular systole The heart sound of S1 indicates the opening of the aortic and pulmonic valves and marks the beginning of ventricular systole or ejection. The beginning of diastole is after S2, propulsion of blood into a noncompliant chamber is S4, and blood going in the wrong direction will cause a murmur.
Systolic left ventricular dysfunction is best defined as: A. the impaired ability of the left ventricle to contract and effectively eject blood B. the impaired ability of the left ventricle to fill and relax C. heart failure with an elevated systolic blood pressure D. heart failure in which the heart stops beating
A. the impaired ability of the left ventricle to contract and effectively eject blood Systolic failure occurs when the ventricle has lower contractility and produces a lower ejection fraction and cardiac output. The ventricle dilates and loses the ability to contract as a unit. Depending on the severity of the dysfunction, the patient may present in cardiogenic shock. Impaired ability to fill the ventricle is a problem with diastolic dysfunction; heart failure with an elevated systolic pressure may more often cause diastolic dysfunction by causing a thickened ventricle that cannot fill properly. Heart failure caused by asystole is not heart failure but electrical standstill.
Common cause(s) of hypoxemia include: A. ventilation-perfusion (V/Q) mismatch B. hypoventilation C. ventilation rate abnormalities D. ventilation decreases
A. ventilation-perfusion (V/Q) mismatch The primary cause of hypoxemia is ventilation-perfusion mismatch; a problem with oxygen getting to the alveolus or a problem with blood moving by the alveolus (or both). Hypoventilation, rate abnormalities and decreases in ventilation all cause CO2 abnormalities.
Which of the following parameters is used as an estimate of alveolar ventilation? A. PaO2 B. PaCO2 C. pH D. alveolar-arterial oxygen gradient
B. PaCO2 A good estimate of alveolar ventilation is the patient's PaCO2 level. With good alveolar ventilation, the patient is washing out the CO2. With ventilatory failure, the PaCO2 increases. Remember: alveolar ventilation=tidal vol - dead space x frequency PaO2 reflects the oxygen in the blood, pH is the measure of acid/base of the blood and alveolar-arterial oxygen gradient is a measure of how much oxygen is transported from the alveolus to the arterial blood. The other answers are incorrect.
You are caring for a patient recently admitted with an inferior wall MI. Which of the following 12-lead ECG findings would you anticipate? A. T wave inversion in leads I and aVL B. Q wave formation and ST segment elevation in leads II, III, and aVF C. QRS duration greater than 0.01 in all leads D. R wave taller in V6
B. Q wave formation and ST segment elevation in leads II, III, and aVF With STEMI, the patient will have ST segment elevation. The inferior leads are II, III, and aVF. T wave inversion in leads I and aVL indicate ischemia in the anterior leads. QRS duration that is prolonged may indicate an intraventricular conduction defect, and an R wave taller in V6 is a bundle branch block.
Patients with occlusion of the right coronary artery are at high risk for the development of Mobitz type I heart blocks. This is because 90% of the population use the right coronary artery to supply which part of the conduction system? A. sinoarterial (SA) node B. artrioventricular (AV) node C. bundle branches D. Purkinje fibers
B. artrioventricular (AV) node Although the right coronary artery perfuses the SA node, it is the AV node ischemia that would cause a Mobitz Type 1 heart block. The bundle branches and the Purkinje fibers are perfused by the right and left circulation and if ischemic, would cause worse dysrhythmias such as complete heart block or idioventricular rhythm.
The primary function of beta blocker therapy in heart failure is to: A. increase BP B. block compensatory vasoconstriction and increase heart rate C. increase urine output D. decrease preload
B. block compensatory vasoconstriction and increase heart rate The treatment of heart failure is to reduce the actions of the sympathetic nervous system and the renin-angiotensin system. Beta blockers block the SNS and reduce afterload, slightly reduce contractility and improve heart rate regulation. These decrease the demands of oxygen for the patient with reduced ventricular function. Beta blockers do not increase heart rate, nor do they increase urine output or change preload in any way.
An NSTEMI is differentiated from an unstable angina by: A. location of chest pain B. cardiac biomarker elevation C. ECG changes D. extent of cardiac history
B. cardiac biomarker elevation In the NSTEMI vs unstable angina patient, the location of pain may be the same. Regarding ECG changes, both may have ST-Twave depression in the associated leads. The history of a patient with myocardial ischemia may not be pertinent. In an unstable angina, the patient may have ECG changes, but no cardiac enzyme changes. In NSTEMI, the patient will have cardiac enzyme elevation.
Which condition would stimulate renin production? A. increased blood supply to the renal tubules B. decreased blood pressure C. decreased sympathetic output D. increased sodium concentration
B. decreased blood pressure Renin secretion is regulated by blood flow to the juxtaglomerular apparatus. Decreased blood pressure would be identified, and renin secretion would occur. This begins a compensatory mechanism that causes vasoconstriction with increased blood pressure as well as sodium and water reabsorption in the kidneys, thereby effectively increasing blood pressure. Increased blood flow would maintain normal renin production. Decreased sympathetic output would not affect renin secretion from the kidneys (it is stimulated by low renal blood flow). Low serum sodium concentrations would stimulate renin production due to decreased osmolality.
The prevention of pulmonary emboli is geared toward prevention of: A. abdominal compartment syndrome B. deep vein thrombus formation C. hyperglycemia D. hyperthermia
B. deep vein thrombus formation Over 90% of pulmonary emboli in the hospitalized patient originate from DVT, usually in the leg. Prevention of DVT has become of great importance and is an outcome goal. Abdominal compartment syndrome, hyperglycemia and hyperthermia are all complications that may occur in the postoperative patient, but do not have primary relationships to DVT and pulmonary emboli.
A patient presents with acute decompensated heart failure and pulmonary edema. The patient has rales, dyspnea, tachycardia and cyanosis. Oxygen therapy is instituted. What other therapies will be started? A. oxygen therapy only B. diuretic therapy C. oxygen therapy and inotropic therapy D. fluid resuscitation will be required
B. diuretic therapy The initial therapy for acute decompensated heart failure (pulmonary edema) is diuretic therapy and oxygen supplementation. The patient is fluid oveerloaded and requires diuresis with oxygen therapy for increased oxygen needs. Administering fluid will worsen the heart failure and increase the patient's work of breathing.
The most common complication after a STEMI is: A. heart failure B. dysrhythmia C. ventricular septal rupture D. ventricular wall rupture
B. dysrhythmia The most common complication after a STEMI is dysrhthmia due to irritability of the ischemic myocardium and the dead myocardium that does not transmit electrical stimuli. With interior-wall STEMI, the most common dysrhythmia is bradycardia and heart block. With anterior-wall STEMI, tachydysrhythmias such as ventricular tachycardia and/or ventricular fibrillation are most common. Heart failure, ventricular septal wall rupture and ventricular rupture are infrequent complications after STEMI and carry a very poor prognosis.
A 70 year old female presents in cardiogenic shock secondary to myocardial infarction. Which of the following symptoms are consistent with cardiogenic shock? A. hypertension with systolic blood pressure greater than 90 mm Hg, bradycardia, chest pain and tachypnea B. hypotension with systolic blood pressure less than 90 mm Hg, tachycardia, dysrhythmias and tachypnea C. hypotension with systolic blood pressure less than 90 mm Hg, dysrhythmias and slow, labored breathing D. hypotension with systolic blood pressure less than 90 mm Hg, bradycardia and slow, labored breathing
B. hypotension with systolic blood pressure less than 90 mm Hg, tachycardia, dysrhythmias and tachypnea Cardiogenic shock presents with low cardiac output syndrome: tachycardia, low systolic pressure, elevated diastolic pressure (decreased pulse pressure), tachypnea due to tissue hypoxia, and dysrhythmias due to myocardial ischemia. Hypertension does not fit with low cardiac output syndrome, nor does slow labored breathing.
Neurohormonal response in heart failure with long-term consequences include: A. increased liver release of glycogen stores B. increased activation of the sympathetic nervous system and the renin-angiotensin system C. increased production of hemoglobin D. increased production of cholesterol to make hormones
B. increased activation of the sympathetic nervous system and the renin-angiotensin system With continued heart failure, the body compensates for the low cardiac output by stimulating the sympathetic nervous system and the renin-angiotensin system. This increases preload and afterload in an already poorly functioning heart. Neurohormonal blockers are the treatment. Activation of increased liver release of glycogen stores increases blood sugar, but not heart failure. Increased production of hemoglobin is a response to hypoxia, and increased production of cholesterol does not have a relation to the neurohormonal response to heart failure.
On the 12 lead ECG, cardiac ischemia is characterized by: A. elevation of the ST segment and elevated peaked T waves B. inverted T wave C. development of Q waves D. abnormal Q wave or decreased R wave progression in the V leads
B. inverted T wave The first clinical ECG sign of myocardial ischemia is the tenting of the T wave; large tented T waves in 2 contiguous leads. This is often missed since it occurs so early in the ischemic period. The second sign is the inverted T wave. If ischemia persists and infarction occurs, the ST segment elevates, and later a Q wave forms. Not all STEMIs develop Q waves, however, so the best answer is the T wave.
The most common cause of heart failure in the US is: A. valvular disease B. ischemic heart disease C. renal failure D. hepatitis
B. ischemic heart disease In the US, the most common cause of heart failure is ischemic heart disease. After STEMI or NSTEMI with damage to the myocardium, ventricular failure may result secondary to decreased ejection fraction. Each insult to the myocardium may make the heart failure worse. For many years, valvular disease, caused by untreated strep throat, was one of the most common causes of heart failure. However, that has changed since the newer strep tests provide rapid results, preventing delayed treatments. Renal failure and hepatitis are serious illnesses but are not common causes of heart failure.
The heart's primary compensatory response to chronic aortic stenosis includes: A. left arterial hypertrophy B. left ventricular hypertrophy C. left ventricular dilation D. right ventricular dysfunction
B. left ventricular hypertrophy With chronic aortic stenosis, the left ventricle hypertrophies over time due to the increased workload of pumping blood through a narrowed opening. This leads to diastolic dysfunction as well as hypertrophy. The left atrium will enlarge over time, but the primary result is left ventricular hypertrophy, not dilation. The right ventricle remains normal for a period of time.
A patient with a closed head injury has developed a fever of 104F (40C). The nurse understands that an increasing temperature: A. may cause improved intracranial pressure B. may cause increased oxygen requirements of the brain tissue C. may cause no change in neurologic functioning D. is easily lowered with acetaminophen (Tylenol)
B. may cause increased oxygen requirements of the brain tissue Elevated systemic and brain temperature will increase the oxygen requirements of the brain tissue at a time when oxygen delivery may be in jeopardy. Increased temperature may actually increase ICP. If the temperature is secondary to the brain injury, acetaminophen will not decrease the hypothalamic mediated increased temperature.
A 55-year old male is admitted from the ICU after an acute Type III aortic dissection. Treatment plan includes blood pressure control. What medications would the nurse anticipate in this patient? A. digoxin (Lanoxin) and furosemide (Lasix) B. metoprolol (Lopressor) and lisinopril (Prinivil) C. furosemide and spironolactone (Aldactone) D. bumetanide (Bumex) and amlodipine (Norvasc)
B. metoprolol (Lopressor) and lisinopril (Prinivil) The blood pressure control of this patient is the most important treatment in his care. The two most common drugs for the treatment of an aortic dissection are a beta blocker and ACE inhibitor. Diuretics may be added for more control of blood pressure, but are not first-line drugs. Digoxin is not required for this patient.
A thoracic aortic aneurysm causes chest pain that: A. radiates to the left arm B. radiates through to the back C. is sharp and worse while reclining D. is associated with diminished breath sounds
B. radiates through to the back Typically aortic aneurysms present with severe, acute onset of chest pain that radiates through to the back. Pain that radiates to the left arm may indicate myocardial ischemia. Sharp pain worsening with the reclined position may be pericarditis, and diminished breath sounds could be anything that is caused by decreased tidal volume.
A hallmark of acute respiratory distress syndrome (ARDS) is: A. refractory hypercapnia B. refractory hypoxemia C. refractory hypotension D. refractory acidosis
B. refractory hypoxemia Early in ARDS, the patient begins to have pulmonary hypertension secondary to increased pulmonary water and vasodilation. Early on, the patient would have respiratory alkalosis and increase his or her respiratory rate. This is also secondary to a decrease partial pressure of oxygen in the blood. This hypoxemia does not respond to increased levels of inhaled oxygen. Therefore, the definition is refractory (cannot make better) hypoxemia. Hypercapnia is not the primary problem in ARDS; it is a problem of hypoxia. Hypotension may occur, but ARDS is primarily a lung problem that causes severe hypoxia. Refractory acidosis is also incorrect.
A patient with chronic obstructive lung disease now has respiratory failure with a PaCO2 of 65 and a pH of 7.30. The patient has dyspnea and is experiencing cardiac dysrhythmias, confusion and hypotension. These findings are consistent with: A. respiratory alkalosis B. respiratory acidosis C. metabolic alkalosis D. metabolic acidosis
B. respiratory acidosis To evaluate an arterial blood gas in a patient with chronic disease, address the pH first. In this case, the pH is abnormal. It is 7.30, which is acidotic, and an acute finding. The PaCO2 is also elevated, meaning that this is a respiratory acidosis. This finding is important and the patient requires immediate care. Respiratory alkalosis would include a pH greater than 7.45; metabolic acidosis would require a base deficit (less than -2.2) or a bicarbonate of less than 22; metabolic alkalosis would require a base excess (greater than +2.2) or a bicarbonate of greater than 26.
After cardiac transplantation, the patient is placed on cyclosporine modified (Gengraf). In assessing this patient, the nurse should monitor: A. Blood glucose B. serum creatinine C. serum amylase D. serum magnesium
B. serum creatinine When a patient is on cyclosporine for antirejection, serum creatinine should be followed closely. Cyclosporine is eliminated via the kidneys and can cause renal injury and failure. Of course, blood glucose should be monitored; however, this questions is looking for the consequence of a drug on renal function. Serum amylase is affected by liver disease or pancreatitis, and serum magnesium should always be monitored; however, it is not affected by cyclosporine.
A patient is discharged with the diagnosis of severe peripheral vascular disease (PVD). In addition to medication and a walking regime, if applicable, which of the following is essential education at time of discharge? A. nutritional counseling B. smoking cessation counseling C. social work consult D. speech therapy consult
B. smoking cessation counseling Cessation of tobacco use is the most important non-pharmacological intervention that can be done to improve signs and symptoms of peripheral bvascular disease. Social work consult and speech therapy may not be indicated in this patient. All patients may benefit from nutrition counseling; however, this is not a primary concern for this patient.
The most common ECG changes that occur during pulmonary embolus are: A. Q waves in AVR and Lead I B. tachycardia C. Bradycardia and ST segment depression D. high degree AV blocks
B. tachycardia The most common ECG changes that occur with pulmonary embolism are tachycardia ( a good first clinical condition of almost anything) and atrial fibrillation due to increased pulmonary pressure, The other answers are incorrect.
Patients with pericardial effusions should be assessed for the development of which of the following complications: A. thrombocytopenia B. tamponade C. low hemoglobin and hematocrit D. endocarditis
B. tamponade Any patient with a pericardial effusion should be assessed for cardiac tamponade physiology. Any accumulation of fluid in the pericardial sac can compress the myocardium, producing tamponade signs and symptoms. All patients are assessed for thrombocytopenia, low H+H and endocarditis; they are not the focus of complications with effusions but could be additional signs of tamponade (low H+H and thrombocytopenia).
Nursing interventions in the patient with pericarditis include all the following except: A. providing comfort by administering pain medications and proper positioning B. auscultating heart sounds to assess for muffled heart sounds C. administering anticoagulants to prevent thrombus in the pericardium D. monitoring for jugular venous distention (JVD) and hypotension
C. administering anticoagulants to prevent thrombus in the pericardium A patient with pericarditis should have pain-relief medication. The nurse should auscultate heart sounds and assess if they are muffled (a sign of possible tamponade), and monitor for JVD and hypotension (more signs of tamponade physiology). Do not give anticoagulants to the patient since they may cause bloody pericardial effusions and tamponade.
An elderly patient is admitted and placed on warfarin (Coumadin) for arterial fibrillation. What is a therapeutic range for anticoagulation for this patient? A. international normalized ration (INR) less than 1.0 B. INR between 1.0 and 1.5 C. INR between 2.5 and 3.5 D. INR between 4.5 and 6.0
C. INR between 2.5 and 3.5 The therapeutic range of INR for any patient with atrial fibrillation is 2.5-3.5, no matter what their age. A normal INR is 1.0, and 4.5-6.0 is a high INR.
During the treatment of supraventricular tachycardia, which medication is given rapidly intravenous (IV) push and may result in a brief sinus pause? A. lidocaine (Xylocaine) B. epinephrine (Adrenaclick) C. adenosine (Adenocard) D. procainamide
C. adenosine (Adenocard) Adenosine is used for the treatment of supraventricular tachycardia. It is given as a rapid IV push with a large saline flush. It often results in a sinus pause, then the rhythm converts to sinus. None of the other medications are used for supraventricular tachycardia.
At which level of FiO2 support is oxygen toxicity thought to develop? A. 30-40% for longer than 48 hrs B. 40-50% for longer than 2 hrs C. more than 50% for longer than 24-28 hrs D. FiO2 does not cause oxygen toxicity
C. more than 50% for longer than 24-28 hrs Oxygen toxicity does occur in adults and is related to the amount of FiO2 over time. FiO2 at more than 50% for more than 24 hrs can cause toxicity. Toxicity is seen as increasing atelectasis due to decreased surfactant production. Inspired oxygen at levels less than 50% will not cause toxicity.
The first 24 hours after stroke, the patient is at high risk for multiple complications. One complication that the nurse can protect the patient from is: A. bleeding B. decreased level of consciousness C. aspiration D. speech abnormality
C. aspiration The post-stroke patient is most risk for aspiration since he or she may have swallow abnormalities. Patients who are poststroke should have a swallow evaluation before the reinstitution of feeding. Aspiration precautions should be initiated after stroke and continued until a complete swallow evaluation is done. The nurse cannot prevent bleeding, changes in consciousness or the presence of a speech abnormality; however, the nurse can assess and monitor these changes.
The most common new-onset dysrhythmia seen in a patient with acute decompensated heart failure is: A. right bundle branch block B. ventricular tachycardia C. atrial fibrillation D. complete heart block
C. atrial fibrillation Atrial fibrillation is the most common dysrhythmia in the heart failure patient.
The most common postoperative complication of coronary artery bypass (CABG) surgery is: A. bleeding B. stroke C. atrial fibrillation D. ventricular fibrillation
C. atrial fibrillation The most common complication after CABG is the dysrhythmia atrial fibrillation. In approximately 33% of all patients who have atrial fibrillation, the mechanism is not completely understood. Postoperative myocardial edema may cause an atrial stretch, facilitating electrophysiological abnormalities. Other complications include bleeding, stroke, and ventricular fibrillation, but they are not the most common.
The gold standard diagnostic tool for the identification, location of disease and severity of coronary artery disease is: A. a stress test B. an echocardiography C. cardiac catheterization D. a spiral computer tomography (CT scan)
C. cardiac catheterization The gold standard, or best diagnostic tool, for the diagnosis, location and severity of coronary artery disease is the cardiac catheterization performed in the cath laboratory. Echocardiography is excellent in revealing structure changes, but not coronary artery disease. A stress test may be a good screening tool, but again, is not the gold standard, nor is CT scanning
Beck's triad, which includes hypotension, muffled heart sounds and jugular venous distention (JVD), is indicative of which condition? A. myocardial infarction B. aortic valve stenosis C. cardiac tamponade D. pulmonary embolism
C. cardiac tamponade The classic presentation of Beck's triad, or cardiac tamponade, is hypotension, JVD and muffled heart sounds. Also typically occurring are tachycardia (due to low cardiac output) and narrow pulse pressure (again, due to low cardiac output and high SVR). This classic presentation requires immediate action by the nurse caring for the patient: a stat echocardiogram, chest X-ray and continued vital signs as well as starting large-bore IV access for fluid resuscitation.
Early symptoms of fluid overload and pulmonary edema are: A. rales and hypoxia B. S3 heart sound and tachycardia C. complaint of shortness of breath and orthopnea D. ST segment elevation in the chest leads
C. complaint of shortness of breath and orthopnea Remember that symptoms are what the patient complains of, not signs that the nurse measures. Rales and hypoxia, S3 and tachycardia are signs that are measured at the bedside. ST segment elevation is a sign of cardiac injury/infarction. A complaint of shortness of breath and the inability to lie down are symptoms of early left-ventricular failure.
With acute arterial insufficiency, the extremity will appear: A. warm with normal color B. warm with increased redness C. cool with pale color D. cool with normal color
C. cool with pale color The patient with acute arterial insufficiency will have a cool extremity and a pale appearance, both due to lack of blood flow. The 6 P's to arterial circulation are: pulse (palpation, Doppler), pain (pt's perception), pallor (color change), polar (decreased temperature), paresthesia (numbness, pins and needles in extremity) and paralysis (not feeling or moving).
A medication that dilates both the venous and arterial beds will cause which of the following results? A. increased preload, decreased afterload B. increased preload, increased afterload C. decreased preload, decreased afterload D. decreased preload, increased afterload
C. decreased preload, decreased afterload When both the venous and arterial beds are dilated, there will be less venous return, causing a decreased preload (ex. nitroglycerin). With arterial vasodilation, the afterload will decrease (ex nitroprusside, ACE-I). Afterload in this case is resistant to LV pumping.
What are the signs of Cushing's triad, which indicates increasing intracranial pressure? A. lowered systolic blood pressure, decreased heart rate, lowered pulse pressure B. lowered systolic blood pressure, increased heart rate, lowered pulse pressure C. elevated systolic blood pressure, decreased heart rate, widened pulse pressure D. elevated systolic blood pressure, increased heart rate, widened pulse pressure
C. elevated systolic blood pressure, decreased heart rate, widened pulse pressure An ICP increases, a variety of vital sign changes occur that is known as Cushing's triad. This includes: elevated systolic blood pressure, decreased diastolic blood pressure with a resultant widening pulse pressure. The heart rate also drops. This type of vital sign change does not occur with any other type of patient problem (such as volume depletion, heart failure or stress)
The nurse auscultates an S3 on a patient just admitted with NSTEMI. What does that indicate? A. normal heart sounds B. mitral valve stenosis C. fluid overload D. increased afterload
C. fluid overload The auscultation of an S3 is always abnormal in the adult patient. It indicates an overfilled left ventricle at the beginning of ventricular diastole and is a marker of poor ventricular function as well as fluid overload. S3 does not reflect mitral valve stenosis (diastolic murmur) or increased afterload
An elderly patient with an abdominal aortic aneurysm decline surgery for the condition. What medication may be helpful in the prevention of rupture of this aneurysm? A. benazepril (Lotensin) B. captopril (Capoten) C. metoprolol (Lopressor) D. ramipril (Altace)
C. metoprolol (Lopressor) Beta blockers are the best treatment for the prevention of an abdominal aortic aneurysm rupture. The other answers are all angiotensin-converting enzyme inhibitors and will decrease the patient's hypertension; it is the beta blocker that is suggested for this patient. Beta blockers, while decreasing blood pressure, also inhibit the force of ventricular contraction, which helps prevent tension on the aortic wall, thereby reducing stress and the possibility of rupture.
After a spinal tap, the patient complains of severe headache, visual disturbances and nausea. An autologous blood patch may be injected near the puncture site in order to: A. prevent infection B. relieve local pain C. plug the puncture hole in the dura D. reduce edema at the puncture site
C. plug the puncture hole in the dura After a spinal tap, the dura is penetrated and may stay open with a cerebrospinal fluid leak -- causing headache, visual disturbances and nausea and/or vomiting. A blood patch is injected epidurally near the puncture site to plug the puncture hole in the dura. The post-procedure headache results from loss of cerebrospinal fluid through the puncture hole, resulting in brain displacement and stress on supporting structures of the brain. Headache onset is usually 12 to 48 hours after puncture but may be delayed. Conservative treatment may include bed rest, fluids, and caffeine. The blood patch does not prevent infection, relieve local pain at the site or reduce edema, it only prevents further leak of cerebrospinal fluid.
A patient is one day following surgery for peripheral vascular disease. She is increasingly short of breath and develops a low-grade fever, hiccoughs, dyspnea, cough, tachycardia and chest pain. Which of the following diagnoses is the most likely? A. atelectasis B. myocardial infarction C. pulmonary embolism D. pneumonitis
C. pulmonary embolism The patient is exhibiting signs of pulmonary embolism. While clinical manifestations may vary according to size and position of the embolus, common symptoms include dyspnea with tachycardia (one of the most common signs), cough (sometimes with hemoptysis), rales, and chest pain. Other common signs are hiccoughs, hemodynamic instability, anxiety, restlessness and fever.
A patient is admitted 4 days postoperatively from an ascending aortic aneurysm repair. He acutely develops shortness of breath after his first time ambulating in the hall. The nurse should consider what possible problem? A. acute heart failure B. acute postoperative pneumonia C. pulmonary embolus D. routine postoperative pain
C. pulmonary embolus At 4 days postoperative with acute shortness of breath after first time ambulation, the nurse should suspect pulmonary embolus. Acute heart failure is not a usual postoperative problem with this type of patient unless he or she had heart failure before surgery. Acute postoperative pneumonia may present with shortness of breath with activity, but the patient may have other signs and symptoms such as tachycardia, increased respiratory rate, fever, and cough. Routine postoperative pain does not occur acutely; this is a change in patient condition.
Which of the following increases the risk of abciximab (ReoPro) (IIb IIIa inhibitor) induced coagulopathy and is a contraindication for use? A. previous stroke within 3 years B. platelet count of 110,000 C. recent warfarin (Coumadin) therapy D. a history of angina
C. recent warfarin (Coumadin) therapy The use of abciximab is contraindicated with recent history of oral anticoagulation with warfarin, recent bleeding or stroke within the previous 2 years or a paltelet count of less than 100,000. Abciximab is used to prevent cardiac ischemia and re-occlusion of percutaneous transluminal coronary angioplasty and stent. Abciximab inhibits the aggregation of platelets and is used with aspirin and/or weight adjusted and low-dose heparin as it potentiates the action of anticoagulants.
Which of the following is a complication of mechanical ventilation and positive end expiratory pressure (PEEP) therapy? A. atelectasis B. oxygen toxicity C. reduced cardiac output D. acute respiratory distress syndrome (ARDS)
C. reduced cardiac output Because positive pressure ventilation increases intrathoracic pressures, this may cause a reduction in venous return and therefore a reduction in cardiac output. Reduced cardiac output is the most common complication of mechanical ventilation and the use of PEEP. PEEP therapy may reduce the FiO2 on the ventilator, and therefore decrease the complication of oxygen toxicity. Atelectasis and ARDS are treated mainly with increased PEEP; they are not complications of this treatment methodology.
A post-STEMI (ST elevation myocardial infarction) patient is started on an angiotensin-converting enzyme (ACE) inhibitor during his hospital stay. Which of the following is the most common serious side effect that may occur? A. a nonproductive cough B. pedal edema C. swelling of the tongue and face D. rhinorrhea
C. swelling of the tongue and face Although all of the answers may occur, swelling og the tongue and face is the most serious and may require intervention. Patients should be instructed to seek medical attention immediately for any signs of swelling in the tongue or throat.
With increasing intracranial pressure (ICP), the patient's blood pressure will change. What is the blood pressure response to increasing ICP? A. only systolic blood pressure will increase B. only diastolic blood pressure will increase C. systolic blood pressure will increase with a decrease in diastolic blood pressure D. the pulse pressure will narrow
C. systolic blood pressure will increase with a decrease in diastolic blood pressure With increasing ICP and brain stem edema, the systolic pressure elevates with a decrease in diastolic pressure, thereby widening the pulse pressure. This is a significant change that accompanies increasing ICP. There will also be a decreased heart rate.
A patient just admitted to your floor from the PACU is agitated and has tingling of the fingers. ABG on room air reveals: pH 7.49 PaCO2 25 PaO2 95 HCO3 24 Which of the following is correct? A. normal acid-base balance B. compensated respiratory alkalosis C. uncompensated respiratory alkalosis D. uncompensated metabolic alkalosis
C. uncompensated respiratory alkalosis The patient has an alkalosis (pH high), from a respiratory parameter of PaCO2 25. The patient is breathing fast and blowing off CO2. This is uncompensated since the pH is abnormal. The patient may be in pain, thus causing an increased respiratory rate.
Stable angina is best defined as: A. pain that increases in severity B. pain that is new C. pain that occurs at rest D. pain that has a predictable pattern over time
D. pain that has a predictable pattern over time Stable angina is predictable -- the patient can describe the pain and how it is initiated accurately each time -- and occurs with exertion. Ex: The patient knows every time he or she climbs stairs, it will be accompanied by chest pain. The pain is relieved with rest and nitroglycerin (Nitrolingual). Pain that is new or occurs at rest is not stable angina. If the pain increases in severity, it is no longer stable.
When assessing myocardial chest pain, which of the following is not a common characteristic of angina: A. discomfort that is precipitated by exercise B. discomfort that is described as pressure or tightness C. discomfort that is relieved with rest or nitroglycerin D. pain that is intermittent and that comes and goes
D. pain that is intermittent and that comes and goes Myocardial ischemia causing pain has the usual characteristics of precipitation by exercise or exertion, described as pressure or tightness, and relief by rest and/or nitroglycerin. Intermittent pain that comes and goes is not the usual presentation of myocardial ischemia.
Which of the following best describes the fourth heart sound (S4): A. It occurs after ventricular contraction B. It is best heard with the diaphragm of the stethoscope C. It is a normal finding in children D. It occurs during late diastole when the atria contracts
D. It occurs during late diastole when the atria contracts The presence of the extra heart sound S4 signifies a poorly compliant (stiff) left ventricle. An S4 is also called an atrial heart sound since it occurs at the end of diastolic filling when the atria contracts and fully fills the left ventricle. Known as "atrial kick", this filling is important to cardiac output. The increased end-diastolic volume in the ventricle improves cardiac output. When the left ventricle is stiff (decreased compliance with long term hypertension, aortic stenosis or with acute STEMI), the atrium has to pump harder to move blood from the atrium to the ventricle, causing a turbulent blood flow and extra heart sound. This heart sound is always pathologic. It occurs before ventricular contraction, is best heard with the bell of the stethoscope and is never a normal heart sound, even in children.
A 68 year old male is 4 hours postoperative after percutaneous transluminal coronary angioplasty and stent placement and complains of flank pain. He is restless, tachycardic, hypotensive, and his hemoglobin and hematocrit levels (H+H) have dropped. Which of the following nursing actions is correct? A. Keep the head of the bed flat and apply pressure at the sheath site to stop bleeding. B. Notify a physician immediately and anticipate ultrasound-guided compression and possible surgery to stop the bleeding. C. Notify a physician immediately, and anticipate anticoagulation or thrombolytic therapy. D. Notify a physician immediately, stop anticoagulation therapy, and anticipate the need for intravenous fluid and/or blood
D. Notify a physician immediately, stop anticoagulation therapy, and anticipate the need for intravenous fluid and/or blood This angioplasty and stent patient is probably experiencing a retroperitoneal arterial bleed into the flank area, requiring cessation of anticoagulants and preparation for fluid administration and/or blood. Lying the patient flat and applying pressure to the sheath site treats the bleeding or hematoma at the sheath site. Ultrasound-guided compression and surgery is indicated if a pulsatile mass or bruit occurs near the insertion site, indicating pseudoaneurysm or arteriovenous fistula formation. Anticoagulation therapy is indicated for decreased circulation in extrremity related to thrombus or embolus.
Which pathologic changes found on the 12-lead ECG indicate myocardial ischemia? A. ST-segment elevation B. ST-segment depression and T-wave elevation C. Q-wave formation D. ST-segment depression and T-wave inversion
D. ST segment depression and T wave inversion Myocardial ischemia changes the repolarization of the ventricular muscle. That change is seen on the 12 lead ECG as ST-segment depression and T wave inversion, which demonstrate subendocardial ischemia -- the innermost layer of muscle in the myocardium. ST-segment elevation indicates acute injury or infarction, ST segment depression and T wave elevation may indicate an electrolyte abnormality, while Q wave formation indicates total infarction.
A patient who has sustained a septal wall infarction several days ago now is complaining of acute shortness of breath. The nurse auscultates rales bilaterally, notes decreasing O2 saturations and lowered blood pressure. These signs and symptoms may indicate: A. Deep vein thrombosis B. pneumonia C. anxiety D. acute ventricular septal defect (VSD) with heart failure
D. acute ventricular septal defect (VSD) with heart failure A complication of septal wall infarction is VSD. This may occur 3-7 days after infarction and appears as acute decompensated heart failure. DVT does not have a presentation of acute onset heart failure. Pneumonia may present with chest pain and rales on the affected side, but not acute decompensated heart failure. Anxiety usually does not change the patient's total physical exam with decreasing saturations, rales bilaterally and acute shortness of breath.
Assessment of the patient with acute respiratory failure should include: A. mental status B. work of breathing C. oxygen saturations D. all of the above
D. all of the above Again, be careful with these questions. Mental status changes occur with oxygenation problems or CO2 elevation and occur early in respiratory failure. Work of breathing and oxygen saturations are part of the basic respiratory assessments as well as respiratory rate.
Which of the following is a complication after a bedside thoracentesis? A. acute bleeding for puncture site B. pneumothorax C. hemothorax D. all of the above
D. all of the above Bedside thoracentesis has been replaced by ultrasound-guided thoracentesis due to the complication of pneumothorax. Patient coagulation studies are done before the procedure to eliminate the possibility of bleeding from the site, as well as causing a hemothorax, although these complications may still occur.
The amount of oxygen delivered to the tissues is determined by what factor: A. cardiac output B. hemoglobin levels C. oxygen saturation D. all of the above
D. all of the above Cardiac output, hemoglobin levels and oxygen saturation all contribute to the amount of oxygen delivered to the tissues
The major physiologic derangements in acute respiratory distress syndrome (ARDS) are the systemic effects of the inflammatory system. They include: A. movement of fluid out of the capillary bed B. release of histamine C. vasodilation D. all of the above
D. all of the above The systemic effects of acute inflammatory response are histamine release, which causes the vasodilation and edema, then movement of fluid out of the capillary bed and into tissues. The term "non-cardiac pulmonary edema" was a common way to describe ARDS, a very wet lung that became noncompliant and stiff not related to left ventricular function.
The most common cardiac complication of post-thoracic (lung) surgery is: A. fluid overload B. pneumonia C. renal failure D. atrial fibrillation
D. atrial fibrillation Because of the lung resection process, pulmonary pressure are elevated after lung surgery and may cause acute elevations in intrathoracic pressure, putting a stretch across the atria. This increase in pressure and stretch causes premature atrial complexes and the development of atrial fibrillation. Pneumonia is a complication of any surgery, but is not the most common in the postoperative lung surgery patient. Fluid overload is a complication of post lung surgery, but not the most common cardiac complication, nor is renal failure a cardiac complication.
The anterior left ventricle receives blood via the: A. left circumflex artery B. right coronary artery C. posterior descending coronary artery D. left anterior descending coronary artery
D. left anterior descending coronary artery The left anterior descending coronary artery perfuses the entire left anterior section of the left ventricle, two-thirds of the septum and the apex of the left ventricle. The right coronary artery perfuses the right ventricle. The left circumflex perfuses the left lateral ventricular wall, and the posterior descending coronary artery perfuses the inferior right and left ventricular wall.
Pulmonary emboli produce all of the following physiologic changes except: A. pulmonary hypertension B. arterial hypoxemia C. hypocarbia D. left ventricular failure
D. left ventricular failure With pulmonary emboli, the pulmonary pressures become elevated and may cause acute right ventricular failure. The left ventricle has no increase in afterload. A patient who becomes hypoxemic will increase his or her respiratory rate causing a lowered PaCO2 (hypocarbia). With pulmonary emboli, the patient typically has hypoxemia due to the decrease in alveolar perfusion.
In preparation for assisting a physician doing a thoracentesis, the patient should be positioned in which of the following manners: A. lying on the affected side with head of the bed flat B. lying on the affected side with head of the bed elevated 15 degrees C. lying on the opposite side with head of the bed flat D. patient upright and slightly bent forward
D. patient upright and slightly bent forward Positioning the patient properly before a thoracentesis is a nursing responsibility. Upright and slightly bent forward is the most optimal position, allowing a posterior drainage approach. If the upright position is not possible and the patient must lie in bed, then the preferred position is decubitus with the side of the chest containing the effusion down. Patient comfort is important as well, having the head of the bed upright will allow the patient to breathe easier and allow for the fluid to flow to the posterior of the lung.
A patient with a known seizure disorder falls to the floor having a generalized grand mal seizure. Which of the following options is most appropriate nursing action? A. position the patient flat on his or her back and loosen clothing B. place a tongue blade between his or her teeth C. do not touch the patient until the seizure subsides D. position the patient on his or her side with head flexed forward
D. position the patient on his or her side with head flexed forward If a patient is having a generalized grand mal seizure, the priority is to first maintain an open airway. Placing the patient on his side with his head flexed forward will keep his tongue forward and prevent aspiration. Placing the patient flat on his back will not prevent aspiration. The patient should never be restrained or anything placed in his mouth. The answer to most medical-surgical questions should be the first priority care: airway, breathing, circulation and drugs.
A patient presents in acute distress with rales halfway up bilaterally; cool and clammy extremities; elevated jugular venous distention (JVD); oxygen saturations at 95%, down from 99%; and complaints of shortness of breath. Which of the following findings correspond to the patient's cardiac status? A. no pulmonary congestion, normal perfusion B. no pulmonary congestion, low perfusion C. pulmonary congestion, normal perfusion D. pulmonary congestion, low perfusion
D. pulmonary congestion, low perfusion Rales indicate fluid in the alveolar sacs, possibly secondary to pulmonary edema, causing pulmonary congestion. Pneumonia can also cause fluid in the alveolar sacs. The patient is complaining of shortness of breath, and the oxygen saturations are lowering, also indicating that the patient has pulmonary congestion. The patient's skin is cool and clammy, indicating that the skin is poorly perfused. Skin does not require oxygen and shunts blood away in decreased cardiac function; therefore, this patient has pulmonary congestion and low perfusion state. The other answers are incorrect.
A physiologic reason for sinus tachycardia is: A. elevated serum potassium B. elevated creatinine C. decreased urine output D. tissue hypoxia
D. tissue hypoxia Sinus tachycardia is generally a compensatory mechanism for decreased tissue oxygenation. Fever, pain, anxiety, hypovolemia and decreased blood pressure all are reasons for tachycardia. The physiology in all is the lack of oxygen delivery at the tissue level. Elevated potassium does not increase heart rate, but if it is high enough, causes sinus bradycardia. Elevated creatinine is a marker of renal failure, and increased potassium would cause sinus bradycardia. Decreased urine output may or may not affect heart rate.
Which of the following is a goal for positive end expiratory pressure (PEEP) therapy? A. to improve CO2 elimination B. to treat a metabolic acidosis C. to reduce postoperative abdominal bleeding D. to allow reduction in FiO2 support
D. to allow reduction in FiO2 support PEEP therapy is used for improving oxygenation and for alveolar recruitment. Improving oxygenation would allow the practioner to decrease FiO2 support. PEEP does not help to eliminate CO2; increasing respiratory rate will lower CO2. Metabolic acidosis is corrected with treatment of the cause of acidosis such as: increased lactic acid, renal failure and/or diabetic ketoacidosis (DKA). For the postoperative cardiothoracic surgery patient who has chest bleeding, increasing the PEEP on the ventilator may reduce chest bleeding by tamponading the bleeder; this is not a common practice with other types of bleeding
A patient who experienced an episode of severe chest pain and weakness four days earlier is undergoing diagnostic tests. Which test would provide the most accurate information to diagnose a myocardial infarction after four days? A. an ECG B. creatine-kinase and isoenzyme (CK-MB) C. myoglobin D. troponin and its isomers (C, I, and T)
D. troponin and its isomers (C, I, and T) Troponin and its isomers regulate contractions and levels increase as with CK-MB with an MI, but remian elevated for up to 2 weeks. An ECG is most helpful if taken immediately after an MI so ECG changes can be monitored. Myoglobin levels increase in 1-4 hrs after an MI and peak within 6-12 hrs. CK-MB levels increase within a few hours and peak at about 24-27 hrs.
An elderly patient on warfarin (Coumadin) therapy has been admitted with an INR of 6.0. What is the antidote that can be used to counteract the effects of warfarin and decrease the risk of bleeding? A. vitamin A B. vitamin B12 C. vitamin C D. vitamin K
D. vitamin K Vitamin K is the antidote for warfarin overdose. None of the other vitamins are antagonists of warfarin.
