Test Bank Test 3

1. The nurse is caring for a 100-kg patient being monitored with a pulmonary artery catheter. The nurse assesses a blood pressure of 90/60 mm Hg, heart rate 110 beats/min, respirations 36/min, oxygen saturation of 89% on 3 L of oxygen via nasal cannula. Bilateral crackles are audible upon auscultation. Which hemodynamic value requires immediate action by the nurse? a. Cardiac index (CI) of 1.2 L/min/m3 b. Cardiac output (CO) of 4 L/min c. Pulmonary vascular resistance (PVR) of 80 dynes/sec/cm-5 d. Systemic vascular resistance (SVR) of 1800 dynes/sec/cm-5

ANS: A A cardiac index of 1.2 L/min/m3 combined with the identified clinical assessment findings indicate a low cardiac output with fluid overload (bilateral crackles) requiring intervention. The remaining hemodynamic values are within normal limits: cardiac output of 4 L/min; pulmonary vascular resistance of 80 dynes/sec/cm-5; and the systemic vascular resistance of 1800 dynes/sec/cm-5.

19. The nurse is caring for a 70-kg patient in septic shock with a pulmonary artery catheter. Which hemodynamic value indicates an appropriate response to therapy aimed at enhancing oxygen delivery to the organs and tissues? a. Arterial lactate level of 1.0 mEq/L b. Cardiac output of 2.5 L/min c. Mixed venous (SvO2 ) of 40% d. Cardiac index of 1.5 L/min/m2

ANS: A An arterial lactate level of 1.0 mEq/L is within normal limits and is indicative of normal oxygen delivery to the tissues. The cardiac output, mixed venous saturation, and cardiac index values are all below normal limits indicating inadequate cardiac output sufficient to provide oxygen delivery to the organs and tissues.

26. The patient is in chronic junctional escape rhythm with no atrial activity noted. Studies have demonstrated normal AV node function. This patient may be a candidate for which type of pacing? a. Atrial pacing b. Ventricular pacing c. Dual-chamber pacing d. Transcutaneous pacing

ANS: A Pacemakers may be used to stimulate the atrium, ventricle, or both chambers (dual-chamber pacemakers). Atrial pacing is used to mimic normal conduction and to produce atrial contraction, thus providing atrial kick. This is the case in the scenario provided. Ventricular pacing stimulates ventricular depolarization and is commonly used in emergency situations or when pacing is required infrequently. Dual-chamber pacing allows for stimulation of both atria and ventricles as needed to synchronize the chambers and mimic the normal cardiac cycle. However, with this patient, ventricular and AV function are normal.

5. A patient is admitted with an acute myocardial infarction (AMI). The nurse monitors for which potential complications? (Select all that apply.) a. Cardiac dysrhythmias b. Heart failure c. Pericarditis d. Ventricular rupture

ANS: A, B, C, D All are potential complications of AMI.

2. Identify the priority interventions for managing symptoms of an acute myocardial infarction (AMI) in the ED. (Select all that apply). a. Administration of morphine b. Administration of nitroglycerin (NTG) c. Dopamine infusion d. Oxygen therapy

ANS: A, B, D The initial pain of AMI is treated with morphine sulfate administered intravenously. NTG may be given to reduce the ischemic pain of AMI. NTG increases coronary perfusion because of its vasodilatory effects. Oxygen administration is important for assisting the myocardial tissue to continue its pumping activity and for repairing the damaged tissue around the site of the infarct.

12. The nurse is working on the night shift when she notices sinus bradycardia on the patients cardiac monitor. The nurse should: a. give atropine to increase heart rate. b. begin transcutaneous pacing of the patient. c. start a dopamine infusion to stimulate heart function. d. assess for hemodynamic instability.

ANS: D Sinus bradycardia may be a normal heart rhythm for some individuals such as athletes, or it may occur during sleep. Assess for hemodynamic instability related to the bradycardia. If the patient is symptomatic, interventions include administration of atropine. If atropine is not effective in increasing heart rate, then transcutaneous pacing, dopamine infusion, or epinephrine infusion may be administered. Atropine is avoided for treatment of bradycardia associated with hypothermia.

10. While instructing a patient on what occurs with a myocardial infarction, the nurse plans to explain which process? a. Coronary artery spasm. b. Decreased blood flow (ischemia). c. Death of cardiac muscle from lack of oxygen (tissue necrosis). d. Sporadic decrease in oxygen to the heart (transient oxygen imbalance).

ANS: C Acute myocardial infarction is death (tissue necrosis) of the myocardium that is caused by lack of blood supply from the occlusion of a coronary artery and its branches.

4. Acute myocardial infarction (AMI) can be classified as which of the following? (Select all that apply.) a. Angina b. Nonischemic c. NonQ wave d. Q wave

ANS: C, D AMI can be classified as Q wave or nonQ wave.

21. The nurse is talking with the patient when the monitor alarms and shows a wavy baseline without a PQRST complex. The nurse should: a. defibrillate the patient immediately. b. initiate basic life support. c. initiate advanced life support. d. assess the patient and the electrical leads.

ANS: D Ventricular fibrillation (VF) is a chaotic rhythm characterized by a quivering of the ventricles, which results in total loss of cardiac output and pulse. VF is a life-threatening emergency, and the more immediate the treatment is, the better the survival will be. VF produces a wavy baseline without a PQRST complex. Because a loose lead or electrical interference can produce a waveform similar to VF, it is always important to immediately assess the patient for pulse and consciousness.

13. The patient presents to the ED with severe chest discomfort. He is taken for cardiac catheterization and angiography that shows 80% occlusion of the left main coronary artery. Which procedure will be most likely followed? a. Coronary artery bypass graft surgery b. Intracoronary stent placement c. Percutaneous transluminal coronary angioplasty (PTCA) d. Transmyocardial revascularization

ANS: A Coronary artery bypass graft surgery is indicated for significant left main coronary occlusion (>50%).

29. The nurse is providing care to a patient on fibrinolytic therapy. Which statement from the patient warrants further assessment and intervention by the critical care nurse? a. My back is killing me! b. There is blood on my toothbrush! c. Look at the bruises on my arms! d. My arm is bleeding where my IV is!

ANS: A The nurse must continually monitor for clinical manifestations of bleeding. Mild gingival bleeding and oozing around venipuncture sites are common and not a cause for concern. Severe lower back pain and ecchymoses are suggestive of retroperitoneal bleeding. If serious bleeding occurs, all fibrinolytic heparin therapies must be discontinued, and volume expanders or coagulation factors, or both, are administered.

19. The patient is having premature ventricular contractions (PVCs). The nurses greatest concern should be: a. the proximity of the R wave of the PVC to the T wave of a normal beat. b. the fact that PVCs are occurring, because they are so rare. c. if the number of PVCs are decreasing. d. if the PVCs are wider than 0.12 seconds.

ANS: A The peak of the T wave through the downslope of the T wave is considered the vulnerable period, which coincides with partial repolarization of the ventricles. If a PVC occurs during the T wave, ventricular tachycardia may occur. When the R wave of PVC falls on the T wave of a normal beat, it is referred to as the R-on-T phenomenon. PVCs may occur in healthy individuals and usually do not require treatment. The nurse must determine if PVCs are increasing in number by evaluating the trend. If PVCs are increasing, the nurse should evaluate for potential causes such as electrolyte imbalances, myocardial ischemia or injury, and hypoxemia. Runs of nonsustained ventricular tachycardia may be a precursor to development of sustained ventricular tachycardia. Because the stimulus depolarizes the ventricles in a slower, abnormal way, the QRS complex appears widened and has a bizarre shape. The QRS complex is wider than 0.12 seconds and often wider than 0.16 seconds.

12. A patient presents to the ED complaining of severe substernal chest pressure radiating to his left shoulder and back that started about 12 hours ago. The patient delayed coming to the ED since he was hoping the pain would go away. The patients 12-lead ECG shows ST-segment depression in the inferior leads. Troponin and CK-MB are both elevated. The hospital does not have the capability for percutaneous coronary intervention. Thrombolysis is one possible treatment. Based on these data, the nurse understands that? a. The patient is not a candidate for thrombolysis. b. The patients history makes him a good candidate for thrombolysis. c. Thrombolysis is appropriate for a candidate having a nonQ wave MI. d. Thrombolysis should be started immediately.

ANS: A To be eligible for thrombolysis, the patient must be symptomatic for less than 6 hours.

7. Which clinical manifestations are indicative of right ventricular failure? (Select all that apply.) a. Jugular venous distention b. Peripheral edema c. Crackles audible in the lungs d. Weak peripheral pulses

ANS: A, B Rationale: Jugular venous distention, liver tenderness, hepatomegaly, and peripheral edema are signs of right ventricular failure.

25. The patient has undergone open chest surgery for coronary artery bypass grafting. One of the nurses responsibilities is to monitor the patient for which common postoperative dysrhythmia? a. Second degree heart block b. Atrial fibrillation or flutter c. Ventricular ectopy d. Premature junctional contractions

ANS: B Atrial fibrillation and flutter are dysrhythmias common after cardiac surgery.

29. The rhythm on the cardiac monitor is showing numerous pacemaker spikes, but no P waves or QRS complexes following the spikes. The nurse realizes this as: a. normal pacemaker function. b. failure to capture. c. failure to pace. d. failure to sense.

ANS: B When the pacemaker generates an electrical impulse (pacer spike) and no depolarization is noted, it is described a failure to capture. On the ECG, a pacer spike is noted, but it is not followed by a P wave (atrial pacemaker) or a QRS complex (ventricular pacemaker). Common causes of failure to capture include output (milliamperes) set too low, or displacement of the pacing lead wire from the myocardium (transvenous or epicardial leads). Other causes of failure to capture include battery failure, fracture of the pacemaker wire, or increased pacing threshold as a result of medication or electrolyte imbalance. This is not normal pacemaker function. Failure to pace or fire occurs when the pacemaker fails to initiate an electrical stimulus when it should fire. The problem is noted by absence of pacer spikes on the rhythm strip. Causes of failure to pace include battery or pulse generator failure, fracture or displacement of a pacemaker wire, or loose connections. When the pacemaker does not sense the patients own cardiac rhythm and initiates an electrical impulse, it is called failure to sense. Failure to sense manifests as pacer spikes that fall too closely to the patients own rhythm, earlier than the programmed rate. The most common cause is displacement of the pacemaker electrode wire.

6. A patient is admitted with an angina attack. The nurse anticipates which drug regimen to be initiated? a. ACE inhibitors and diuretics b. Morphine sulfate and oxygen c. Nitroglycerin, oxygen, and beta-blockers d. Statins, bile acid, and nicotinic acid

ANS: C Conservative intervention for the patient experiencing angina includes nitrates, beta-blockers, and oxygen.

7. A patient with coronary artery disease is having a cardiac evaluation to assess for possible valvular disease. Which study best identifies valvular function and measures the size of the cardiac chambers? a. 12-lead electrocardiogram b. Cardiac catheterization c. Echocardiogram d. Electrophysiology study

ANS: C Echocardiography is a noninvasive, acoustic imaging procedure and involves the use of ultrasound to visualize the cardiac structures and the motion and function of cardiac valves and chambers.

28. The patient has a permanent pacemaker in place with a demand rate set at 60 beats/min. The cardiac monitor is showing a heart rate of 44 beats/min with no pacemaker spikes. The nurse realizes this as: a. normal pacemaker function. b. failure to capture. c. failure to pace. d. failure to sense.

ANS: C Failure to pace or fire occurs when the pacemaker fails to initiate an electrical stimulus when it should fire. The problem is noted by absence of pacer spikes on the rhythm strip. Causes of failure to pace include battery or pulse generator failure, fracture or displacement of a pacemaker wire, or loose connections. This is not normal pacemaker function. When the pacemaker generates an electrical impulse (pacer spike) and no depolarization is noted, it is described a failure to capture. On the ECG, a pacer spike is noted, but it is not followed by a P wave (atrial pacemaker) or a QRS complex (ventricular pacemaker). Common causes of failure to capture include output (milliamperes) set too low, or displacement of the pacing lead wire from the myocardium (transvenous or epicardial leads). Other causes of failure to capture include battery failure, fracture of the pacemaker wire, or increased pacing threshold as a result of medication or electrolyte imbalance. When the pacemaker does not sense the patients own cardiac rhythm and initiates an electrical impulse, it is called failure to sense. Failure to sense manifests as pacer spikes that fall too closely to the patients own rhythm, earlier than the programmed rate. The most common cause is displacement of the pacemaker electrode wire.

20. The physician orders a pharmacological stress test for a patient with activity intolerance. The nurse would anticipate that the drug of choice would be a. Dopamine b. Dobutamine c. Adenosine d. Atropine

ANS: C If a patient is unable physically to perform the exercise, a pharmacological stress test can be done. Adenosine is preferred over dobutamine because of its short duration of action and because reversal agents are not needed.

2. The nurse is assessing a patient with left-sided heart failure. Which symptom would the nurse expect to find? a. Dependent edema b. Distended neck veins c. Dyspnea and crackles d. Nausea and vomiting

ANS: C In left-sided heart failure, signs and symptoms are related to pulmonary congestion. Dependent edema and distended neck veins are related to right-sided heart failure.

11. A 72-year-old woman is brought to the ED by her family. The family states that shes just not herself. Her respirations are slightly labored, and her heart monitor shows sinus tachycardia (rate 110 beats/min) with frequent premature ventricular contractions (PVCs). She denies any chest pain, jaw pain, back discomfort, or nausea. Her troponin levels are elevated, and her 12-lead electrocardiogram (ECG) shows elevated ST segments in leads II, III, and AVF. The nurse knows that these symptoms are most likely associated with which diagnosis? a. Hypokalemia b. NonQ wave MI c. Silent myocardial infarction d. Unstable angina

ANS: C Some individuals may have ischemic episodes without knowing it, thereby having a silent infarction. These can occur with no presenting signs or symptoms. Asymptomatic or nontraditional symptoms are more common in elderly persons, in women, and in diabetic patients.

8. The QT interval is the total time taken for ventricular depolarization and repolarization. Prolongation of the QT interval: a. decreases the risk of lethal dysrhythmias. b. usually occurs when heart rate increases. c. increases the risk of lethal dysrhythmias. d. can only be measured with irregular rhythms.

ANS: C The QT interval is measured from the beginning of the QRS complex to the end of the T wave. This interval measures the total time taken for ventricular depolarization and repolarization. Abnormal prolongation of the QT interval increases vulnerability to lethal dysrhythmias, such as ventricular tachycardia and fibrillation. Normally, the QT interval becomes longer with slower heart rates and shortens with faster heart rates, thus requiring a correction of the value (QTc). Generally, the QT interval is less than half the RR interval. QTc accuracy is based on a regular rhythm. In irregular rhythms such as atrial fibrillation, an average QTc may be necessary because the QT varies from beat to beat.

15. The patient presents to the ED with sudden severe sharp chest discomfort radiating to his back and down both arms, as well as numbness in his left arm. While taking the patients vital signs, the nurse notices a 30-point discrepancy in systolic blood pressure between the right and left arm. Based on these findings, the nurse should: a. contact the physician and report the cardiac enzyme results. b. contact the physician and prepare the patient for thrombolytic therapy. c. contact the physician immediately and begin prepping the patient for surgery. d. give the patient aspirin and heparin.

ANS: C These symptoms indicate the possibility of acute aortic dissection. Symptoms often mimic those of AMI or pulmonary embolism. Aortic dissection is a surgical emergency. Signs and symptoms include chest pain and arm paresthesia.

4. When assessing the 12-lead electrocardiogram (ECG) or a rhythm strip, it is helpful to understand that the electrical activity is viewed in relation to the positive electrode of that particular lead. When an electrical signal is aimed directly at the positive electrode, the inflection will be: a. negative. b. upside down. c. upright. d. equally positive and negative.

ANS: C When an electrical signal is aimed directly at the positive electrode, an upright inflection is visualized. If the impulse is going away from the positive electrode, a negative deflection is seen; and if the signal is perpendicular to the imaginary line between the positive and negative poles of the lead, the tracing is equiphasic, with equally positive and negative deflection.

9. Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to verify proper catheter placement. The radiologist reports to the nurse: The tip of the catheter is located in the superior vena cava. What is the best interpretation of these results by the nurse? a. The catheter is not positioned correctly and should be removed. b. The catheter position increases the risk of ventricular dysrhythmias. c. The distal tip of the catheter is in the appropriate position. d. The physician should be called to advance the catheter into the pulmonary artery.

ANS: C X-ray results indicate proper position of the catheter. The tip of the central venous catheter should rest just above the right atrium in the superior vena cava. The central venous catheter is positioned correctly in the superior vena cava. Dysrhythmias occur if the catheter migrates to the right ventricle. Central venous catheters are placed into great vessels of the venous system and not advanced into the pulmonary artery.

23. Percutaneous coronary intervention is contraindicated for patients with lesions in which coronary artery? a. Right coronary artery b. Left coronary artery c. Circumflex d. Left main coronary artery

ANS: D Stenosis of the left mainstem artery is considered unacceptable for percutaneous intervention.

8. A patient has elevated blood lipids. The nurse anticipates which classification of drugs to be prescribed for the patient? a. Bile acid resins b. Nicotinic acid c. Nitroglycerin d. Statins

ANS: D The statins have been found to lower low-density lipoproteins (LDLs) more than other types of lipid-lowering drugs.

17. A patient has been prescribed nitroglycerin in the ED for chest pain. In taking the health history, the nurse will be sure to verify whether the patient has taken medications prior to admission for: a. Erectile dysfunction b. Prostate enlargement c. Asthma d. Peripheral vascular disease

ANS: A A history of the patients use of sildenafil citrate (Viagra) or similar medications taken for erectile dysfunction is necessary to know when considering NTG administration. These medications potentiate the hypotensive effects of nitrates; thus, concurrent use is contraindicated. It is also important to determine whether the patient has any food or drug allergies.

16. The nurse is reading the cardiac monitor and notes that the patients heart rhythm is extremely irregular and there are no discernible P waves. The ventricular rate is 90 beats per minute, and the patient is hemodynamically stable. The nurse realizes that the patients rhythm is: a. atrial fibrillation. b. atrial flutter. c. atrial flutter with rapid ventricular response. d. junctional escape rhythm.

ANS: A Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction. The AV node is bombarded with hundreds of atrial impulses and conducts these impulses in an unpredictable manner to the ventricles. The atrial rate may be as high 700 and no discernible P waves can be identified, resulting in a wavy baseline and an extremely irregular ventricular response. Atrial flutter arises from a single irritable focus in the atria. The atrial focus fires at an extremely rapid, regular rate, between 240 and 320 beats per minute. The P waves are called flutter waves and may have a sawtooth appearance. The ventricular response may be regular or irregular based on how many flutter waves are conducted through the AV node. Atrial flutter with rapid ventricular response occurs when atrial impulses cause a ventricular response greater than 100 beats per minute. A junctional escape rhythm is a ventricular rate between 40 and 60 beats per minute with a regular rhythm. P waves may be absent, inverted, or follow the QRS complex. If a P wave is present before the QRS complex, the PR interval is shortened less than 0.12 milliseconds. QRS complex is normal.

5. A patient is admitted to the hospital with multiple trauma and extensive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vascular resistance of 3000 dynes/sec/cm-5, and a hematocrit of 20%. The nurse anticipates administration of which the following therapies or medications? a. Blood transfusion b. Furosemide (Lasix) c. Dobutamine (Dobutrex) infusion d. Dopamine hydrochloride (Dopamine) infusion

ANS: A Both hemodynamic parameters and the reported hematocrit value indicate hypovolemia and blood loss requiring volume resuscitation with blood products. Furosemide administration will worsen fluid volume status. Inotropic agents will not correct the underlying fluid volume deficit and anemia. Vasoconstrictors are contraindicated in a volume-depleted state.

11. The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate action? a. Diminished breath sounds over left lung field b. Localized pain at catheter insertion site c. Measured central venous pressure of 5 mm Hg d. Slight bloody drainage around insertion site

ANS: A Diminished breaths sounds over the lung field on the same side of the line insertion site may be indicative of a pneumothorax. A pneumothorax, which can develop slowly, is a major complication following insertion of central lines when the subclavian route is used. Localized pain at catheter insertion site is not the immediate priority in this scenario. A measured central venous pressure of 5 mm Hg is normal. Slight bloody drainage at the insertion site soon after the procedure does not require immediate action.

16. The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best reduces the risk of catheter- related bloodstream infection (CRBSI)? a. Review daily the necessity of the central venous catheter. b. Cleanse the insertion site daily with isopropyl alcohol. c. Change the pressurized tubing system and flush bag daily. d. Maintain a pressure of 300 mm Hg on the flush bag.

ANS: A Duration of the catheter is an independent risk factor for CRBSI, and removal of the catheter when not needed to guide treatment is associated with a reduction in mortality. Maintaining of the insertion site should be guided by institutional guidelines and is best accomplished with chlorhexidine skin antisepsis. Minimizing the number of times the flush system is opened by changing tubing no more frequently than every 72 to 96 hours reduces the risk of CRBSI. Maintaining a pressure of 300 mm Hg on the flush solution bag helps maintain the integrity of the invasive line and does not reduce the risk of infection.

17. The patients heart rhythm shows an inverted P wave with a PR interval of 0.06 seconds. The heart rate is 54 beats per minute. The nurse recognizes the rhythm as a junctional escape rhythm, and understands that the rhythm is due to the: a. loss of sinus node activity. b. increased rate of the AV node. c. increased rate of the SA node. d. decreased rate of the AV node.

ANS: A Junctional escape rhythm occurs when the dominant pacemaker, the SA node, fails to fire. The normal heart rate of the AV node is 40 to 60 beats per minute, so the AV node rate has neither increased nor decreased. An increased SA node rate would override the AV node.

16. A patient is admitted to the emergency department with clinical indications of an acute myocardial infarction. Symptoms began 3 hours ago. The facility does not have the capability for percutaneous coronary intervention. Given this scenario, what is the priority intervention in the treatment and nursing management of this patient? a. Administer thrombolytic therapy unless contraindicated b. Diurese aggressively and monitor daily weight c. Keep oxygen saturation levels at least 88% d. Maintain heart rate above 100 beats/min

ANS: A Medical treatment of AMI is aimed at relieving pain, providing adequate oxygenation to the myocardium, preventing platelet aggregation, and restoring blood flow to the myocardium through thrombolytic therapy or acute interventional therapy such as angioplasty. Since interventional cardiology is not available, thrombolytic therapy is indicated. Oxygen saturation should be maintained at higher levels to ensure adequate oxygenation to the heart muscle. An elevated heart rate increases oxygen demands and should be avoided. Diuresis is not indicated with this scenario.

27. The patient has a permanent pacemaker inserted. The provider has set the pacemaker to the demand mode at a rate of 60 beats per minute. The nurse realizes that: a. the pacemaker will pace only if the patients intrinsic heart rate is less than 60 beats per minute. b. the demand mode often competes with the patients own rhythm. c. the demand mode places the patient at risk for the R-on-T phenomenon. d. the fixed rate mode is safer and is the mode of choice.

ANS: A Pacemakers can be operated in a demand mode or a fixed rate (asynchronous) mode. The demand mode paces the heart when no intrinsic or native beat is sensed. For example, if the rate control is set at 60 beats per minute, the pacemaker will only pace if the patients heart rate drops to less than 60. The fixed rate mode paces the heart at a set rate, independent of any activity the patients heart generates. The fixed rate mode may compete with the patients own rhythm and deliver an impulse on the T wave (R-on-T phenomenon), with the potential for producing ventricular tachycardia or fibrillation. The demand mode is safer and is the mode of choice.

1. The patient is admitted with a suspected acute myocardial infarction (MI). In assessing the 12-lead electrocardiogram (ECG) changes, which findings would indicate to the nurse that the patient is in the process of an evolving Q wave myocardial infarction(MI)? a. ST-segment elevation on ECG and elevated CPK-MB or troponin levels b. Depressed ST-segment on ECG and elevated total CPK c. Depressed ST-segment on ECG and normal cardiac enzymes d. Q wave on ECG with normal enzymes and troponin levels

ANS: A ST segment elevation and elevated cardiac enzymes are seen in Q wave MI.

13. Which of the following is true about a patient diagnosed with sinus arrhythmia? a. The heart rate varies, dependent on vagal tone and respiratory pattern. b. Immediate treatment is essential to prevent death. c. Sinus arrhythmia is not well tolerated by most patients. d. PR and QRS interval measurements are prolonged.

ANS: A Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate increases slightly during inspiration and slows slightly during exhalation because of changes in vagal tone. The ECG tracing demonstrates an alternating pattern of faster and slower heart rate that changes with the respiratory cycle. Interval measurements are normal. This rhythm is tolerated well, and no treatment is required.

9. The patient has an irregular heart rhythm. To determine an accurate heart rate, the nurse first: a. identifies the markers on the ECG paper that indicate a 6-second strip. b. counts the number of large boxes between two consecutive P waves. c. counts the number of small boxes between two consecutive QRS complexes. d. divides the number of complexes in a 6-second strip by 10.

ANS: A Six-second method: A quick and easy estimate of heart rate can be accomplished by counting the number of P waves or QRS waves within a 6-second strip to obtain atrial and ventricular heart rates per minute. This is the optimal method for irregular rhythms. Identify the lines above the ECG paper that represent 6 seconds, and count the number of P waves within the lines; then add a zero (multiply by 10) to identify the atrial heart rate estimate for 1 minute. Next, identify the number of QRS waves in the 6-second strip and again add a zero to identify the ventricular rate. Large box method: In this method, two consecutive P and QRS waves are located. The number of large boxes between the highest points of two consecutive P waves is counted, and that number of large boxes is divided into 300 to determine the atrial rate in beats per minute. The number of large boxes between the highest points of two consecutive QRS waves is counted, and that number of large boxes is divided into 300 to determine the ventricular rate. This method is accurate only if the rhythm is regular. Small box method: The small box method is used to calculate the exact rate of a regular rhythm. In this method, two consecutive P and QRS waves are located. The number of small boxes between the highest points of these consecutive P waves is counted, and that number is divided into 1500 to determine the atrial rate in beats per minute. The number of small boxes between the highest points of two consecutive QRS waves is counted, and that number is divided into 1500 to determine the ventricular rate. This method is accurate only if the rhythm is regular.

2. The nurse is caring for a patient who is on a cardiac monitor. The nurse realizes that the sinus node is the pacemaker of the heart because it is: a. the fastest pacemaker cell in the heart. b. the only pacemaker cell in the heart. c. the only cell that does not affect the cardiac cycle. d. located in the left side of the heart.

ANS: A The cardiac cycle begins with an impulse that is generated from a small concentrated area of pacemaker cells high in the right atria called the sinoatrial node (sinus node or SA node). The SA node has the fastest rate of discharge and thus is the dominant pacemaker of the heart. The AV node has pacemaker properties and can discharge an impulse if the SA node fails. The ventricles have pacemaker capabilities if the sinus node or the AV node ceases to generate impulses.

4. A patient presents to the emergency department (ED) with chest pain that he has had for the past 2 hours. He is nauseous and diaphoretic, and his skin is dusky in color. The electrocardiogram shows ST elevation in leads II, III, and aVF. Which therapeutic intervention would the nurse question? a. Emergent pacemaker insertion b. Emergent percutaneous coronary intervention c. Emergent thrombolytic therapy d. Immediate coronary artery bypass graft surgery

ANS: A The goals of management of AMI are to dissolve the lesion that is occluding the coronary artery and to increase blood flow to the myocardium. Options include emergent percutaneous intervention, such as angioplasty, emergent coronary artery bypass graft surgery, or thrombolytic therapy if the patient has been symptomatic for less than 6 hours. No data in this scenario warrant insertion of a pacemaker.

6. The patients husband tells the nurse, We didnt think she was having a heart attack because the pain was in her neck and back. The nurse explains: (Select all that apply.) a. Pain can occur anywhere in the chest, neck, arms, or back. Dont hesitate to call the emergency medical services if you think its a heart attack. b. For many people chest pain from a heart attack occurs in the center of the chest, behind the breastbone. c. The sooner the patient can get medical help, the less damage is likely to occur in case of a heart attack. d. You need to make sure its a heart attack before you call the emergency response personnel.

ANS: A, B, C Angina may occur anywhere in the chest, neck, arms, or back, but the most commonly described is pain or pressure behind the sternum. The pain often radiates to the left arm but can also radiate down both arms and to the back, the shoulder, the jaw, and/or the neck.

1. The patient has been in chronic heart failure for the past 10 years. He has been treated with beta-blockers and angiotensin-converting enzyme inhibitors as well as diuretics. His symptoms have recently worsened, and he presents to the ED with severe shortness of breath and crackles throughout his lung fields. His respirations are labored and arterial blood gases show that he is at risk for respiratory failure. Which of the following therapies may be used for acute, short-term management of the patient? (Select all that apply). a. Dobutamine b. Intraaortic balloon pump c. Nesiritide (Natrecor) d. Ventricular assist device

ANS: A, B, C This patient is showing signs and symptoms of an acute exacerbation of heart failure. Dobutamine and nesiritide are medications administered for acute short-term management; mechanical assist with an intraaortic balloon pump also may be warranted.

5. Because of the location of the AV node, the possible P waveforms that are associated with junctional rhythms include which of the following? (Select all that apply.) a. No P wave b. Inverted P wave c. Shortened PR interval d. P wave after the QRS complex e. Normal P wave and PR interval

ANS: A, B, C, D Because of the location of the AV nodein the center of the heartimpulses generated may be conducted forward, backward, or both. With the potential of forward, backward, or bidirectional impulse conduction, three different P waveforms may be associated with junctional rhythms: When the AV node impulse moves forward, P waves may be absent because the impulse enters the ventricle first. The atria receives the wave of depolarization at the same time as the ventricles; thus, because of the larger muscle mass of the ventricles, there is no P wave. When the AV node impulse is conducted backward, the impulse enters the atria first. When depolarization occurs backward, an inverted P wave is created. Once the atria have been depolarized, the impulse moves down the bundle of His and depolarizes both ventricles normally. A short PR interval (<0.12 second) is noted. When the impulse is conducted both forward and backward, P waves may be present after the QRS complex.

3. Sinus bradycardia is a symptom of which of the following? (Select all that apply.) a. Calcium channel blocker medication b. Beta-blocker medication c. Athletic conditioning d. Hypothermia e. Hyperthyroidism

ANS: A, B, C, D Vasovagal response; medications such as digoxin or AV nodal blocking agents, including calcium channel blockers and beta-blockers; myocardial infarction; normal physiological variant in the athlete; disease of the sinus node; increased intracranial pressure; hypoxemia; and hypothermia may cause sinus bradycardia. Hyperthyroidism is a cause of sinus tachycardia.

2. Which of the following are common causes of sinus tachycardia? (Select all that apply.) a. Hyperthyroidism b. Hypovolemia c. Hypothyroidism d. Heart Failure e. Sleep

ANS: A, B, D Common causes of sinus tachycardia include hyperthyroidism, hypovolemia, heart failure, anemia, exercise, use of stimulants, fever, and sympathetic response to fear or pain and anxiety. Hypothyroidism and sleep tend to slow the heart rate.

1. The normal width of the QRS complex is which of the following? (Select all that apply.) a. 0.06 to 0.10 seconds. b. 0.12 to 0.20 seconds. c. 1.5 to 2.5 small boxes. d. 3.0 to 5.0 small boxes. e. 0.04 seconds or greater.

ANS: A, C The waveform that initiates the QRS complex (whether it is a Q wave or an R wave) marks the beginning of the interval. The normal width of the QRS complex is 0.06 to 0.10 seconds. This width equals 1.5 to 2.5 small boxes. The normal PR interval is 0.12 to 0.20 seconds, three to five small boxes wide; not the QRS interval. A pathological Q wave has a width of 0.04 seconds and a depth that is greater than one fourth of the R wave amplitude; therefore, the QRS complex would be wider than that.

3. Which statements are true regarding the symptoms of an AMI? (Select all that apply.) a. Dysrhythmias are common occurrences. b. Men have more atypical symptoms than women. c. Midsternal chest pain is a common presenting symptom. d. Some patients are asymptomatic.

ANS: A, C, D Chest pain is a common presenting symptom in AMI. Dysrhythmias are commonly seen in AMI. Some individuals may have ischemic episodes without knowing it, thereby having a silent infarction. Women are more likely to have atypical signs and symptoms, such as shortness of breath, nausea and vomiting, and back or jaw pain.

6. The patient is in third-degree heart block (complete heart block) and is symptomatic. The treatment for this patient is which of the following? (Select all that apply.) a. transcutaneous pacemaker. b. atropine IV. c. temporary transvenous pacemaker. d. permanent pacemaker. e. amiodarone IV.

ANS: A, C, D Treatments include transcutaneous or transvenous pacing and implanting a permanent pacemaker. Atropine reduces vagal tone, but that is not a cause of complete heart block and will produce more P waves, but the P waves will still not be associated with the QRS complexes. It is important to note that the only treatment is pacing. Amiodarone IV is used to suppress ventricular dysrhythmia and is not used to treat third-degree heart block.

4. The nurse is caring for a patient who has atrial fibrillation. Sequelae that place the patient at greater risk for mortality/morbidity include which of the following? (Select all that apply.) a. Stroke b. Ashman beats c. Pulmonary emboli d. Prolonged PR interval e. Decreased cardiac output

ANS: A, C, E One complication of atrial fibrillation is thromboembolism. The blood that collects in the atria is agitated by fibrillation, and normal clotting is accelerated. Small thrombi, called mural thrombi, begin to form along the walls of the atria. These clots may dislodge, resulting in pulmonary embolism or stroke. The ineffectual contraction of the atria results in loss of atrial kick. If too many impulses conduct to the ventricles, atrial fibrillation with rapid ventricular response may result and compromise cardiac output. Ashman beats are not clinically significant. No recognizable or discernible P waves are present; therefore, PR interval is absent.

13. The nurse is educating a patients family member about a pulmonary artery catheter (PAC). Which statement by the family member best indicates understanding of the purpose of the PAC? a. The catheter will provide multiple sites to give intravenous fluid. b. The catheter will allow the physician to better manage fluid therapy. c. The catheter tip comes to rest inside my brothers pulmonary artery. d. The catheter will be in position until the heart has a chance to heal.

ANS: B A pulmonary artery catheter provides hemodynamic measurements that guide interventions that include appropriate fluid therapy. Even though a pulmonary catheter provides multiple intravenous access sites, this is not the primary purpose of the catheter. Although the catheter is positioned in the pulmonary artery, positioning is not the purpose of the catheter. The primary purpose of the catheter is not to aid in the healing of the heart but to guide therapy.

24. Which comment by the patient indicates a good understanding of her diagnosis of coronary heart disease? a. I had a heart attack because I work too hard and it puts too much strain on my heart. b. The pain in my chest gets worse each time it happens. I think that there is more damage to my heart vessels as time goes on. c. If I change my diet and exercise more, I should get over this and be healthy. d. What kind of pills can you give me to get me over this and back to my lifestyle?

ANS: B Coronary heart disease is a progressive atherosclerotic disorder of the coronary arteries that results in narrowing or complete occlusion.

6. Electrocardiogram (ECG) paper contains a standardized grid where the horizontal axis measures time and the vertical axis measures voltage or amplitude. The nurse must understand that each horizontal box indicates: a. 200 milliseconds or 0.20 seconds duration. b. 40 milliseconds or 0.04 seconds duration. c. 3 seconds duration. d. millivolts of amplitude.

ANS: B ECG paper contains a standardized grid where the horizontal axis measures time and the vertical axis measures voltage or amplitude. Horizontally, the smaller boxes denote 0.04 seconds each or 40 milliseconds; the larger box contains five smaller boxes and thus equals 0.20 seconds or 200 milliseconds.

18. Which of the following cardiac diagnostic tests would include monitoring the gag reflex before giving the patient anything to eat or drink? a. Barium swallow b. Transesophageal echocardiogram c. MUGA scan d. Stress test

ANS: B In transesophageal echocardiography, an ultrasound probe is fitted on the end of a flexible gastroscope, which is inserted into the posterior pharynx and advanced into the esophagus. After the procedure, the patient is unable to eat until the gag reflex returns.

19. A patient was admitted in terminal heart failure and is not eligible for transplant. The family wants everything possible done to maintain life. Which procedure might be offered to the patient for this condition to increase the patients quality of life? a. Intraaortic balloon pump (IABP) b. Left ventricular assist device (LVAD) c. Nothing, because the patient is in terminal heart failure d. Nothing additional; medical management is the only option

ANS: B LVADs are capable of partial to complete circulatory support for short- to long-term use. At present, the LVAD is therapy for patients with terminal heart failure. It would provide better management than medical therapy alone. The IABP is for short-term management of acute heart failure

3. The nursing is caring for a patient who has had an arterial line inserted. To reduce the risk of complications, what is the priority nursing intervention? a. Apply a pressure dressing to the insertion site. b. Ensure all tubing connections are tightened. c. Obtain a portable x-ray to confirm placement. d. Restrain the affected extremity for 24 hours.

ANS: B Loose connections in hemodynamic monitoring tubing can lead to hemorrhage, a major complication of arterial pressure monitoring. Application of a pressure dressing is required only upon arterial line removal. Blood return is adequate confirmation of arterial line placement; x-ray studies are not performed to confirm arterial line placement. Neutral positioning of the extremity and use of an arm board, without limb restraint, is the standard of care.

2. While caring for a patient with a small bowel obstruction, the nurse assesses a pulmonary artery occlusion pressure (PAOP) of 1 mm Hg and hourly urine output of 5 mL. The nurse anticipates which therapeutic intervention? a. Diuretics b. Intravenous fluids c. Negative inotropic agents d. Vasopressor

ANS: B Low pulmonary artery occlusion pressures usually indicate volume depletion, so intravenous fluids would be indicated. Administration of diuretics would worsen the patients volume status. Negative inotropes would not improve the patients volume status. Vasopressors will increase blood pressure but are contraindicated in a low volume state.

7. The nurse is examining the patients cardiac rhythm strip in lead II and notices that all of the P waves are upright and look the same except one that has a different shape and is inverted. The nurse realizes that the P wave with the abnormal shape is probably: a. from the SA node since all P waves come from the SA node. b. from some area in the atria other than the SA node. c. indicative of ventricular depolarization. d. normal even though it is inverted in lead II.

ANS: B Normally a P wave indicates that the SA node initiated the impulse that depolarized the atrium. However, a change in the shape of the P wave may indicate that the impulse arose from a site in the atria other than the SA node. The P wave represents atrial depolarization. It is usually upright in leads I and II and has a rounded, symmetrical shape. The amplitude of the P wave is measured at the center of the waveform and normally does not exceed three boxes, or 3 millimeters, in height.

7. The nurse is caring for a patient with a left subclavian central venous catheter (CVC) and a left radial arterial line. Which assessment finding by the nurse requires immediate action? a. A dampened arterial line waveform b. Numbness and tingling in the left hand c. Slight bloody drainage at subclavian insertion site d. Slight redness at subclavian insertion site

ANS: B Numbness and tingling in the left hand, which is the location of an arterial catheter, indicates possible neurovascular compromise and requires immediate action. A dampened waveform can indicate problems with arterial line patency but is not an emergent situation. Slight bloody drainage at the subclavian insertion site is not an unusual finding. Slight redness at the insertion site, while of concern, does not require immediate action.

26. An essential aspect of teaching that may prevent recurrence of heart failure is: a. notifying the physician if a 2-lb weight gain occurs in 24 hours. b. compliance with diuretic therapy. c. taking nitroglycerin if chest pain occurs. d. assessment of an apical pulse.

ANS: B Reduction or cessation of diuretics usually results in sodium and water retention, which may precipitate heart failure.

11. The patient is admitted with a fever and rapid heart rate. The patients temperature is 103 F (39.4 C).The nurse places the patient on a cardiac monitor and finds the patients atrial and ventricular rates are above 105 beats per minute. P waves are clearly seen and appear normal in configuration. QRS complexes are normal in appearance and 0.08 seconds wide. The rhythm is regular, and blood pressure is normal. The nurse should focus on providing: a. medications to lower heart rate. b. treatment to lower temperature. c. treatment to lower cardiac output. d. treatment to reduce heart rate.

ANS: B Sinus tachycardia results when the SA node fires faster than 100 beats per minute. Sinus tachycardia is a normal response to stimulation of the sympathetic nervous system. Sinus tachycardia is also a normal finding in children younger than 6 years. Both atrial and ventricular rates are greater than 100 beats per minute, up to 160 beats per minute, but may be as high as 180 beats per minute. Sinus tachycardia is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P and QRS waves are consistent in shape. P waves are small and rounded. A P wave precedes every QRS complex, which is then followed by a T wave. The fast heart rhythm may cause a decrease in cardiac output because of the shorter filling time for the ventricles. Lowering cardiac out further may complicate the situation. The dysrhythmia itself is not treated, but the cause is identified and treated appropriately. For example, if the patient has a fever or is in pain, the infection or pain is treated appropriately.

22. The patients wife is feeling overwhelmed and tells the nurse that she doesnt know if she can manage to cook different dinners for her husband and the rest of the family to satisfy his cholesterol-reducing diet. The nurse tells her: a. It will be worth it to have him healthy, wont it? b. The low-cholesterol diet is one from which everyone can benefit. c. As long as you change at least a few things in the diet, it will be okay. d. You can go on the diet with him, and then just let the children eat whatever they want.

ANS: B Some cardiologists advocate a reduction of the low-density lipoprotein goal to the 50 to 70 mg/dL range for everyone, not only those with a known cardiovascular disease.

28. The patients wife is confused about the scheduling of a stent insertion. She says that she thought the angioplasty was surgery to fix her husbands heart problem. The nurse explains to her: a. The angioplasty was a failure, and so this procedure has to be done to fix the heart vessel. b. The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again. c. This procedure is being done instead of using clot-dissolving medication to help keep the heart vessel open. d. The stent will remove any clots that are in the vessel and protect the heart muscle from damage.

ANS: B Stents are inserted to optimize the results of other treatments for acute vessel closure (percutaneous transluminal coronary angioplasty, atherectomy, fibrinolytics) and to prevent restenosis.

3. One of the functions of the atrioventricular (AV) node is to: a. pace the heart if the ventricles fail. b. slow the impulse arriving from the SA node. c. send the impulse to the SA node. d. allow for ventricular filling during systole.

ANS: B The impulse from the SA node quickly reaches the atrioventricular (AV) node located in the area called the AV junction, between the atria and the ventricles. Here the impulse is slowed to allow time for ventricular filling during relaxation or ventricular diastole. The AV node has pacemaker properties and can discharge an impulse if the SA node (not the ventricle) fails. The electrical impulse is then rapidly conducted through the bundle of His to the ventricles (not the SA node) via the left and right bundle branches.

18. The patients heart rate is 70 beats per minute, but the P waves come after the QRS complex. The nurse correctly determines that the patients heart rhythm is: a. a normal junctional rhythm. b. an accelerated junctional rhythm. c. a junctional tachycardia. d. atrial fibrillation.

ANS: B The normal intrinsic rate for the AV node and junctional tissue is 40 to 60 beats per minute, but rates can accelerate. An accelerated junctional rhythm has a rate between 60 and 100 beats per minute, and the rate for junctional tachycardia is greater than 100 beats per minute. If P wave precedes QRS, it is inverted or upside down; the P wave may not be visible, or it may follow the QRS. If a P wave is present before the QRS, the PR interval is shortened less than 0.12 milliseconds. Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction. The AV node is bombarded with hundreds of atrial impulses and conducts these impulses in an unpredictable manner to the ventricles.

9. The patient is admitted with an acute myocardial infarction (AMI). Three days later the nurse is concerned that the patient may have a papillary muscle rupture. Which assessment data may indicate a papillary muscle rupture? a. Gallop rhythm b. Murmur c. S1 heart sound d. S3 heart sound

ANS: B The presence of a new murmur warrants special attention, particularly in a patient with an AMI. A papillary muscle may have ruptured, causing the valve to close incorrectly, which can be indicative of severe damage and impending complications.

10. The nurse is calculating the rate for a regular rhythm. There are 20 small boxes between each P wave and 20 small boxes between each R wave. What is the ventricular rate? a. 50 beats/min b. 75 beats/min c. 85 beats/min d. 100 beats/min

ANS: B The rule of 1500 is used to calculate the exact rate of a regular rhythm. The number of small boxes between the highest points of two consecutive R waves is counted, and that number of small boxes is divided into 1500 to determine the ventricular rate. 1500/20 = 75 beats/min. This method is accurate only if the rhythm is regular.

1. The normal rate for the SA node when the patient is at rest is: a. 40 to 60 beats per minute. b. 60 to 100 beats per minute. c. 20 to 40 beats per minute. d. more than 100 beats per minute.

ANS: B The sinus node reaches threshold at a rate of 60 to 100 times per minute. Because this is the fastest pacemaker in the heart, the SA node is the dominant pacemaker of the heart. The AV node has an inherent rate of 40 to 60 beats per minute and the His-Purkinje system can fire at a rate of 20 to 40 beats per minute. Sinus tachycardia results when the SA node fires faster than 100 beats per minute.

18. Following insertion of a pulmonary artery catheter (PAC), the physician orders the nurse to obtain a blood sample for mixed venous oxygen saturation (SvO2). Which action by the nurse best ensures the obtained value is accurate? a. Zero referencing the transducer at the level of the phlebostatic axis following insertion b. Calibrating the system with a central venous blood sample and arterial blood gas value c. Ensuring patency of the catheter using a 0.9% normal saline solution pressurized at 300 mm Hg d. Using noncompliant pressure tubing that is no longer than 36 to 48 inches and has minimal stopcocks

ANS: B To ensure that an accurate SvO2 is obtained, calibration of the invasive monitoring system (e.g., PAC) is accomplished upon insertion and requires both a central venous blood sample from the PAC and an arterial blood gas sample. This process is unique to the accuracy of venous oxygen saturation monitoring systems. Zero referencing the transducer at the level of the phlebostatic axis, ensuring patency of the catheter with a pressurized flush system, and using tubing of adequate length ensure accuracy of all hemodynamic monitoring systems.

8. The physician writes an order to discontinue a patients left radial arterial line. When discontinuing the patients invasive line, what is the priority nursing action? a. Apply an air occlusion dressing to insertion site. b. Apply pressure to the insertion site for 5 minutes. c. Elevate the affected limb on pillows for 24 hours. d. Keep the patients wrist in a neutral position.

ANS: B Upon removal of an invasive arterial line, adequate pressure must be applied for at least 5 minutes to ensure adequate hemostasis. Application of an air occlusion dressing is not standard of care following removal of an arterial line. Elevation of the affected limb following removal of an arterial line is not a necessary intervention. Neutral wrist position is optimum while the catheter is in place and not necessary after catheter discontinuation.

43. The nurse notes the following rhythm on the heart monitor. The patient is unresponsive and not breathing. The nurse should a. treat with intravenous amiodarone or lidocaine. b. provide emergent basic and advanced life support. c. provide electrical cardioversion. d. ignore the rhythm because it is benign.

ANS: B Ventricular fibrillation (VF) is a chaotic rhythm characterized by a quivering of the ventricles, which results in total loss of cardiac output and pulse. VF is a life-threatening emergency, and the more immediate the treatment, the better the survival will be. VF produces a wavy baseline without a PQRST complex. Because a loose lead or electrical interference can produce a waveform similar to VF, it is always important to immediately assess the patient for pulse and consciousness. If no pulse is present, provide emergent basic and advanced life-support interventions, including defibrillation.

20. The nurse notices ventricular tachycardia on the heart monitor. When the patient is assessed, the patient is found to be unresponsive with no pulse. The nurse should: a. treat with intravenous amiodarone or lidocaine. b. begin cardiopulmonary resuscitation and advanced life support. c. provide electrical cardioversion. d. ignore the rhythm since it is benign.

ANS: B Ventricular tachycardia (VT) is a rapid, life-threatening dysrhythmia originating from a single ectopic focus in the ventricles. Determine whether the patient has a pulse. If no pulse is present, provide emergent basic and advanced life-support interventions, including defibrillation. If a pulse is present and the blood pressure is stable, the patient can be treated with intravenous amiodarone or lidocaine. Cardioversion is used as an emergency measure in patients who become hemodynamically unstable but continue to have a pulse. It also may be used in nonemergency situations, such as when a patient has asymptomatic VT.

8. Which nursing interventions would be appropriate after angioplasty? (Select all that apply.) a. Elevate the head of the bed by 45 degrees for 6 hours b. Assess pedal pulses on the involved limb every 15 minutes for 2 hours c.Monitor the vascular hemostatic device for signs of bleeding d. Instruct the patient bend his/her knee every 15 minutes while the sheath is in place

ANS: B, C, D The head of the bed must not be elevated more than 30 degrees, and the patient should be instructed to keep the affected leg straight. Bed rest is 6 to 8 hours in duration, unless a vascular hemostatic device is used. The nurse observes the patient for bleeding or swelling at the puncture site and frequently assesses adequacy of circulation to the involved extremity.

15. The charge nurse is supervising care for a group of patients monitored with a variety of invasive hemodynamic devices. Which patient should the charge nurse evaluate first? a. A patient with a central venous pressure (RAP/CVP) of 6 mm Hg and 40 mL of urine output in the past hour b. A patient with a left radial arterial line with a BP of 110/60 mm Hg and slightly dampened arterial waveform c. A patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula d. A patient with a pulmonary artery pressure of 25/10 mm Hg and an oxygen saturation of 94% on 2 L of oxygen via nasal cannula

ANS: C A high pulmonary artery occlusion pressure of 25 mm Hg combined with low oxygen saturation is indicative of fluid volume overload and warrants priority action because the patient is at risk for hypoxemia. A CVP of 6 mm Hg with 40 mL of hourly urine output are acceptable assessment findings. A patient with a normal blood pressure and with a slightly dampened waveform does not require immediate action. A pulmonary artery pressure of 25/10 mmHg and a normal oxygen saturation does not require immediate treatment.

27. The patients wife asks the nurse if the angioplasty will remove all the buildup in the vessel walls so that the patient will be healthy again. The nurse explains: a. The operation will remove all of the plaque, and if your husband exercises and diets he will be free of cardiac problems. b. The surgery will remove all the buildup, but it will reaccumulate and he will probably need this surgery again this time next year. c. The best outcome will be if 20% to 50% of the diameter of the vessel can be restored. Your husband will need to diet and exercise carefully to avoid further cardiac risk. d. The surgeon will only be able to get 5% to 10% of the plaque, but this will bring about marked relief of your husbands symptoms.

ANS: C A successful angioplasty procedure is one in which the stenosis is reduced to less than 50% of the vessel lumen diameter, although most clinicians aim for less than 20% final diameter stenosis.

14. The patient is admitted with sinus pauses causing periods of loss of consciousness. The patient is asymptomatic, awake and alert, but fatigued. He answers questions appropriately. When admitting this patient, the nurse should first: a. prepare the patient for temporary pacemaker insertion. b. prepare the patient for permanent pacemaker insertion. c. assess the patients medication profile. d. apply transcutaneous pacemaker paddles.

ANS: C AV nodal blocking medications (such as beta-blockers, calcium channel blockers, and digoxin) and increased vagal tone may cause sinus exit block. Causes are explored, and prescribed medications may need to be adjusted or discontinued. If patients are symptomatic, significant numbers of pauses may require treatment, including temporary (including transcutaneous) and permanent implantation of a pacemaker.

22. The physician orders a pulmonary artery occlusive (PAOP) for a patient being monitored with a pulmonary artery catheter. Immediately after obtaining an occlusive pressure, the nurse notes the change in waveform indicated on the strip below. What are the best actions by the nurse? Figure from Geiter H, Jr.: Swan-Ganz Catheters. Nurse411.com. http://www.nurse411.com/Swan_Ganz.asp. Accessed April 2012. a. Turn the patient to the left side; obtain a stat portable chest xray. b. Place the patient supine; repeat zero-referencing of the system. c. Document the wedge pressure; continue monitoring the patient. d. Perform an immediate dynamic response test; obtain a chest xray.

ANS: C After obtaining a pulmonary artery occlusive pressure and deflating the balloon, the monitor tracing indicates the waveform has returned to a normal pulmonary artery waveform. The nurse should document the occlusive value and continue monitoring the patient. Turning the patient to the left side, zero-referencing the system and performing a dynamic response test are not necessary as the waveform displayed is normal.

10. While inflating the balloon of a pulmonary artery catheter (PAC) with 1.0 mL of air to obtain a pulmonary artery occlusion pressure (PAOP), the nurse encounters resistance. What is the best nursing action? a. Add an additional 0.5 mL of air to the balloon and repeat the procedure. b. Advance the catheter with the balloon deflated and repeat the procedure. c. Deflate the balloon and obtain a chest x-ray study to determine line placement. d. Lock the balloon in the inflated position and flush the distal port of the PAC with normal saline.

ANS: C Balloon inflation should never be forced because the PAC may have migrated further into the pulmonary artery, creating resistance to balloon inflation. Verification of proper line placement is warranted to avoid pulmonary artery rupture. In addition, the PAC waveform should be observed to assist in identifying location of the tip of the PAC. In this scenario, adding additional air to the balloon will further risk pulmonary artery rupture. Advancing a pulmonary artery catheter is not within the nurses scope of practice. Flushing the distal port with saline may be indicated to ensure patency; however, the balloon of the PAC should never be locked in the inflated position as rupture of the pulmonary artery may occur.

24. The patient is asymptomatic but is diagnosed with second-degree heart block Mobitz I. The patient is on digitalis medication at home. The nurse should expect that: a. the patient has had an anterior wall myocardial infarction. b. the physician will order the digitalis to be continued in the hospital. c. a digitalis level would be ordered upon admission. d. the patient will require a transcutaneous pacemaker.

ANS: C Digitalis toxicity is a major cause of this rhythm, and further digitalis doses should not be given until a digitalis level is obtained. Other causes of Mobitz I include AV nodal blocking drugs, acute inferior wall myocardial infarction or right ventricular infarction, ischemic heart disease, and excess vagal response. This type of block is usually well tolerated and no treatment is indicated unless the dropped beats occur frequently.

12. The nurse is caring for a mechanically ventilated patient with a pulmonary artery catheter who is receiving continuous enteral tube feedings. When obtaining continuous hemodynamic monitoring measurements, what is the best nursing action? a. Do not document hemodynamic values until the patient can be placed in the supine position. b. Level and zero reference the air-fluid interface of the transducer with the patient in the supine position and record hemodynamic values. c. Level and zero reference the air-fluid interface of the transducer with the patients head of bed elevated to 30 degrees and record hemodynamic values. d. Level and zero reference the air-fluid interface of the transducer with the patient supine in the side-lying position and record hemodynamic values.

ANS: C Elevation of the head of bed is an important intervention to prevent aspiration and ventilator-associated pneumonia. Patients who require hemodynamic monitoring while receiving tube feedings should have the air-fluid interface of the transducer leveled with the phlebostatic axis while the head of bed is elevated to at least 30 degrees. Readings will be accurate. Supine positioning of a mechanically ventilated patient increases the risk of aspiration and ventilator-associated pneumonia and is contraindicated in this patient. Hemodynamic values can be accurately measured and trended in with the head of the bed elevated as high as 60 degrees. Even though hemodynamic values can be obtained in lateral positions, it is technically difficult and not accurate unless the positioning of the transducer is exact. Regardless, head of bed elevation is indicated for this patient.

22. The nurse notices that the patient has a first-degree AV block. Everything else about the rhythm is normal. The nurse should: a. prepare to place the patient on a transcutaneous pacemaker. b. give the patient atropine to shorten the PR interval. c. monitor the rhythm and patients condition. d. give the patient an antiarrhythmic medication.

ANS: C First-degree AV block is a common dysrhythmia in the elderly and in patients with cardiac disease. As the normal conduction pathway ages or becomes diseased, impulse conduction becomes slower than normal. It is well tolerated. No treatment is required. Continue to monitor the patient and the rhythm.

21. The cardiologist has told the patient and family that the diagnosis is hypertrophic cardiomyopathy. Later they ask the nurse what the patient did wrong to cause this condition. The nurse explains: a. This is a result of a high-cholesterol diet and poor exercise habits. b. The heart has not been getting enough aerobic exercise and has developed this condition. In cardiac rehabilitation they will work with the patient to strengthen his heart through special exercises. c. This is an inherited condition. You should give serious consideration to having family members screened for it. d. This is a result of clot formation in the blood vessels in the heart. We will need to use medications to reduce the risk of further clotting.

ANS: C Hypertrophic cardiomyopathy is a genetically inherited disease that affects the myocardial sarcomere.

25. The patient is scheduled to have a permanent pacemaker implanted. The patient asks the nurse, How long will the battery in this thing last? The nurse should answer, a. Life expectancy is about 1 year. Then it will need to be replaced. b. Pacemaker batteries can last up to 25 years with constant use. c. Battery life varies depending on usage, but it can last up to 10 years. d. Pacemakers are used to treat temporary problems so the batteries dont last long.

ANS: C Implanted permanent pacemakers are used to treat chronic conditions. These devices have a battery life of up to 10 years, which varies based on the manufacturers recommendations.

23. The nurse understands that in a third-degree AV block: a. every P wave is conducted to the ventricles. b. some P waves are conducted to the ventricles. c. none of the P waves are conducted to the ventricles. d. the PR interval is prolonged.

ANS: C In first-degree AV block, a P wave precedes every QRS complex, which is followed by a T wave indicating complete conduction. It is represented on the ECG as a prolonged PR interval. Second-degree heart block refers to AV conduction that is intermittently blocked. Therefore, some P waves are conducted and some are not. Third-degree block is often called complete heart block because no atrial impulses are conducted through the AV node to the ventricles.

2. The nurse is assessing a patient with left-sided heart failure. Which symptom would the nurse expect to find? a. Dependent edema b. Distended neck veins c. Dyspnea and crackles d.Nausea and vomiting

ANS: C In left-sided heart failure, signs and symptoms are related to pulmonary congestion. Dependent edema and distended neck veins are related to right-sided heart failure.

5. A patient is admitted with the diagnosis of unstable angina. The nurse knows that the physiological mechanism present is most likely which of the following? a. Complete occlusion of a coronary artery b. Fatty streak within the intima of a coronary artery c. Partial occlusion of a coronary artery with a thrombus d. Vasospasm of a coronary artery

ANS: C In unstable angina, some blood continues to flow through the affected coronary artery; however, flow is diminished related to partial occlusion. The pain in unstable angina is more severe, may occur at rest, and requires more frequent nitrate therapy.

3. A patient is admitted with an acute myocardial infarction (AMI). The nurse knows that an angiotensin-converting enzymes (ACE) inhibitor should be started within 24 hours to reduce the incidence of which process? a. Myocardial stunning b. Hibernating myocardium c. Myocardial remodeling d. Tachycardia

ANS: C Myocardial remodeling is a process mediated by angiotensin II, aldosterone, catecholamine, adenosine, and inflammatory cytokines, which causes myocyte hypertrophy and loss of contractile function in the areas of the heart distant from the site of infarctions. ACE inhibitors reduce the incidence of remodeling.

14. The patient is admitted with recurrent supraventricular tachycardia that the cardiologist believes to be related to an accessory conduction pathway or a reentry pathway. The nurse anticipates which procedure to be planned for this patient? a. Implantable cardioverter-defibrillator placement b. Permanent pacemaker insertion c. Radiofrequency catheter ablation d. Temporary transvenous pacemaker placement

ANS: C Radiofrequency catheter ablation is a method of interrupting a supraventricular tachycardia, a dysrhythmia caused by a reentry circuit, and an abnormal conduction pathway.

6. After pulmonary artery catheter insertion, the nurse assesses a pulmonary artery pressure of 45/25 mm Hg, a pulmonary artery occlusion pressure (PAOP) of 20 mm Hg, a cardiac output of 2.6 L/min and a cardiac index of 1.9 L/min/m2. Which physician order is of the highest priority? a. Apply 50% oxygen via venture mask. b. Insert an indwelling urinary catheter. c. Begin a dobutamine (Dobutrex) infusion. d. Obtain stat cardiac enzymes and troponin.

ANS: C The pulmonary pressures are higher than normal, indicating elevated preload, and the cardiac index and output values are low. The priority order for the nurse to implement is to begin a dobutamine (Dobutrex) infusion to improve cardiac output, possibly reducing pulmonary artery occlusion pressures. The other treatments are important, but the dobutamine infusion is the most important at this time.

20. The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 125 beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO2) of 90% on a 50% venturi mask. Hemodynamic values include a cardiac output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pressure (PAOP) of 3 mm Hg. The nurse questions which of the following physicians order? a. Titrate supplemental oxygen to achieve a SpO2 > 94%. b. Infuse 500 mL 0.9% normal saline over 1 hour. c. Obtain arterial blood gas and serum electrolytes. d. Administer furosemide (Lasix) 20 mg intravenously.

ANS: D A central venous pressure of 1 mm Hg, pulmonary artery occlusion pressure of 1 mm Hg along with a blood pressure of 85/40 mm Hg and heart rate of 125 are indicative of a low volume state. Infusion of 500 mL of 0.9% normal saline will increase circulating fluid volume. Administration of furosemide (Lasix) is contraindicated and could further reduce circulating fluid volume. Titrating supplemental oxygen, obtaining serum blood gas and electrolyte samples, although not a priority, are appropriate interventions.

4. While caring for a patient with a pulmonary artery catheter, the nurse notes the pulmonary artery occlusion pressure (PAOP) to be significantly higher than previously recorded values. The nurse assesses respirations to be unlabored at 16 breaths/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear to auscultation bilaterally. What is the priority nursing action? a. Increase supplemental oxygen and notify respiratory therapy. b. Notify the physician immediately of the assessment findings. c. Obtain a stat chest x-ray film to verify proper catheter placement. d. Zero reference and level the catheter at the phlebostatic axis.

ANS: D A hemodynamic value not supported by clinical assessment should be treated as questionable. To ensure the accuracy of hemodynamic readings, the catheter transducer system must be leveled at the phlebostatic axis and zero referenced. In this example, the catheter transducer system may be lower than the phlebostatic axis, resulting in erroneously higher pressures. Clinical manifestations do not support increasing supplemental oxygen. Clinical manifestations do not warrant physician intervention; aberrant values should be investigated further. An aberrant value warrants further investigation, which includes zero referencing and checking the level as an initial measure. A chest x-ray study is not warranted at this time.

5. The patient is admitted with a condition that requires cardiac rhythm monitoring. To apply the monitoring electrodes, the nurse must first: a. apply a moist gel to the chest. b. make certain that the electrode gel is dry. c. avoid soaps to avoid skin irritation. d. clip chest hair if needed.

ANS: D Adequate skin preparation of electrode sites requires clipping the hair, cleansing the skin, and drying vigorously (moisture gels are not applied). Cleansing includes washing with soap and water, or alcohol, to remove skin debris and oils. Before application, the electrodes are checked to ensure that the gel is moist. It is difficult for electrodes to adhere to the chest in the presence of chest hair. Clipping, not shaving, is recommended since shaving may create small nicks that can become a portal for infection.

17. During insertion of a pulmonary artery catheter, the physician asks the nurse to assist by inflating the balloon with 1.5 mL of air. As the physician advances the catheter, the nurse notices premature ventricular contractions on the monitor. What is the best action by the nurse? a. Deflate the balloon while slowly withdrawing the catheter. b. Instruct the patient to cough and deep-breathe forcefully. c. Inflate the catheter balloon with an additional 1 mL of air. d. Ensure lidocaine hydrochloride (IV) is immediately available.

ANS: D During the insertion of the pulmonary artery catheter, ventricular dysrhythmias may occur as the catheter passes through the right ventricle. Treatment with lidocaine hydrochloride may be necessary to suppress the irritated ventricle and should be readily available. Withdrawing of the catheter is not within the scope of practice of the nurse and may not be necessary. Having the patient cough and deep-breathe will not correct the problem. The maximum volume of air necessary to inflate the balloon is 1.5 mL. Any additional volumes added may increase the risk of complications.

15. The patients heart rate is 165 beats per minute. His cardiac monitor shows a rapid rate with narrow QRS complexes. The P waves cannot be seen, but the rhythm is regular. The patients blood pressure has dropped from 124/62 to 78/30. His skin is cold and diaphoretic and he is complaining of nausea. The nurse prepares the patient for: a. administration of beta-blockers. b. administration of atropine. c. transcutaneous pacemaker insertion. d. emergent cardioversion.

ANS: D If an abnormal P wave cannot be visualized on the ECG but the QRS complex is narrow, the term supraventricular tachycardia (SVT) is often used. This is a generic term that describes any tachycardia that is not ventricular in origin; it is also used when the source above the ventricles cannot be identified, usually because the rate is too fast. Treatment is directed at assessing the patients tolerance of the tachycardia. If the rate is higher than 150 beats per minute and the patient is symptomatic, emergent cardioversion is considered. Cardioversion is the delivery of a synchronized electrical shock to the heart by an external defibrillator. Beta-blockers are a possibility if the patient is not symptomatic. Atropine is used in the treatment of bradycardia. If atropine is not effective in increasing heart rate, then transcutaneous pacing is implemented.

14. The nurse is preparing to obtain a pulmonary artery occlusion pressure (PAOP) reading for a patient who is mechanically ventilated. Ensuring that the air-fluid interface is at the level of the phlebostatic axis, what is the best nursing action? a. Place the patient in the supine position and record the PAOP immediately after exhalation. b. Place the patient in the supine position and document the average PAOP obtained after three measurements. c. Place the patient with the head of bed elevated 30 degrees and document the average PAOP pressure obtained. d. Place the patient with the head of bed elevated 30 degrees and record the PAOP just before the increase in pressures during inhalation.

ANS: D Pressures are highest when measured at end exhalation in the spontaneously breathing patient. In mechanically ventilated patients, pressures increase with inhalation and decrease with exhalation. Measurements are obtained just before the increase in pressure during inhalation. Supine positioning is contraindicated in the mechanically ventilated patient. The head of bed should be elevated to 30 degrees. Pulmonary artery occlusion pressure is not averaged, but measured during inhalation in the mechanically ventilated patient while appropriate positioning is maintained.

21. The charge nurse has a Vigileo pulse contour cardiac output monitoring system available for use in the surgical intensive care unit. For which patient is use of this device most appropriate? a. A patient with a history of aortic insufficiency admitted with a postoperative myocardial infarction b. A mechanically ventilated patient with cardiogenic shock being treated with an intraaortic balloon pump c. A patient with a history of atrial fibrillation having frequent episodes of paroxysmal supraventricular tachycardia d. A mechanically ventilated patient admitted following repair of an acute bowel obstruction

ANS: D Pulse contour analysis systems provide stroke volume variation and pulse pressure variation data and are better predictors of fluid responsiveness in mechanically ventilated patients. A patient postoperative from repair of an acute bowel obstruction that is mechanically ventilated is an appropriate candidate for this method of monitoring. Aortic insufficiency, intraaortic balloon pump therapy, and the presence of cardiac dysrhythmias are conditions in which pulse contour analysis systems are either inaccurate or contraindicated.

42. The patient is alert and talking when the nurse notices the following rhythm. The patients blood pressure is 90/44 mm Hg. The nurse should a. defibrillate immediately. b. begin basic life support. c. begin advanced life support. d. treat with intravenous amiodarone or lidocaine.

ANS: D Ventricular tachycardia (VT) is a rapid, life-threatening dysrhythmia originating from a single ectopic focus in the ventricles. It is characterized by at least three PVCs in a row. VT occurs at a rate greater than 100 beats per minute, but the rate is usually around 150 beats per minute and may be up to 250 beats per minute. Depolarization of the ventricles is abnormal and produces a widened QRS complex. The patient may or may not have a pulse. Determine whether the patient has a pulse. If no pulse is present, provide emergent basic and advanced life-support interventions, including defibrillation. If a pulse is present and the blood pressure is stable, the patient can be treated with intravenous amiodarone or lidocaine.