Advanced CBA #2-Urden questions

Which statement regarding the use of cuff blood pressures is true? a. Cuff pressures may be unreliable when a patient is in shock. b. Cuff pressures are more accurate than arterial line pressures. c. Cuff pressures and arterial line pressures should be nearly identical. d. Cuff pressures should not be compared to arterial line pressures.

A If the arterial line becomes unreliable or dislodged, a cuff pressure can be used as a reserve system. In the normotensive, normovolemic patient, little difference exists between the arm cuff blood pressure and the intravascular catheter pressure, and differences of 5 to 10 mm Hg do not generally alter clinical management. The situation is different if the patient has a low cardiac output (CO) or is in shock. The concern is that the cuff pressure may be unreliable because of peripheral vasoconstriction, and an arterial line is generally required. It is usual practice to compare a cuff pressure after the arterial line is inserted.

When assessing a patient with PVCs, the nurse knows that the ectopic beat is multifocal because it appears in what way? a. In various shapes in the same lead b. With increasing frequency c. Wider than a normal QRS d. On the T wave

A If the ventricular ectopic beats are of various shapes in the same lead, they are multifocal. Multifocal ventricular ectopics are more serious than unifocal ventricular ectopics because they indicate a greater area of irritable myocardial tissue and are more likely to deteriorate into ventricular tachycardia or fibrillation.

Why is a new-onset of atrial fibrillation serious? a. It increases the patient's risk for a stroke. b. It increases the patient's risk for a deep venous thrombosis. c. It may increase cardiac output to dangerous levels. d. It indicates the patient is about to have a myocardial infarction

A In atrial fibrillation the atria do not contract normally; they quiver. This increases the chance of the blood clotting in the atria because of a lack of complete emptying of the atria. These clots can break free and cause embolic strokes and pulmonary emboli. Atrial fibrillation does not indicate impending myocardial infarction or an increased risk of deep venous thrombosis. Atrial fibrillation decreases cardiac output from the loss of atrial kick

Which hemodynamic alteration is the most common cause of a decrease in cardiac output in the postoperative cardiovascular patient? a. Reduced preload b. Increased afterload c. Increased contractility d. Bradycardia

A In most patients, reduced preload is the cause of low postoperative cardiac output. To enhance preload, volume may be administered in the form of crystalloid, colloid, or packed red blood cells.

In the acute phase after ST segment elevation myocardial infarction (STEMI), fibrinolytic therapy is used in combination with heparin to recanalize the coronary artery. What dosage is the initial heparin bolus? a. 60 units/kg maximum 5000 units b. 30 units/kg maximum 3000 units c. 25 units/kg maximum of 2500 units d. 12 units/kg maximum of 1000 units

A In the acute phase after ST segment elevation myocardial infarction, heparin is administered in combination with fibrinolytic therapy to recanalize (open) the coronary artery. For patients who will receive fibrinolytic therapy, an initial heparin bolus of 60 units/kg (maximum, 5000 units) is given intravenously followed by a continuous heparin drip at 12 units/kg/hr (maximum 1000 units/hr) to maintain an activated partial thromboplastin time between 50 and 70 seconds (1.5 to 2.0 times control).

A patient is admitted with an acute inferior myocardial infarction (MI). A 12-lead electrocardiogram (ECG) is done to validate the area of infarction. Which leads on the ECG would correlate with an inferior wall MI? a. II, III, aVF b. V5 to V6, I, aVL c. V2 to V4 d. V1 to V2

A Inferior infarctions are manifested by electrocardiographic (ECG) changes in leads II, III, and aVF. Lateral wall infarctions are manifested by ECG changes in leads V5 to V6, I, and aVL. Anterior wall infarctions are manifested by ECG changes in leads V2 to V4. Posterior wall infarctions are manifested by ECG changes in leads V1 to V2.

Which finding is a reliable indicator of reperfusion after fibrinolytic therapy? a. Dysrhythmias b. Q waves c. Elevated ST segments d. Immediate rapid decrease in cardiac biomarkers

A Initially, when there is reperfusion, ischemic chest pain ceases abruptly as blood flow is restored. Another reliable indicator of reperfusion is the appearance of various "reperfusion" dysrhythmias. Premature ventricular contractions, bradycardias, heart block, ventricular tachycardia, and (rarely) ventricular fibrillation may occur.

A patient is admitted with left-sided heart failure related to mitral stenosis. Physical assessment findings reveal tachycardia with an S3 and a 3/6 systolic murmur. The grading of a murmur as a 3/6 refers to which characteristics of the murmur? a. Intensity b. Quality c. Timing d. Pitch

A Intensity, or the "loudness," is graded on a scale of 1 to 6; the higher the number, the louder the murmur.

What sounds are created by the turbulence of blood flow through a vessel caused by constriction of the blood pressure cuff? a. Korotkoff sounds b. Grating murmurs c. Blowing murmurs d. Gallops

A Korotkoff sounds are the sounds created by turbulence of blood flow within a vessel caused by constriction of the blood pressure cuff. Abnormal heart sounds are known as the third heart sound (S3) and the fourth heart sound (S4); they are referred to as gallops when auscultated during an episode of tachycardia. Murmurs are produced by turbulent blood flow through the chambers of the heart, from forward flow through narrowed or irregular valve openings, or backward regurgitate flow through an incompetent valve

Why do women have higher mortality rates from acute myocardial infarction (MI) than men? a. Women wait longer to seek medical care. b. Women have more risk factors for coronary artery disease than men. c. Women have a higher risk of coronary spasm than men. d. Women have smaller hearts than men.

A Many reasons contribute to higher mortality rates from acute myocardial infarction (MI) in women, and these include waiting longer to seek medical care, having smaller coronary arteries, being older when symptoms occur, and experiencing very different symptoms from those of men of the same age. Women do not have a higher risk of coronary spasm than men

How does a percutaneous transluminal coronary angioplasty (PTCA) improve blood flow? a. The balloon stretches the vessel wall, fractures the plaque, and enlarges the vessel lumen. b. Medication is delivered through the catheter that dissolves the plague and enhances vessel patency. c. The balloon removes blood clots from the vessel improving patency of the vessel. d. The balloon compresses the plaque against the vessel wall enlarging the vessel lumen.

A Percutaneous transluminal coronary angioplasty involves the use of a balloon-tipped catheter that, when advanced through an atherosclerotic lesion (atheroma), can be inflated intermittently for the purpose of dilating the stenotic area and improving blood flow through it. The high balloon-inflation pressure stretches the vessel wall, fractures the plaque, and enlarges the vessel lumen.

A patient is admitted with hypertrophic cardiomyopathy. The nurse would expect the medical management of this patient to include which intervention? a. Administration of beta-blockers b. Administration of positive inotropes c. Plans for intensive exercise regimen d. Plans for an aortic valve replacement

A Pharmacologic management includes beta-blockers to decrease left ventricular workload, medications to control and prevent atrial and ventricular dysrhythmias, anticoagulation if atrial fibrillation or left ventricular thrombi are present, and, finally, drugs to manage heart failure.

The patient is 72 hours postoperative for a coronary artery bypass graft (CABG). The patient's vital signs include temperature 103° F, heart rate 112, respiratory rate 22, blood pressure 134/78 mm Hg, and O2 saturation 94% on 3L nasal cannula. The nurse suspects that the patient has developed what problem? a. Infection and notifies the physician immediately b. Infection, which is common postoperatively, and monitors the patient's condition c. Cardiac tamponade and notifies the physician immediately d. Delirium caused by the elevated temperature

A Postoperative fever is fairly common after cardiopulmonary bypass. However, persistent temperature elevation to greater than 101° F (38.3° C) must be investigated. Sternal wound infections and infective endocarditis are the most devastating infectious complications, but leg wound infections, pneumonia, and urinary tract infections also can occur. A potentially lethal complication, cardiac tamponade may occur after surgery if blood accumulates in the mediastinal space, impairing the heart's ability to pump. Signs of tamponade include elevated and equalized filling pressures (eg, central venous pressure, pulmonary artery diastolic pressure, pulmonary artery occlusion pressure), decreased cardiac output, decreased blood pressure, jugular venous distention, pulsus paradoxus, muffled heart sounds, sudden cessation of chest tube drainage, and a widened cardiac silhouette on radiographs. The risk of delirium is increased in cardiac surgery patients, especially elderly patients, and is associated with increased mortality rates and reduced quality of life and cognitive function. Nursing staff can play a critical role in the prevention and recognition of delirium.

An assessment finding of pulsus alternans may indicate evidence of what disorder? a. Left-sided heart failure b. Jugular venous distention c. Pulmonary embolism d. Myocardial ischemia

A Pulsus alternans describes a regular pattern of pulse amplitude changes that alternate between stronger and weaker beats. This finding is suggestive of end-stage left ventricular heart failure.

Pulsus paradoxus may be noted on the bedside monitor when what is observed? a. A decrease of more than 10 mm Hg in the arterial waveform during inhalation b. A single, nonperfused beat on the electrocardiogram (ECG) waveform c. Tall, tented T waves on the ECG waveform d. An increase in pulse pressure greater than 20 mm Hg on exhalation

A Pulsus paradoxus is a decrease of more than 10 mm Hg in the arterial waveform that occurs during inhalation. It is caused by a fall in cardiac output (CO) as a result of increased negative intrathoracic pressure during inhalation.

A physician orders removal of the central venous catheter (CVC) line. The patient has a diagnosis of heart failure with chronic obstructive pulmonary disease. The nurse would place the patient in what position for this procedure? a. Supine in bed b. Supine in a chair c. Flat in bed d. Reverse Trendelenburg position

A Recommended techniques to avoid air embolus during central venous catheter (CVC) removal include removing the catheter when the patient is supine in bed (not in a chair) and placing the patient flat or in the reverse Trendelenburg position if the patient's clinical condition permits this maneuver. Patients with heart failure, pulmonary disease, and neurologic conditions with raised intracranial pressure should not be placed flat.

Which statement regarding the difference between stable and unstable angina is accurate? a. Stable angina responds predictably well to nitrates. b. Stable angina is not precipitated by activity. c. Stable angina has a low correlation to coronary artery disease (CAD). d. Stable angina is a result of coronary artery spasm.

A Stable angina is predictable and caused by similar precipitating factors each time; typically, it is exercise induced. Pain control is usually achieved by rest and by sublingual nitroglycerin within 5 minutes. Stable angina is the result of fixed lesions (blockages) of more than 75% of the coronary artery lumen and thus has a high correlation to coronary artery disease (CAD), not coronary spasm.

Which statement best describes the purpose of the Allen test? a. The Allen test assesses the adequacy of blood flow through the ulnar artery. b. The Allen test evaluates oxygen saturation in the brachial artery. c. The Allen test assesses the patency of an internal graft. d. The Allen test determines the size of needle to be used for puncture.

A The Allen test assesses the adequacy of blood flow to the hand through the ulnar artery.

Why is the Allen test performed before placement of a radial arterial line placement? a. To evaluate collateral circulation to the hand b. To estimate patency of the radial artery c. To appraise the neurologic function of the hand d. To assess the sensitivity of the insertion point

A The Allen test involves occluding the radial or ulnar artery after blanching the hand. If the hand turns pink, then the nonoccluded artery provides enough circulation to the hand. If the hand remains blanched, then no collateral circulation exists, and that wrist should not be used for arterial line placement.

The abdominojugular reflux test determines the presence of which disorder? a. Right ventricular failure b. Cirrhosis c. Liver failure d. Coronary artery disease

A The abdominojugular reflux sign can assist with the diagnosis of right ventricular failure. A positive abdominojugular reflux sign is an increase in the jugular venous pressure (CVP equivalent) of greater than 3 cm sustained for at least 15 seconds.

What is the function of the atrioventricular (AV) valves? a. Prevent backflow of blood into the atria during ventricular contraction b. Prevent blood regurgitation back into the ventricles c. Assist with blood flow to the lungs and aorta d. Contribute to ventricular filling by atrial kick

A The atrioventricular (AV) valves are open during ventricular diastole (filling) and prevent backflow of blood into the atria during ventricular systole (contraction). Semilunar valves prevent the backflow of pulmonic and aortic blood back into the ventricles.

What are the clinical manifestations of right-sided heart failure? a. Elevated central venous pressure and sacral edema b. Pulmonary congestion and jugular venous distention c. Hypertension and chest pain d. Liver tenderness and pulmonary edema

A The common manifestations of right ventricular failure are the following: jugular venous distention, elevated central venous pressure, weakness, peripheral or sacral edema, hepatomegaly (enlarged liver), jaundice, and liver tenderness. Gastrointestinal symptoms include poor appetite, anorexia, nausea, and an uncomfortable feeling of fullness.

A patient's bedside electrocardiogram (ECG) strips show the following changes: increased PR interval; increased QRS width; and tall, peaked T waves. Vital signs are temperature 98.2° F; heart rate 118 beats/min; blood pressure 146/90 mm Hg; and respiratory rate 18 breaths/min. The patient is receiving the following medications: digoxin 0.125 mg PO every day; D51/2 normal saline with 40 mEq potassium chloride at 125 mL/hr; Cardizem at 30 mg PO q8h; and aldosterone at 300 mg PO q12h. The practitioner is notified of the ECG changes. What orders should the nurse expect to receive? a. Change IV fluid to D51/2 normal saline and draw blood chemistry. b. Give normal saline with 40 mEq of potassium chloride over a 6-hour period. c. Hold digoxin and draw serum digoxin level. d. Hold Cardizem and give 500 mL normal saline fluid challenge over a 2-hour period.

A The electrocardiographic (ECG) changes are most consistent with hyperkalemia. Removing the potassium from the intravenous line and drawing laboratory values to check the potassium level is the best choice with the least chance of further harm. Digoxin toxicity can be suspected related to the prolonged PR interval, but hyperkalemia explains all the ECG changes. The patient is not hypotensive or bradycardic, so holding the Cardizem is not indicated.

Zeroing the pressure transducer on hemodynamic monitoring equipment occurs when the displays reads which number? a. 0 b. 250 c. 600 d. 760

A The monitor is adjusted so that "0" is displayed, which equals atmospheric pressure. Atmospheric pressure is not zero; it is 760 mm Hg at sea level. Using zero to represent current atmospheric pressure provides a convenient baseline for hemodynamic measurement purposes.

A nurse is providing care to a patient on fibrinolytic therapy. Which of the following statements from the patient warrants further assessment and intervention by the 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!"

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

A transvenous pacemaker is inserted through the right subclavian vein and threaded into the right ventricle. The pacemaker is placed on demand at a rate of 70. What is the three letter code for this pacing mode? a. VVI b. AOO c. DDD d. VAT

A The original code is based on three categories, each represented by a letter. The first letter refers to the cardiac chamber that is paced. The second letter designates which chamber is sensed, and the third letter indicates the pacemaker's response to the sensed event. A VVI pacemaker paces the ventricle when the pacemaker fails to sense an intrinsic ventricular depolarization.

A patient is undergoing ventricular pacing via a transvenous pacing lead. The nurse notes a pacing artifact, but it is not followed by a QRS on the electrocardiogram (ECG) monitoring. Which nursing intervention may correct this situation? a. Position the patient on the left side b. Decrease the milliamperes as ordered c. Increase the rate as ordered d. Monitor the patient in a different lead

A The patient is experiencing "loss of capture," which most often can be attributed either to displacement of the pacing electrode or to an increase in threshold as a result of drugs, metabolic disorders, electrolyte imbalances, or fibrosis or myocardial ischemia at the site of electrode placement. In many cases, increasing the output milliamperes (mA) may elicit capture. For transvenous leads, repositioning the patient to the left side may improve lead contact and restore capture.

Patient education for a patient with a Holter monitor should include which instruction? a. Keep a diary of activities, symptoms, and any medications that are taken. b. Do not drink coffee while the recorder is on. c. Do not take a bath but a shower is alright. d. Carry the monitor in a purse or backpack.

A The patient should be instructed to keep a diary of activities, symptoms, and any medications that are taken and to carry the monitor by a shoulder strap or clipped to a belt or pocket. The only activities that are restricted while wearing a Holter monitor are those that would get the chest electrodes or monitor wet, eliminating swimming and taking a shower or tub bath. The patient can drink coffee during the test

A patient is admitted with a diagnosis of acute myocardial infarction. The monitor pattern reveals bradycardia. Occlusion of which coronary artery most likely resulted in bradycardia from sinoatrial node ischemia? a. Right b. Left anterior descending c. Circumflex d. Dominant

A The right coronary artery provides the blood supply to the sinoatrial and atrioventricular (AV) nodes in more than half the population. The left coronary artery is a short but important artery that divides into two large arteries, the left anterior descending and the circumflex arteries. These vessels serve the left atrium and most of the left ventricle. The term dominant coronary artery is used to describe the artery that supplies the posterior part of the heart.

Which lead is best to monitor a patient? a. Varies based on the patient's clinical condition and recent clinical history b. Lead aVF c. Lead V1 d. Lead II

A The selection of an electrocardiographic monitoring lead is not a decision to be made casually or according to habit. The monitoring lead should be chosen with consideration of the patient's clinical condition and recent clinical history. Lead II is recommended for monitoring of atrial dysrhythmias. Lead V1 is recommended for monitoring of ventricular dysrhythmias. Leads I and aVF are selected to detect a sudden change in ventricular axis.

The physician is going to place a central venous catheter. Which anatomic site is associated with a lower risk of infection? a. Subclavian vein b. External jugular vein c. Internal jugular vein d. Femoral vein

A The subclavian site should be used for insertion rather than jugular or femoral insertion sites to minimize infection risk.

Place the following components of the cardiac conduction pathway in the correct anatomic order. 1. Atrioventricular node 2. Bundle branches 3. Bundle of His 4. Internodal pathways 5. Purkinje fibers 6. Sinoatrial node a. 6, 1, 4, 3, 2, 5 b. 6, 1, 3, 2, 4, 5 c. 6, 1, 4, 2, 3, 5 d. 4, 3, 2, 5, 6, 1

A The three main areas of impulse propagation and conduction are (1) the sinoatrial node, (2) the atrioventricular node, and (3) the conduction fibers within the ventricle, specifically the bundle of His, the bundle branches, and the Purkinje fibers. Interruption or malfunction of any part of the conduction pathway can result in dysrhythmias specific to that structure.

A patient is admitted with right- and left-sided heart failure. The nurse's assessment reveals that the patient has 3+ pitting edema on the sacrum, blood pressure of 176/98 mm Hg, and bilateral crackles in the lungs. The patient is experiencing shortness of breath and chest discomfort. Increased afterload is probably present related to the patient's blood pressure. Which therapeutic measure will most likely decrease afterload in this patient? a. Administration of vasodilators b. Placement in high Fowler position c. Elevation of extremities d. Increasing intravenous fluids

A Therapeutic management to decrease afterload is aimed at decreasing the work of the heart with the use of vasodilators. Placing the patient in high Fowler position will cause an increase in the workload of the heart. Elevation of the extremities will ease the venous return back to the heart. Increasing IV fluids will cause an increased workload on the heart.

The patient is admitted with a diagnosis of cardiogenic shock. The patient's heart rate (HR) is 135 beats/min with weak peripheral pulses. The patient has bilaterally crackles in the bases of the lungs. O2 saturation is 90% on 4L/NC. The practitioner orders diuretics and vasodilators. What response should the nurse expect after starting the medications? a. Decreased preload and afterload b. Increased preload and afterload c. Decreased preload and increased afterload d. Increased preload and decreased afterload

A Vasodilators are used to decrease afterload, and diuretics are used to decrease preload.

The patient's admitting 12-lead ECG shows wide, M-shaped P waves. What diagnosis could be responsible for this finding? a. Mitral stenosis b. Chronic pulmonary disease c. Hypotension d. Pericarditis

A Wide, M-shaped P waves are seen in left atrial hypertrophy and are called P mitrale because left atrial hypertrophy is often caused by mitral stenosis.

Which mechanisms responsible for a myocardial infarction (MI)? (Select all that apply.) a. Coronary artery thrombosis b. Plaque rupture c. Coronary artery spasm near the ruptured plaque d. Preinfarction angina e. Hyperlipidemia

A, B, C The three mechanisms that block the coronary artery and are responsible for the acute reduction in oxygen delivery to the myocardium are (1) plaque rupture, (2) new coronary artery thrombosis, and (3) coronary artery spasm close to the ruptured plaque.

Heart murmurs are characterized by which criteria? (Select all that apply.) a. Intensity b. Location c. Quality d. Pitch e. Pathologic cause

A, B, C, D Murmurs are characterized by specific criteria. Timing is the place in the cardiac cycle (systole/diastole). Location is where it is auscultated on the chest wall (mitral or aortic area). Radiation is how far the sound spreads across chest wall. Quality is whether the murmur is blowing, grating, or harsh. Pitch is whether the tone is high or low. Intensity is the loudness is graded on a scale of 1 through 6; the higher the number, the louder the murmur.

Which physiologic effects can be associated with physical exercise? (Select all that apply.) a. Decreased LDL cholesterol b. Increased HDL cholesterol c. Decreased triglycerides d. Increased insulin resistance e. Decreased incidence of depression

A, B, C, E Many research trials have demonstrated the positive effects of physical activity on the other major cardiac risk factors. Exercise alters the lipid profile by decreasing low-density lipoprotein (LDL) cholesterol and triglyceride levels and increasing high-density lipoprotein (HDL) cholesterol levels. Exercise reduces insulin resistance at the cellular level, lowering the risk for developing type 2 diabetes, especially if combined with a weight loss program.

Which statements describe S1, the first heart sound? (Select all that apply.) a. It is associated with closure of the mitral and tricuspid valves. b. It is a high-pitched sound. c. It can be heard most clearly with the diaphragm of the stethoscope. d. The best listening point is in the aortic area. e. The "split" sound can best be detected in the tricuspid area.

A, B, C, E S1 is the sound associated with mitral and tricuspid valve closure and is heard most clearly in the mitral and tricuspid areas. S1 sounds are high pitched and heard best with the diaphragm of the stethoscope.

A patient is diagnosed with third-degree heart failure. The nurse reviews the patient's medication list. Which classifications of drugs should be avoided with this patient? (Select all that apply.) a. Nonsteroidal antiinflammatory drugs (NSAIDs) b. Antidysrhythmics c. Angiotensin-converting enzyme (ACE) inhibitors d. Calcium channel blockers e. Beta-blockers

A, B, D Types of medications that have been found to worsen heart failure should be avoided, including most antidysrhythmics, calcium channel blockers, and nonsteroidal antiinflammatory medications. Angiotensin-converting enzyme inhibitors and beta-blockers are used to treat heart failure.

Which factors influence stroke volume? (Select all that apply.) a. Afterload b. Cardiac output c. Contractility d. Heart rate e. Preload

A, C, E Stroke volume (SV) as a value is influenced by three primary factors: preload, afterload, and contractility. Cardiac output (CO) is determined by SV × HR = CO. Preload is the volume of blood in the left ventricle at the end of diastole.

Which clinical manifestations are indicative of left ventricular failure? (Select all that apply.) a. Cool, pale extremities b. Jugular venous distention c. Liver tenderness d. Weak peripheral pulses e. Rales

A, D, E Patients presenting with left ventricular failure have one of the following: (1) decreased exercise tolerance, (2) fluid retention, or (3) discovery during examination of noncardiac problems. Clinical manifestations of left ventricular failure include decreased peripheral perfusion with weak or diminished pulses; cool, pale extremities; and, in later stages, peripheral cyanosis.

The presence of a carotid or femoral bruit may be evidence of what anomaly? a. Left-sided heart failure b. Blood flow through a partially occluded vessel c. Early onset of pulmonary embolism d. Myocardial rupture

B A bruit is an extracardiac vascular sound that results from blood flow through a tortuous or partially occluded vessel.

A positive signal-averaged electrocardiogram (ECG) indicates that a patient is at risk for what problem? a. Myocardial infarction b. Sudden cardiac death c. Coronary artery disease d. Stroke

B A positive signal-averaged electrocardiogram (ECG)—in combination with other specific indicators—is a predictor of increased risk for sudden cardiac death. Many patients with a positive signal-averaged ECG (abnormal) display a normal signal-averaged ECG when placed on antidysrhythmic medications. The signal-averaged ECG is not analyzed in isolation. It is used in conjunction with other cardiac diagnostic tests, including the electrophysiology study (EPS). It is a helpful adjunct to the EPS but does not replace it.

A patient asks why he had to take a deep breath when the radiology technician took his chest radiograph. Which statement is the best response? a. "Deep breaths get the chest wall closer to the machine." b. "When the lungs are filled with air, you get a clearer picture." c. "Taking a deep breath decreases the error caused by motion." d. "Holding your breath makes the heart appear larger."

B A radiograph is taken when the patient has taken a deep breath (inspiration). During exhalation, the lungs are less full of air, which can make the lung tissue appear "cloudy" as if there is additional lung water. The heart also appears larger during exhalation. This could lead to an erroneous diagnosis of heart failure

What are the two important proteins contained within the cardiac cells that contribute to contraction? a. Z-disk and A-band b. Actin and myosin c. I-band and M-band d. Renin and angiotensin

B Actin and myosin form cross-bridges, allowing myocardial contraction to take place. Z-disk, A-band, I-band, and M-band are all portions of the sarcomere functional unit to promote contraction in the heart. Renin converts the protein angiotensinogen to angiotensin I. When angiotensin I passes through the pulmonary vascular bed, it is activated by angiotensin-converting enzyme to become angiotensin II.

On returning from the cardiac catheterization laboratory, the patient asks if he can get up in the chair. What should the nurse tell the patient? a. "You cannot get up because you may pass out." b. "You cannot get up because you may start bleeding." c. "You cannot get up because you may fall." d. "You cannot get up until you urinate."

B After catheterization, the patient remains flat for up to 6 hours (varies by institutional protocol and catheter size) to allow the femoral arterial puncture site to form a stable clot. Most bleeding occurs within the first 2 to 3 hours after the procedure.

What is the physiologic effect of left ventricular afterload reduction? a. Decreased left atrial tension b. Decreased systemic vascular resistance c. Increased filling pressures d. Decreased cardiac output

B Afterload is defined as the pressure the ventricle generates to overcome the resistance to ejection created by the arteries and arterioles. After a decrease in afterload, wall tension is lowered. The technical name for afterload is systemic vascular resistance (SVR). Resistance to ejection from the right side of the heart is estimated by calculating the pulmonary vascular resistance (PVR). The PVR value is normally one-sixth of the SVR.

When is a patient a candidate for a surgical repair of an abdominal aortic aneurysm (AAA)? a. Size is 1 cm b. Patient experiencing symptoms c. Aneurysm size unchanged over several years d. Size less than 4 cm

B An abdominal aortic aneurysm (AAA) is usually repaired when the aneurysm is 5 cm or larger, creating symptoms, or rapidly expanding. This is done to prevent the high mortality rate associated with abdominal rupture.

During a history examination, a patient tells the nurse, "The cardiologist says I have a leaking valve." The nurse documents that the patient has a history of what condition? a. Acute mitral regurgitation b. Aortic insufficiency c. Chronic mitral regurgitation d. Pericarditis

B Aortic insufficiency is an incompetent aortic valve. If the valve cusps do not maintain this seal, the sound of blood flowing back into the left ventricle during diastole is heard as a decrescendo, high-pitched, blowing murmur. A pericardial friction rub is a sound that can occur within 2 to 7 days after a myocardial infarction. The friction rub results from pericardial inflammation (pericarditis). Classically, a pericardial friction rub is a grating or scratching sound that is both systolic and diastolic, corresponding to cardiac motion within the pericardial sac. Acute mitral regurgitation occurs when the ventricle contracts during systole and a jet of blood is sent in a retrograde manner to the left atrium, causing a sudden increase in left atrial pressure, acute pulmonary edema, and low cardiac output (CO) and leading to cardiogenic shock. Chronic mitral regurgitation is auscultated in the mitral area and occurs during systole. It is high pitched and blowing, although the pitch and intensity vary, depending on the degree of regurgitation. As mitral regurgitation progresses, the murmur radiates more widely.

Which dosage of dopamine results in stimulation of beta1 receptors and increased myocardial contractility? a. 1 mcg/kg/min b. 5 mcg/kg/min c. 15 mcg/kg/min d. 20 mcg/kg/min

B At low dosages of 1 to 2 mcg/kg/min, dopamine stimulates dopaminergic receptors, causing renal and mesenteric vasodilation. Moderate dosages result in stimulation of beta1 receptors to increase myocardial contractility and improve cardiac output. At dosages greater than 10 mg/kg/min, dopamine predominantly stimulates alpha receptors, resulting in vasoconstriction that often negates both the beta-adrenergic and dopaminergic effects.

What percentage of volume does atrial kick contribute to ventricular filling? a. 10% b. 20% c. 5% d. 45%

B Atrial contraction, also known as "atrial kick," contributes approximately 20% of blood flow to ventricular filling; the other 80% occurs passively during diastole

Which serum lipid value is a significant predictor of future acute myocardial infarction (MI) in persons with established coronary artery atherosclerosis? a. High-density lipoprotein (HDL) b. Low-density lipoprotein (LDL) c. Triglycerides d. Very-low-density lipoprotein

B Both the LDL-C and total serum cholesterol levels are directly correlated with risk for coronary artery disease, and high levels of each are significant predictors of future acute myocardial infarction in persons with established coronary artery atherosclerosis. LDL-C is the major atherogenic lipoprotein and thus is the primary target for cholesterol-lowering efforts.

Which of the following values reflects a normal cardiac output at rest? a. 2.5 L/min b. 5.8 L/min c. 7.3 L/min d. 9.6 L/min

B Cardiac output is normally expressed in liters per minute (L/min). The normal cardiac output in the human adult is approximately 4 to 8 L/min. It is approximately 4 to 6 L/min at rest and increases with exercise.

Why is mixed venous oxygen saturation (SVO2) monitoring helpful in the management of the critically ill patient? a. It facilitates oxygen saturation monitoring at the capillary level. b. It can detect an imbalance between oxygen supply and metabolic tissue demand. c. It assesses the diffusion of gases at the alveolar capillary membrane. d. It estimates myocardial workload during heart failure and acute pulmonary edema.

B Continuous venous oxygen monitoring permits a calculation of the balance achieved between arterial oxygen supply () and oxygen demand at the tissue level by sampling desaturated venous blood from the PA catheter distal tip

Mechanical contraction of the heart occurs during which phase of the cardiac cycle? a. Phase 0 b. Phase 2 c. Phase 3 d. Phase 4

B During phases 1 and 2, an electrical plateau is created, and during this plateau, mechanical contraction occurs. Because there is no significant electrical change, no waveform appears on the electrocardiogram (ECG). During phase 0 (depolarization), the electrical potential changes rapidly from a baseline of -90 mV to +20 mV and stabilizes at about 0 mV. Because this is a significant electrical change, it appears as a wave on the ECG as the QRS. During phase 3 (repolarization), the electrical potential again changes, this time a little more slowly, from 0 mV back to -90 mV. This is another major electrical event and is reflected on the ECG as a T wave. During phase 4 (resting period), the chemical balance is restored by the sodium pump, but because positively charged ions are exchanged on a one-for-one basis, no electrical activity is generated, and no visible change occurs on the ECG tracing.

Through what mechanism does enalapril decrease blood pressure? a. Direct arterial vasodilation b. Block the conversion of angiotensin I to angiotensin II c. Increase fluid excretion at the loop of Henle d. Peripheral vasoconstriction and central vasodilation.

B Enalapril is an angiotensin-converting enzyme (ACE) inhibitors that produces vasodilation by blocking the conversion of angiotensin I to angiotensin II. Because angiotensin is a potent vasoconstrictor, limiting its production decreases peripheral vascular resistance. In contrast to the direct vasodilators and nifedipine, ACE inhibitors do not cause reflex tachycardia or induce sodium and water retention.

Which anticoagulant enhances the activity of antithrombin III and does not require activated partial thromboplastin time (aPTT) or activated clotting time (ACT) monitoring? a. Heparin b. Enoxaparin c. Bivalirudin d. Argatroban

B Enoxaparin (Lovenox) enhances activity of antithrombin III, a more predictable response than heparin, because enoxaparin is not largely bound to protein. There is no need for activated partial thromboplastin time (aPTT) or activated clotting time (ACT) monitoring, and there is a lower risk of heparin-induced thrombocytopenia (HIT) than with unfractionated heparin (UFH). Heparin sodium enhances activity of antithrombin III, a natural anticoagulant, to prevent clot formation. The effectiveness of treatment may be monitored by aPTT or ACT. Response is variable because of binding with plasma proteins effects may be reversed with protamine sulfate. Bivalirudin (Angiomax) directly inhibits thrombin. It may be administered alone or in combination with glycoprotein IIb/IIIa inhibitors and produces a dose-dependent increase in aPTT and ACT. It may be used instead of UFH for patients with HIT. Argatroban (Argatroban) directly inhibits thrombin. It may be used instead of UFH for patients with HIT. Whereas ACT is monitored during percutaneous coronary intervention, aPTT is used during prolonged infusion.

When assessing the pulmonary arterial waveform, the nurse notices dampening. After tightening the stopcocks and flushing the line, the nurse decides to calibrate the transducer. What are two essential components included in calibration? a. Obtaining a baseline blood pressure and closing the transducer to air b. Leveling the air-fluid interface to the phlebostatic axis and opening the transducer to air c. Having the patient lay flat and closing the transducer to air d. Obtaining blood return on line and closing all stopcocks

B Ensuring accuracy of waveform calibration of the system includes opening the transducer to air and leveling the air-fluid interface of the transducer to the phlebostatic axis.

A patient with heart failure may be at risk for hypomagnesemia as a result of which factor? a. Pump failure b. Diuretic use c. Fluid overload d. Hemodilution

B Hypomagnesemia can be caused by diuresis. Diuretic use with heart failure often contributes to low serum magnesium levels.

What is one hemodynamic effect of a pericardial effusion? a. Increased ventricular ejection b. Decreased ventricular filling c. Myocardial ischemia d. Increased afterload

B If the fluid collection in the sac (pericardial effusion) impinges on ventricular filling, ventricular ejection, or coronary artery perfusion, a clinical emergency may exist that necessitates removal of the excess pericardial fluid to restore normal cardiac function. Myocardial ischemia is damage of the myocardium muscle as the result of a heart attack.

What type of atrioventricular (AV) block can be described as a gradually lengthening PR interval until ultimately the final P wave in the group fails to conduct? a. First-degree AV block b. Second-degree AV block, type I c. Second-degree AV block, type II d. Third-degree AV block

B In Mobitz type I block, the atrioventricular (AV) conduction times progressively lengthen until a P wave is not conducted. This typically occurs in a pattern of grouped beats and is observed on the electrocardiogram (ECG) by a gradually lengthening PR interval until ultimately the final P wave in the group fails to conduct. When all atrial impulses are conducted to the ventricles but the PR interval is greater than 0.20 second, a condition known as first-degree AV block exists. Mobitz type II block is always anatomically located below the AV node in the bundle of His in the bundle branches or even in the Purkinje fibers. This results in an all-or-nothing situation with respect to AV conduction. Sinus P waves are or are not conducted. When conduction does occur, all PR intervals are the same. Because of the anatomic location of the block, on the surface, ECG the PR interval is constant and the QRS complexes are wide. Third-degree, or complete, AV block is a condition in which no atrial impulses can conduct from the atria to the ventricles. This is also described by the term complete heart block.

What is the most common complication of a central venous catheter (CVC)? a. Air embolus b. Infection c. Thrombus formation d. Pneumothorax

B Infection related to the use of central venous catheters (CVCs) is a major problem. The incidence of infection strongly correlates with the length of time the CVC has been inserted, with longer insertion times leading to a higher infection rate. The risk of air embolus, although uncommon, is always present for a patient with a central venous line in place. Air can enter during insertion through a disconnected or broken catheter by means of an open stopcock, or air can enter along the path of a removed CVC. Unfortunately, clot formation (thrombus) at the CVC site is common. Thrombus formation is not uniform; it may involve development of a fibrin sleeve around the catheter, or the thrombus may be attached directly to the vessel wall. Pneumothorax has a higher occurrence during placement of a CVC than during removal.

Which of the following statements regarding beta-blockers is correct? a. They increase heart rate and are contraindicated in tachydysrhythmias. b. They result in bronchospasm and should not be used in patients with chronic obstructive pulmonary disease (COPD). c. They increase cardiac output and help with left ventricular failure. d. They are helpful in increasing atrioventricular node conduction and are used in heart blocks.

B Knowledge of the effects of adrenergic-receptor stimulation allows for anticipation of not only the therapeutic responses brought about by beta-blockade but also the potential adverse effects of these agents. For example, bronchospasm can be precipitated by noncardioselective beta-blockers in a patient with chronic obstructive pulmonary disease secondary to blocking the effects of beta2 receptors in the lungs.

Which calcium channel blocker is beneficial in the treatment of patients with coronary artery disease or ischemic stroke? a. Nifedipine b. Nicardipine c. Clevidipine d. Diltiazem

B Nicardipine was the first available intravenous calcium channel blocker and as such could be more easily titrated to control blood pressure. Because this medication has vasodilatory effects on coronary and cerebral vessels, it has proven beneficial in treating hypertension in patients with coronary artery disease or ischemic stroke. Nifedipine is available only in an oral form, but in the past it was prescribed sublingually during hypertensive emergencies. Clevidipine is a new, short-acting calcium channel blocker that allows for even more precise titration of blood pressure in the management of acute hypertension. Diltiazem (Cardizem) is from the benzothiazine group of calcium channel blockers. These medications dilate coronary arteries but have little effect on the peripheral vasculature. They are used in the treatment of angina, especially that which has a vasospastic component, and as antidysrhythmics in the treatment of supraventricular tachycardias.

A patient with a serum potassium level of 6.8 mEq/L may exhibit what type of electrocardiographic changes? a. A prominent U wave b. Tall, peaked T waves c. A narrowed QRS d. Sudden ventricular dysrhythmias

B Normal serum potassium levels are 3.5 to 4.5 mEq/L. Tall, narrow peaked T waves are usually, although not uniquely, associated with early hyperkalemia and are followed by prolongation of the PR interval, loss of the P wave, widening of the QRS complex, heart block, and asystole. Severely elevated serum potassium (greater than 8 mEq/L) causes a wide QRS tachycardia.

What parameter must be assessed frequently in the patient with an intraaortic balloon in place? a. Skin turgor in the affected extremity b. Peripheral pulses distal to the insertion site c. Blood pressures in both arms and legs d. Oxygen saturation

B One complication of intraaortic balloon support is lower extremity ischemia resulting from occlusion of the femoral artery by the catheter itself or by emboli caused by thrombus formation on the balloon. Although ischemic complications have decreased with sheathless insertion techniques and the introduction of smaller balloon catheters, evaluation of peripheral circulation remains an important nursing assessment. The presence and quality of peripheral pulses distal to the catheter insertion site are assessed frequently along with color, temperature, and capillary refill of the involved extremity. Signs of diminished perfusion must be reported immediately.

What is the preferred initial treatment of an acute myocardial infarction? a. Fibrinolytic therapy b. Percutaneous coronary intervention (PCI) c. Coronary artery bypass surgery (CABG) d. Implanted Cardioverter defibrillator (ICD)

B Percutaneous coronary intervention (PCI) is now preferred as the initial method of treatment for acute myocardial infarction (MI; primary PCI). PCI includes balloon angioplasty, atherectomy, and stent implantation, as well as a number of adjunctive devices used to facilitate successful revascularization in coronary vessels.

A patient reports feeling dizzy after standing quickly. Which finding could provide a clue regarding the cause? a. Hemoglobin level of 14.0 g/dL and hematocrit level of 42.3% b. Poor skin turgor with extended tenting c. Supine blood pressure of 146/93 mm Hg d. Resting heart rate of 96 beats/min

B Poor skin turgor could suggest dehydration. Dehydration can cause orthostatic hypotension because of low capacitance reserves from hypovolemia. Supine blood pressure of 146/93 mm Hg would be considered hypertensive, and the patient would most likely experience a headache rather than dizziness. A resting heart rate of 96 beats/min is still considered a normal value.

Which intervention is an essential aspect of the patient teaching plan for the patient with chronic heart failure? a. Instructing the patient to call the practitioner prior to dental surgery b. Stressing the importance of compliance with diuretic therapy c. Instructing the patient to take nitroglycerin if chest pain occurs d. Teaching the patient how to take an apical pulse

B Primary topics of education include (1) the importance of a daily weight, (2) fluid restrictions, and (3) written information about the multiple medications used to control the symptoms of heart failure. Reduction or cessation of diuretics usually results in sodium and water retention, which may precipitate heart failure.

Which of the following is most indicative of decreased left ventricular preload? a. Increased pulmonary artery occlusion pressure (PAOP) b. Decreased pulmonary artery occlusion pressure (PAOP) c. Increased central venous pressure (CVP) d. Decreased central venous pressure (CVP)

B Pulmonary artery occlusion pressure (PAOP) normally reflect the pressure in the left ventricle at the end of diastole. Left ventricular end-diastolic pressure is preload, and so an increase in preload will first increase the PAOP measurements and vice versa. Central venous pressure changes are reflective of right ventricular preload.

The nurse assesses the dorsalis pedis and posterior tibial pulses as weak and thready. What should the nurse document for the pulse volume? a. 0 b. 1+ c. 2+ d. 3+

B Pulse volumes are 0, not palpable; 1+, faintly palpable (weak and thready); 2+, palpable (normal pulse); and 3+, bounding (hyperdynamic pulse).

A heart murmur is described as blowing, grating, or harsh. This description would fall under which criteria? a. Intensity b. Quality c. Timing d. Pitch

B Quality is whether the murmur is blowing, grating, or harsh. Intensity is the loudness graded on a scale of 1 through 6; the higher the number, the louder is the murmur. Timing is the place in the cardiac cycle (systole/diastole). Pitch is whether the tone is high or low.

What is the initial intervention in a patient with sinus tachycardia with the following vital signs: heart rate, 136 beats/min; blood pressure, 102/60 mm Hg; respiratory rate, 24 breaths/min; temperature, 99.2° F; SpO2, 94% on oxygen 2 L/min by nasal cannula? a. Administer adenosine IV push. b. Identify the cause. c. Administer nitroglycerine 0.4 mg sublingual. d. Administer lidocaine 75 mg IV push.

B Sinus tachycardia can be caused by a wide variety of factors, such as exercise, emotion, pain, fever, hemorrhage, shock, heart failure, and thyrotoxicosis. Many medications used in critical care can also cause sinus tachycardia; common culprits are aminophylline, dopamine, hydralazine, atropine, and catecholamines such as epinephrine. This patient has a stable heart rate and SpO2; therefore, there is time to identify the cause of the sinus tachycardia. Lidocaine is indicated for ventricular dysrhythmias. Nitroglycerine is not indicated because the patient is not having chest pain at this time. Adenosine is usually not indicated unless the heart rate is greater than 150 beats/min.

What effect does ventricular tachycardia have on cardiac output? a. Increases cardiac output due to an increase in ventricular filling time b. Decreases cardiac output due to a decrease in stroke volume c. Increases cardiac output due to an increase in preload d. Decreases cardiac output due to a decrease in afterload

B Tachycardia is detrimental to anyone with ischemic heart disease because it decreases the time for ventricular filling, decreases stroke volume, and compromises cardiac output. Tachycardia increases heart work and myocardial oxygen demand while decreasing oxygen supply by decreasing coronary artery filling time.

The patient's admitting 12-lead ECG shows tall, peaked P waves. What diagnosis could be responsible for this finding? a. Mitral stenosis b. Pulmonary edema c. Ischemia d. Pericarditis

B Tall, peaked P waves occur in right atrial hypertrophy and are referred to as P pulmonale because this condition is often the result of chronic pulmonary disease. Ischemia occurs when the delivery of oxygen to the tissues is insufficient to meet metabolic demand. Cardiac ischemia in an unstable form occurs because of a sudden decrease in supply, such as when the artery is blocked by a thrombus or when coronary artery spasm occurs. If the pulmonary edema is caused by heart failure, sometimes described as hydrostatic pulmonary edema, the fluid may be in a "bat-wing" distribution, with the white areas concentrated in the hilar region (origin of the major pulmonary vessels). However, as the heart failure progresses, the quantity of fluid in the alveolar spaces increases, and the white, fluffy appearance is seen throughout the lung. Pericarditis is inflammation of the sac around the heart.

What does the P wave component of the electrocardiographic waveform represent? a. Atrial contraction b. Atrial depolarization c. Sinus node discharge d. Ventricular contraction

B The P wave is an electrical event and represents atrial depolarization. Atrial contraction should accompany the P wave but does not always. The sinus node discharge is too faint to be recorded on the surface electrocardiogram. Ventricular contraction usually accompanies the QRS complex

Which portion of the electrocardiogram (ECG) is most valuable in diagnosing atrioventricular (AV) conduction disturbances? a. P wave b. PR interval c. QRS complex d. QT interval

B The PR interval is an indicator of atrioventricular nodal function. The P wave represents atrial depolarization. The QRS complex represents ventricular depolarization, corresponding to phase 0 of the ventricular action potential. The QT interval is measured from the beginning of the QRS complex to the end of the T wave and indicates the total time interval from the onset of depolarization to the completion of repolarization.

A patient is admitted with left-sided heart failure related to mitral stenosis. Physical assessment findings reveal tachycardia with an S3 and a 3/6 systolic murmur. Which statement about an S3 is accurate? a. It is normal for a person this age. b. It is synonymous with a ventricular gallop. c. It is only heard during systole. d. It is best heard best with the diaphragm of the stethoscope.

B The abnormal heart sounds are labeled the third heart sound (S3) and the fourth heart sound (S4) and are referred to as gallops when auscultated during an episode of tachycardia. Not unexpectedly, the development of an S3 heart sound is strongly associated with elevated levels of brain natriuretic peptide.

The atrioventricular (AV) node delays the conduction impulse from the atria (0.8-1.2 seconds) for what reasons? a. To limit the amount of blood that fills the ventricle from the atria b. To provide time for the ventricles to fill during diastole c. To limit the number of signals the ventricles receive in some rhythms d. To allow the atria to rest between signals

B The atrioventricular (AV) node delays the conduction impulse from the atria (0.8-1.2 seconds) to provide time for the ventricles to fill during diastole.

A patient presents with atrial flutter with an atrial rate of 280 beats/min and a ventricular rate of 70 beats/min. Which statement best explains this discrepancy in rates? a. The ventricles are too tired to respond to all the atrial signals. b. The atrioventricular (AV) node does not conduct all the atrial signals to the ventricles. c. Some of the atrial beats are blocked before reaching the AV node. d. The ventricles are responding to a ventricular ectopic pacemaker.

B The atrioventricular (AV) node does not allow conduction of all these impulses to the ventricles. In this case, the rhythm would be described as atrial flutter with a 4:1 AV block, indicating that only one of every four atrial signals is conducted to the ventricles.

Which mechanism is responsible for the augmentation of coronary arterial blood flow and increased myocardial oxygen supply seen with the intraaortic balloon pump? a. The vacuum created in the aorta as a result of balloon deflation b. Diastolic inflation with retrograde perfusion c. Forward flow to the peripheral circulation d. Inflation during systole to augment blood pressure

B The blood volume in the aorta below the level of the balloon is propelled forward toward the peripheral vascular system, which may enhance renal perfusion. Subsequently, the deflation of the balloon just before the opening of the aortic valve creates a potential space or vacuum in the aorta, toward which blood flows unimpeded during ventricular ejection. This decreased resistance to left ventricular ejection, or decreased afterload, facilitates ventricular emptying and reduces myocardial oxygen demands.

Depolarization of one myocardial cell will likely result in what physiologic response? a. Completion of the action potential in that cell before a new cell can accept an impulse b. Quick depolarization and spread to all of the heart c. Depolarization of only cells superior to the initial depolarization d. Quick depolarization of only cells inferior to the initial depolarization

B The cardiac muscle is a functional syncytium in which depolarization started in any cardiac cell is quickly spread to all of the heart.

Which description best describes the pain associated with aortic dissection? a. Substernal pressure b. Tearing in the chest, abdomen, or back c. Numbness and tingling in the left arm d. Stabbing in the epigastric area

B The classic clinical presentation is the sudden onset of intense, severe, tearing pain, which may be localized initially in the chest, abdomen, or back. As the aortic tear (dissection) extends, pain radiates to the back or distally toward the lower extremities. Many patients have hypertension upon initial presentation, and the focus is on control of blood pressure and early operation.

Which step of impulse conduction is most conducive to atrial kick? a. The firing of the sinoatrial node, which results in atrial depolarization b. The conduction delay at the atrioventricular (AV) node, allowing time for filling c. Conduction through the bundle of His, enhancing ventricular depolarization d. Conduction to the Purkinje fibers, allowing for ventricular contraction

B The conduction delay at the atrioventricular (AV) node allows adequate time for ventricular filling from atrial contraction.

Which statement expresses the correct order when working with an invasive pressure monitor? a. Level the transducer, locate the phlebostatic axis, zero the transducer, and take the reading. b. Locate the phlebostatic axis, level the transducer, zero the transducer, and take the reading. c. Take the reading, level the transducer, locate the phlebostatic axis, and zero the transducer. d. Locate the phlebostatic axis, zero the transducer, level the transducer, and take the reading.

B The correct order is locate the phlebostatic axis, level the transducer, zero the transducer, and take the reading. The transducer cannot be zeroed before it is leveled. Readings cannot be taken before the transducer is zeroed, and leveling the transducer cannot occur until the phlebostatic axis has been identified.

What is the major factor influencing the patient's response to atrial flutter? a. Atrial rate b. Ventricular response rate c. PR interval d. QRS duration

B The major factor underlying atrial flutter symptoms is the ventricular response rate. If the atrial rate is 300 and the atrioventricular (AV) conduction ratio is 4:1, the ventricular response rate is 75 beats/min and should be well tolerated. If, on the other hand, the atrial rate is 300 beats/min but the AV conduction ratio is 2:1, the corresponding ventricular rate of 150 beats/min may cause angina, acute heart failure, or other signs of cardiac decompensation.

When analyzing the electocardiogram (ECG) strip of the patient with a pacemaker, the nurse notices there is a spike before each QRS complex. What is this phenomenon indicative of? a. 60-cycle electrical interference; check equipment b. Pacing artifact; the pacemaker is sensing and capturing c. Electrical artifact; the pacemaker is not sensing d. Patient movement; check electrodes

B The pacing artifact is the spike that is seen on the electrocardiographic tracing as the pacing stimulus is delivered to the heart. A P wave is visible after the pacing artifact if the atrium is being paced. Similarly, a QRS complex follows a ventricular pacing artifact. With dual-chamber pacing, a pacing artifact precedes both the P wave and the QRS complex.

Which criteria are representative of the patient in normal sinus rhythm? a. Heart rate, 64 beats/min; rhythm regular; PR interval, 0.10 second; QRS, 0.04 second b. Heart rate, 88 beats/min; rhythm regular; PR interval, 0.18 second; QRS, 0.06 second c. Heart rate, 54 beats/min; rhythm regular; PR interval, 0.16 second; QRS, 0.08 second d. Heart rate, 92 beats/min; rhythm irregular; PR interval, 0.16 second; QRS, 0.04 second

B The parameters for normal sinus rhythm are heart rate, 60 to 100 beats/min; rhythm, regular; PR interval, 0.12 to 0.20 second; and QRS, 0.06 to 0.10 second.

A patient with a potassium level of 2.8 mEq/L is given 60 mEq over a 12-hour period. A repeat potassium level is obtained, and the current potassium level is 3.2 mEq/L. In addition to administering additional potassium supplements, what intervention should now be considered? a. Discontinue spironolactone b. Drawing a serum magnesium level c. Rechecking the potassium level d. Monitoring the patient's urinary output

B The patient should have serum magnesium level drawn. Hypomagnesemia is commonly associated with other electrolyte imbalances, most notably alterations in potassium, calcium, and phosphorus. Low serum magnesium levels can result from many causes.

The possibility of microshock when handling a temporary pacemaker can be minimized by which intervention? a. Decreasing the milliamperes b. Wearing gloves c. Positioning the patient on the left side d. Wearing rubber-soled shoes

B The possibility of "microshock" can be minimized by wearing gloves when handling the pacing wires and by proper insulation of terminal pins of pacing wires when they are not in use. The latter can be accomplished either by using caps provided by the manufacturer or by improvising with a plastic syringe or section of disposable rubber glove. The wires are to be taped securely to the patient's chest to prevent accidental electrode displacement.

A patient reports that he has been having "indigestion" for the last few hours. Upon further review the nurse suspects the patient is having of chest pain. Cardiac biomarkers and a 12-lead electrocardiogram (ECG) are done. What finding is most significant in diagnosing an acute coronary syndrome (ACS) within the first 3 hours? a. Inverted T waves b. Elevated troponin I c. Elevated B-type natriuretic peptide (BNP) d. Indigestion and chest pain

B The troponins are biomarkers for myocardial damage. The elevation of Troponin I and troponin T occurs 3 to 6 hours after acute myocardial damage. Because troponin I is found only in cardiac muscle, it is a highly specific biomarker for myocardial damage. B-type natriuretic peptide (BNP) are usually drawn when heart failure is suspected, not acute coronary syndrome (ACS). Usually within 4 to 24 hours from the onset of the infarction, abnormal Q waves begin to develop in the affected leads, and T waves begin to invert.

What dysrhythmia is most frequently associated with sudden cardiac death? a. Premature ventricular contractions b. Ventricular tachycardia c. Third degree heart block d. Asystole

B When the onset of symptoms is rapid, the most likely mechanism of death is ventricular tachycardia, which degenerates into ventricular fibrillation.

Which electrocardiographic (ECG) abnormality is most often found in ventricular dysrhythmias? a. Retrograde P waves b. Wide QRS complexes c. No P waves d. An inverted T wave

B icular dysrhythmias result from an ectopic focus in any portion of the ventricular myocardium. The usual conduction pathway through the ventricles is not used, and the wave of depolarization must spread from cell to cell. As a result, the QRS complex is prolonged and is always greater than 0.12 second. It is the width of the QRS, not the height that is important in the diagnosis of ventricular ectopy.

Which signs and symptoms would indicate successful reperfusion after administration of a fibrinolytic agent? (Select all that apply.) a. Gradual decrease in chest pain b. Intermittent, multifocal premature ventricular contractions c. Rapid resolution of ST elevation d. Rapid rise in creatine kinase MB fraction

B, C, D A reliable indicator of reperfusion is the appearance of various "reperfusion" dysrhythmias such as premature ventricular contractions, bradycardia, heart block, and ventricular tachycardia. Rapid resolution of the previously elevated ST segment should occur. The serum concentration of creatine kinase rises rapidly and markedly, a phenomenon termed washout.

Nursing interventions after angioplasty would include which of the following? (Select all that apply.) a. Elevating the head of the bed to 45 degrees b. Hydration as a renal protection measure c. Assessing pedal pulses on the involved limb every 15 minutes for the first 2 hours after the procedure d. Monitoring the vascular hemostatic device for signs of bleeding e. Educating the patient on the necessity of staying supine for 1 to 2 hours after the procedure

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.

Which patients would be a candidate for fibrinolytic therapy? (Select all that apply.) a. The patient's chest pain started 8 hours ago. She has a diagnosis of non-ST-elevation myocardial infarction (NSTEMI). b. The patient's chest pain started 3 hours ago, and her electrocardiogram (ECG) shows a new left bundle branch block. c. The patient presents to the emergency department with chest pain of 30 minutes' duration. She has a history of cerebrovascular accident 1 month ago. d. The patient has a history of unstable angina. He has been experiencing chest pain with sudden onset. e. The patient's chest pain started 1 hour ago, and his ECG shows ST elevation.

B, E Eligibility criteria for administering fibrinolytics include chest pain of less than 12 hours' duration and persistent ST elevation. Exclusion criteria include recent surgery, cerebrovascular accident, and trauma.

Why is the measurement of the QT interval important? a. It facilitates rhythm identification and is best assessed in Lead II. b. It helps differentiate myocardial ischemia from infarction. c. An increasing QT interval increases the risk of torsades de pointes. d. A decreasing QT interval increases the risk of torsades de pointes

C A prolonged QT interval is significant because it can predispose the patient to the development of polymorphic ventricular tachycardia, known also as torsades de pointes. A long QT interval can be congenital, as a result of genetic inheritance, or it can be acquired from an electrolyte imbalance or medications.

Which of the electrocardiogram (ECG) findings would be positive for an inferior wall myocardial infarction (MI)? a. ST segment depression in leads I, aVL, and V2 to V4 b. Q waves in leads V1 to V2 c. Q waves in leads II, III, and aVF d. T-wave inversion in leads V4 to V6, I, and aVL

C Abnormal Q waves develop in leads overlying the affected area. An inferior wall infarction is seen with changes in leads II, III, and aVF. Leads I and aVF are selected to detect a sudden change in ventricular axis. If ST segment monitoring is required, the lead is selected according to the area of ischemia. If the ischemic area is not known, leads V3 and III are recommended to detect ST segment ischemia.

What is the effect of preload on cardiac output? a. As preload increases, cardiac output increases. b. As preload increases, cardiac output decreases. c. As preload increases, cardiac output increases until it overstretches the ventricle and cardiac output decreases. d. Increased preload has no effect on cardiac output.

C According to the Frank-Starling law of the heart, if preload increases stroke volume, then cardiac output may increase. If, however, preload causes excessive left ventricular stretch, it can actually decrease cardiac output and may result in congestive heart failure.

A patient presents with severe substernal chest pain. The patient exclaims, "This is the most severe pain I have ever felt!" The patient reports that the pain came on suddenly about 2 hours ago and that three sublingual nitroglycerin tablets have not relieved the pain. The 12-lead electrocardiogram (ECG) reveals only the following abnormalities: T-wave inversion in leads I, aVL, V4, and V5; pathologic Q waves in leads II, III, and aVF; ST segment elevation in leads V1, V2, V3, and V4. Which statement is accurate about this patient? a. This patient has an old lateral wall infarction. b. This patient is having an inferior wall infarction. c. This patient is having an acute anterior wall infarction. d. This patient is having a posterior wall infarction.

C Acute anterior wall infarctions are manifested by electrocardiographic (ECG) changes in leads V2 to V4. Inferior infarctions are manifested by ECG changes in leads II, III, and aVF. Lateral wall infarctions are manifested by ECG changes in leads V5 to V6, I, and aVL. Posterior wall infarctions are manifested by ECG changes in leads V1 to V2.

After a myocardial infarction, a patient presents with an increasing frequency of premature ventricular contractions (PVCs). The patient's heart rate is 110 beats/min, and electrocardiogram (ECG) indicates a sinus rhythm with up to five unifocal PVCs per minute. The patient is alert and responsive and denies any chest pain or dyspnea. What action should the nurse take next? a. Administer lidocaine 100 mg bolus IV push stat. b. Administer Cardizem 20 mg IV push stat. c. Notify the physician and monitor the patient closely. d. Nothing; PVCs are expected in this patient.

C Although premature ventricular contractions (PVCs) are frequently present after myocardial infarction, they are not always benign. In individuals with underlying heart disease, PVCs or episodes of self-terminating ventricular tachycardia (VT) are potentially malignant. Nonsustained VT is defined as three or more consecutive premature ventricular beats at a rate faster than 110 beats/min lasting less than 30 seconds. The patient does not appear symptomatic from the PVCs at this time; therefore, lidocaine is not indicated. Cardizem is not prescribed for ventricular ectopy.

To accurately measure the heart rate of a patient in normal sinus rhythm, which technique would be the most accurate? a. The number of R waves in a 6-second strip b. The number of large boxes in a 6-second strip c. The number of small boxes between QRS complexes divided into 1500 d. The number of large boxes between consecutive R waves divided into 300

C Calculation of heart rate if the rhythm is regular may be done using the following methods. Method 1: number of RR intervals in 6 seconds multiplied by 10 (eg, 8 × 10 = 80/min). Method 2: number of large boxes between QRS complexes divided into 300 (eg, 300 ÷ 4 = 75/min). Method 3: number of small boxes between QRS complexes divided into 1500 (eg, 1500 ÷ 18 = 84/min).

What characteristic is associated with junctional escape rhythms? a. Irregular rhythm b. Rate greater than 100 beats/min c. P wave may be present or absent d. QRS greater than 0.10 seconds

C Characteristics of a junctional escape rhythm include a rate of 40 to 60 beats/min, regular rhythm, present or absent P waves, PR less than 0.12 seconds, and QRS between 0.06 and 0.10 seconds.

Which diagnostic test is most effective for measuring overall heart size? a. 12-lead electrocardiography b. Echocardiography c. Chest radiography d. Vectorcardiography

C Chest radiography is the oldest noninvasive method for visualizing images of the heart, and it remains a frequently used and valuable diagnostic tool. Information about cardiac anatomy and physiology can be obtained with ease and safety at a relatively low cost. Radiographs of the chest are used to estimate the cardiothoracic ratio and measure overall heart size.

A patient was admitted 3 days ago with an acute myocardial infarction (MI). The patient complains of fatigue, not sleeping the past two nights, and change in appetite. Based on these findings the nurse suspects the patient may be experiencing which problem? a. Angina b. Anxiety c. Depression d. Endocarditis

C Depression is a phenomenon that occurs across a wide spectrum of human experience. Key symptoms of depression mentioned frequently by cardiac patients are fatigue, change in appetite, and sleep disturbance.

What is the rationale for giving the patient additional fluids after a cardiac catheterization? a. Fluids help keep the femoral vein from clotting at the puncture site. b. The patient had a nothing-by-mouth order before the procedure. c. The radiopaque contrast acts as an osmotic diuretic. d. Fluids increase cardiac output.

C Fluid is given for rehydration because the radiopaque contrast acts as an osmotic diuretic. Fluid is also used to prevent contrast-induced nephropathy or damage to the kidney from the contrast dye used to visualize the heart structures

A patient is admitted with a diagnosis of "rule out myocardial infarction." The patient reports midchest pressure radiating into the jaw and shortness of breath when walking up stairs. What factor influences the amount of history obtained during the admission assessment? a. Presence of cardiovascular risk factors b. Prior medical history c. Presenting symptoms d. Current medications

C For a patient in acute distress, the history taking is shortened to just a few questions about the patient's chief complaint, precipitating events, and current medications. For a patient who is not in obvious distress, the history focuses on the following four areas: review of the patient's present illness; overview of the patient's general car ral health status, including family history of coronary artery disease (CAD), hypertension, diabetes, peripheral arterial disease, or stroke; and survey of the patient's lifestyle, including risk factors for CAD.

A patient has an implantable cardioverter defibrillator (ICD) for chronic ventricular tachydysrhythmias. What action should the nurse take when the patient's rhythm deteriorates to ventricular fibrillation? a. Apply an external defibrillator to the patient. b. Call a code and start cardiopulmonary resuscitation (CPR) on the patient. c. Wait for the ICD to defibrillate the patient. d. Turn the ICD off and administer epinephrine.

C If the dysrhythmia deteriorates into ventricular fibrillation, the implantable cardioverter defibrillator is programmed to defibrillate at a higher energy. If the dysrhythmia terminates spontaneously, the device will not discharge.

A patient becomes unresponsive. The patient's heart rate is 32 beats/min in an idioventricular rhythm; blood pressure is 60/32 mm Hg; SpO2 is 90%; and respiratory rate is 14 breaths/min. Which intervention would the nurse do first? a. Notify the physician and hang normal saline wide open. b. Notify the physician and obtain the defibrillator. c. Notify the physician and obtain a temporary pacemaker. d. Notify the physician and obtain a 12-lead ECG.

C If the sinus node and the atrioventricular (AV) junction fail, the ventricles depolarize at their own intrinsic rate of 20 to 40 times per minute. This is called an idioventricular rhythm and is naturally protective mechanism. Rather than trying to abolish the ventricular beats, the aim of treatment is to increase the effective heart rate (HR) and reestablish dominance of a higher pacing site such as the sinus node or the AV junction. Usually, a temporary pacemaker is used to increase the HR until the underlying problems that caused failure of the other pacing sites can be resolved.

Most chest radiographs of critically ill patients are obtained using a portable chest radiograph machine. What is the difference between a chest radiograph taken in the radiology department and one taken in the critical care unit? a. Portable chest radiographs are usually clearer. b. Only posterior views can be obtained in the critical care unit. c. The sharpness of the structures is decreased with a portable chest radiograph. d. Chest radiographs taken in radiology enlarge some thoracic structures.

C In the supine radiograph with the patient lying flat on the bed, the x-ray tube can be only approximately 36 inches from the patient's chest because of ceiling height and x-ray equipment construction. This results in a lower quality film from a diagnostic standpoint because the images of the heart and great vessels are magnified and are not as sharply defined.

A patient is admitted with a fever of unknown origin. The patient is complaining of fatigue, malaise, joint pain, and shivering. The patient's vital signs include temperature, 103° F; heart rate, 90 beats/min; respiratory rate, 22 breaths/min; blood pressure, 132/78; and oxygen saturation, 94% on 2L nasal cannula. The patient has developed a cardiac murmur. The nurse suspects that the patient has developed which problem? a. Coronary artery disease b. Heart failure c. Endocarditis d. Pulmonary embolus

C Initial symptoms include fever, sometimes accompanied by rigor (shivering), fatigue, and malaise, with up to 50% of patients complaining of myalgias and joint pain. Blood cultures are drawn during periods of elevated temperature.

A patient has been newly diagnosed with stable angina. He tells the nurse he knows a lot about his diagnosis already because his father had the same diagnosis 15 years ago. The nurse asks him to state what he already knows about angina. Which response indicates the need for additional education? a. He should stop smoking. b. He can no longer drink colas or coffee. c. He can no longer get a strong back massage. d. He should take stool softeners to prevent straining.

C Longer term education of the patient and the family can begin. Points to cover include (1) risk factor modification, (2) signs and symptoms of angina, (3) when to call the physician, (4) medications, and (5) dealing with emotions and stress. It is essential to teach avoidance of the Valsalva maneuver, which is defined as forced expiration against a closed glottis. This can be explained to the patient as "bearing down" during defecation or breath holding when repositioning in bed. Relaxation therapy and techniques including back rubs are encouraged when appropriate.

Which noninvasive imaging technique is useful in diagnosing complications of a myocardial infarction (MI)? a. 12-lead ECG b. CT c. MRI d. Echocardiography

C Magnetic resonance imaging is useful in diagnosing complications of myocardial infarction, such as pericarditis or pericardial effusion, valvular dysfunction, ventricular septal rupture, aneurysm, and intracardiac thrombus. Computed tomography is used to calculate the coronary artery calcium score. Echocardiography uses ultrasound reflected best at interfaces between tissues that have different densities. In the heart, these are the blood, cardiac valves, myocardium, and pericardium. Because all these structures differ in density, their borders can be seen on the echocardiogram. The standard 12-lead electrocardiogram provides a picture of electrical activity in the heart using 10 different electrode positions to create 12 unique views of electrical activity occurring within the heart.

A patient is admitted with an acute myocardial infarction (MI). What common complication should the nurse anticipate in this patient? a. Pulmonary edema b. Cardiogenic shock c. Dysrhythmias d. Deep vein thrombosis

C Many patients experience complications occurring either early or late in the postinfarction course. These complications may result from electrical dysfunction or from a cardiac contractility problem. Cardiac monitoring for early detection of ventricular dysrhythmias is ongoing. Pumping complications can cause heart failure, pulmonary edema, and cardiogenic shock. The presence of a new murmur in a patient with an acute myocardial infarction warrants special attention because it may indicate rupture of the papillary muscle. The murmur can be indicative of severe damage and impending complications such as heart failure and pulmonary edema.

The nursing management plan for a patient with angina would include which intervention? a. Immediate administration of antiplatelet therapy b. Teaching the patient how to perform the Valsalva maneuver c. Assessment and documentation of chest pain episodes d. Administration of prophylactic lidocaine for ventricular ectopy

C Nursing interventions focus on early identification of myocardial ischemia, control of chest pain, recognition of complications, maintenance of a calm environment, and patient and family education. It is important to document the characteristics of the pain and the patient's heart rate and rhythm, blood pressure, respirations, temperature, skin color, peripheral pulses, urine output, mentation, and overall tissue perfusion. It is essential to teach avoidance of the Valsalva maneuver, which is defined as forced expiration against a closed glottis.

Assessment of a patient with pericarditis may reveal which signs and symptoms? a. Ventricular gallop and substernal chest pain b. Narrowed pulse pressure and shortness of breath c. Pericardial friction rub and pain d. Pericardial tamponade and widened pulse pressure

C Pain is the most common symptom of pericarditis, and a pericardial friction rub is the most common initial sign. A friction rub is best auscultated with a stethoscope at the sternal border and is described as a grating, scraping, or leathery scratching. Pericarditis frequently produces a pericardial effusion.

The nurse is caring for a patient with left-sided heart failure. The nurse suspects the patient is developing pulmonary edema. Which finding would confirm the nurse's suspicions? a. Pulmonary crackles b. Peripheral edema c. Pink, frothy sputum d. Elevated central venous pressure

C Patients experiencing heart failure and pulmonary edema are extremely breathless and anxious and have a sensation of suffocation. They expectorate pink, frothy sputum and feel as if they are drowning. They may sit bolt upright, gasp for breath, or thrash about. The respiratory rate is elevated, and accessory muscles of ventilation are used, with nasal flaring and bulging neck muscles. Respirations are characterized by loud inspiratory and expiratory gurgling sounds.

When checking the patient's back, the nurse pushes her thumb into the patient's sacrum. An indentation remains. What assessment finding should the nurse document? a. Sacral compromise b. Delayed skin turgor c. Pitting edema d. Dehydration

C Pitting edema occurs when an impression is left in the tissue when the thumb is removed. The dependent tissues within the legs and sacrum are particularly susceptible. Edema may be dependent, unilateral, or bilateral and pitting or nonpitting.

A patient's blood pressure is 90/72 mm Hg. What is the patient's pulse pressure? a. 40 mm Hg b. 25 mm Hg c. 18 mm Hg d. 12 mm Hg

C Pulse pressure describes the difference between systolic and diastolic values. The normal pulse pressure is 40 mm Hg (ie, the difference between an SBP of 120 mm Hg and a DBP of 80 mm Hg). A patient with a blood pressure of 90/72 mm Hg has a pulse pressure of 18 mm Hg.

Which statement about coronary artery disease (CAD) is accurate? a. There is a low correlation between modifiable risk factors and CAD. b. The onset of CAD occurs in middle age women sooner than men of the same age. c. There is an association between development of specific risk factors and CAD. The lower the C-reactive protein level the higher the risk for a coronary event.

C Research and epidemiologic data collected during the past 50 years have demonstrated a strong association between specific risk factors and the development of coronary artery disease (CAD). In general, CAD symptoms are seen in persons age 45 years and older. Primary cardiovascular risk factors are different in men and women, with women having higher rates of diabetes and hypertension compared with men. C-reactive protein (CRP) is associated with an increased risk for development of other cardiovascular risk factors including diabetes, hypertension, and weight gain. The higher the value, the greater the risk of a coronary event, especially if all other potential causes of systemic inflammation such as infection can be ruled out.

A patient is admitted with a diagnosis of "rule out myocardial infarction." The patient reports midchest pressure radiating into the jaw and shortness of breath when walking up stairs. When inspecting the patient, the nurse notes that the patient needs to sit in a high Fowler position to breathe. The nurse suspects the patient may be experiencing what problem? a. Pericarditis b. Anxiety c. Heart failure d. Angina

C Sitting upright to breathe may be necessary for the patient with acute heart failure, and leaning forward may be the least painful position for a patient with pericarditis

What is the name of outermost layer of an artery? a. Tunica b. Intima c. Adventitia d. Media

C The adventitia is the outermost layer of the artery that helps strengthen and shape the vessel. The media is the middle layer that is made up of smooth muscle and elastic tissue. The intima is the innermost layer consists of a thin lining of endothelium and a small amount of elastic tissue.

Which phase is the final repolarization phase of the action potential? a. Phase 1 b. Phase 2 c. Phase 3 d. Phase 4

C The final repolarization phase is phase 3 of the action potential. Phases 1 and 2 (partial repolarization) occur as the AP slope returns toward zero. The plateau that follows is described as phase 2. In phase 4 the AP returns to an RMP of -80 to -90 mV.

A 55-year-old patient is scheduled for a stress test. What is the estimation of the patient's maximal predicted heart rate? a. 65 beats/min b. 155 beats/min c. 165 beats/min d. 265 beats/min

C The maximal predicted heart rate is estimated using the formula: 220 - Patient's age: 220 - 55 = 165.

What is the formula for calculating mean arterial pressure (MAP)? a. Averaging three of the patient's blood pressure readings over a 6-hour period b. Dividing the systolic pressure by the diastolic pressure c. Adding the systolic pressure and two diastolic pressures and then dividing by 3 d. Dividing the diastolic pressure by the pulse pressure

C The mean arterial pressure is one-third systole and two-thirds diastole.

What is the most common complication of fibrinolytic therapy? a. Reperfusion chest pain b. Lethargy c. Bleeding d. Heart blocks

C The most common complication related to thrombolysis is bleeding.

A patient is admitted for palliative care for end-stage heart failure. What is the nurse's primary goal when caring for this patient? a. To reverse heart failure with the use of diuretics b. To increase activity tolerance c. To manage symptoms and relieve pain d. To increase cardiac output related to alteration of contractility

C The primary aim of palliative care is symptom management and the relief of suffering. Fundamental to all symptom management strategies for heart failure is the optimization of medications, according to current guidelines.

A patient is connected to an external temporary pulse generator. What does the sensitivity control regulate? a. The time interval between the atrial and ventricular pacing stimuli b. The amount of electrical current and is measured in milliamperes c. The ability of the pacemaker to detect the heart's intrinsic electrical activity d. The number of impulses that can be delivered to the heart per minute

C The sensitivity control regulates the ability of the pacemaker to detect the heart's intrinsic electrical activity. Sensitivity is measured in millivolts (mV) and determines the size of the intracardiac signal that the generator will recognize.

When performing a 12-lead electrocardiogram (ECG), how many wires are connected to the patient? a. 3 b. 5 c. 10 d. 12

C The standard 12-lead electrocardiogram provides a picture of electrical activity in the heart using 10 different electrode positions to create 12 unique views of electrical activity occurring within the heart. Fours wires are applied to the extremities to produce leads I, II, III, aVR, aVL, and aVF. Six wires are attached to the V1 to V6 chest lead positions.

The nurse developing a patient education plan for the patient with endocarditis. What information would be included in the plan? a. Endocarditis is a viral infection that is easily treated with antibiotics. b. The risk of this diagnosis is occlusion of the coronary arteries. c. A long course of antibiotics is needed to treat this disorder. d. Complications are rare after antibiotics have been started

C Treatment requires prolonged IV therapy with adequate doses of antimicrobial agents tailored to the specific infective endocarditis microbe and patient circumstances. Antibiotic treatment is prolonged, administered in high doses intravenously, and may involve combination therapy. Best outcomes are achieved if therapy is initiated before hemodynamic compromise.

A patient with coronary artery disease (CAD) is admitted with chest pain. The patient is suddenly awakened with severe chest pain. Three nitroglycerin sublingual tablets are administered 5 minutes apart without relief. A 12-lead electrocardiograph (ECG) reveals nonspecific ST segment elevation. The nurse suspects the patient may have which disorder? a. Silent ischemia b. Stable angina c. Unstable angina d. Prinzmetal angina

C Unstable angina usually is more intense than stable angina, may awaken the person from sleep, or may necessitate more than nitrates for pain relief. A change in the level or frequency of symptoms requires immediate medical evaluation. Severe angina that persists for more than 5 minutes, worsens in intensity, and is not relieved by one nitroglycerin tablet is a medical emergency. Stable angina is predictable and caused by similar precipitating factors each time; typically, it is exercise induced. Patients become used to the pattern of this type of angina and may describe it as "my usual chest pain." Pain control should be achieved within 5 minutes of rest and by taking sublingual nitroglycerin. Silent ischemia describes a situation in which objective evidence of ischemia is observed on an electrocardiographic monitor but the person does not complain of anginal symptoms. Variant unstable angina, or Prinzmetal angina, is caused by a dynamic obstruction from intense vasoconstriction of a coronary artery. Spasm can occur with or without atherosclerotic lesions. Variant angina commonly occurs when the individual is at rest, and it is often cyclic, occurring at the same time every day.

Why are vasopressors used cautiously in the treatment of critical care patients? a. They cause vasoconstriction of the smooth muscles. b. They cause vasodilation of the smooth muscles. c. They increase afterload. d. They decrease preload.

C Vasopressors are not widely used in the treatment of critically ill cardiac patients because the dramatic increase in afterload is taxing to a damaged heart. Vasopressin, also known as antidiuretic hormone, has become popular in the critical care setting for its vasoconstrictive effects. At higher doses, vasopressin directly stimulates V1 receptors in vascular smooth muscle, resulting in vasoconstriction of capillaries and small arterioles.

A patient was admitted with of acute myocardial infarction. Upon auscultation, the nurse hears a harsh, holosystolic murmur along the left sternal border. The nurse notifies the physician immediately because the symptoms indicate the patient has developed what complication? a. Papillary muscle rupture b. Tricuspid stenosis c. Ventricular septal rupture d. Pericarditis

C Ventricular septal rupture is a new opening in the septum between the two ventricles. It creates a harsh, holosystolic murmur that is loudest (by auscultation) along the left sternal border. Papillary muscle rupture is auscultation of a new, high-pitched, holosystolic, blowing murmur at the cardiac apex. Tricuspid stenosis is a quiet murmur that becomes louder with inspiration and is located in the epigastrium area. A pericardial friction rub is a sound that can occur within 2 to 7 days after a myocardial infarction. The friction rub results from pericardial inflammation (pericarditis). Classically, a pericardial friction rub is a grating or scratching sound that is both systolic and diastolic, corresponding to cardiac motion within the pericardial sac.

A nurse palpates the descending aorta and feels a strong, bounding pulse. The nurse reports the findings to the physician because this result is suggestive of what disorder? a. Decreased cardiac output b. Increased cardiac output c. An aneurysm d. Aortic insufficiency

C When the patient is in the supine position, the abdominal aortic pulsation is located in the epigastric area and can be felt as a forward movement when firm fingertip pressure is applied above the umbilicus. An abnormally strong or bounding pulse suggests the presence of an aneurysm or an occlusion distal to the examination site. If it is prominent or diffuse, the pulsation may indicate an abdominal aneurysm. A diminished or absent pulse may indicate low cardiac output (CO), arterial stenosis, or occlusion proximal to the site of the examination.

A patient is admitted with right- and left-sided heart failure. The nurse's assessment reveals that the patient has 3+ pitting edema on the sacrum, blood pressure of 176/98 mm Hg, and bilateral crackles in the lungs. The patient is experiencing shortness of breath and chest discomfort. On the basis of this information, how would the nurse evaluate the patient's preload status? a. The patient is hypovolemic and has too little preload. b. The patient is experiencing congestive heart failure (CHF) and has too little preload. c. The patient is experiencing heart failure and has too much preload. d. The patient is hypertensive and the preload is not a factor.

C Whereas a patient with hypovolemia has too little preload, a patient with heart failure has too much preload.

Which structure is the primary or natural pacemaker of the heart? a. Ventricular tissue b. Atrioventricular node c. Sinoatrial node d. Purkinje fibers

C With an intrinsic rate of 60 to 100 beats/min, the sinoatrial node is the primary pacemaker in a healthy heart. The atrioventricular node beats 40 to 60 beats/min. Ventricular tissue must have an electrical impulse to contract. Purkinje fibers beat 15 to 40 beats/min.

A patient was admitted 3 days ago with a myocardial infarction. The patient is complaining of increased chest pain when coughing, swallowing, and changing positions. The nurse hears a systolic scratching sound upon auscultation of the apical pulse. Based on the symptoms, the nurse suspects the patient may have developed what condition? a. Acute mitral regurgitation b. Aortic insufficiency c. Chronic mitral regurgitation d. Pericarditis

D A pericardial friction rub is a sound that can occur within 2 to 7 days after a myocardial infarction. The friction rub results from pericardial inflammation (pericarditis). Classically, a pericardial friction rub is a grating or scratching sound that is both systolic and diastolic, corresponding to cardiac motion within the pericardial sac. Acute mitral regurgitation occurs when the ventricle contracts during systole and a jet of blood is sent in a retrograde manner to the left atrium, causing a sudden increase in left atrial pressure, acute pulmonary edema, and low cardiac output (CO) and leading to cardiogenic shock. Chronic mitral regurgitation is auscultated in the mitral area and occurs during systole. It is high pitched and blowing, although the pitch and intensity vary, depending on the degree of regurgitation. As mitral regurgitation progresses, the murmur radiates more widely. Aortic insufficiency is an incompetent aortic valve. If the valve cusps do not maintain this seal, the sound of blood flowing back into the left ventricle during diastole is heard as a decrescendo, high-pitched, blowing murmur.

What is the target range for an international normalized ratio (INR)? a. 1.0 to 2.0 b. 1.5 to 3.0 c. 1.5 to 2.5 d. 2.0 to 3.0

D A target international normalized ratio of 2.5 (range, 2.0 to 3.0) is desirable.

Abnormal heart sounds are labeled S3 and S4 and are referred to as what when auscultated during a tachycardic episode? a. Korotkoff sounds b. Grating murmurs c. Blowing murmurs d. Gallops

D Abnormal heart sounds are known as the third heart sound (S3) and the fourth heart sound (S4); they are referred to as gallops when auscultated during an episode of tachycardia. Murmurs are produced by turbulent flood flow through the chambers of the heart, from forward flow through narrowed or irregular valve openings, or backward regurgitate flow through an incompetent valve. Korotkoff sounds are the sounds created by turbulence of blood flow within a vessel caused by constriction of the blood pressure cuff. Pulse pressure describes the difference between systolic and diastolic values. A normal pulse pressure is 40 mm Hg.

Which value, when elevated, places the patient at lowest risk for coronary artery disease (CAD)? a. Very-low-density lipoproteins (VLDLs) b. Triglycerides c. Low-density lipoproteins (LDLs) d. High-density lipoproteins (HDLs)

D All of the reasons are not completely understood, but one recognized physiologic effect is the ability of high-density lipoprotein (HDL) to promote the efflux of cholesterol from cells. This process may minimize the accumulation of foam cells in the artery wall and thus decrease the risk of developing atherosclerosis. High HDL levels confer both antiinflammatory and antioxidant benefits on the arterial wall. In contrast, a low HDL level is an independent risk factor for the development of CAD and other atherosclerotic conditions.

At what size is an aortic aneurysm evaluated for surgical repair or stent placement? a. 2 cm b. 4 cm c. 5 cm d. >5 cm

D An aneurysm smaller than 4 cm in diameter can be managed on an outpatient basis with frequent blood pressure monitoring and ultrasound testing to document any changes in the size of the aneurysm. control of hypertension as appropriate. An aortic aneurysm larger than 5 cm in diameter requires evaluation for surgical repair or placement of an aortic stent to eliminate the risk of rupture.

A new-onset myocardial infarction (MI) can be recognized by what electrocardiogram (ECG) change? a. Q waves b. Smaller R waves c. Widened QRS d. ST segment elevation

D Any change from baseline is expressed in millimeters and may indicate myocardial ischemia (one small box equals 1 mm). ST segment elevation of 1 to 2 mm is associated with acute myocardial injury, preinfarction, and pericarditis. ST segment depression (decrease from baseline more of 1 to 2 mm) is associated with myocardial ischemia. Widened QRS complexes are indicative of ventricular depolarization abnormalities such as bundle branch blocks and ventricular dysrhythmias. Q waves and smaller R waves are indications usually present 24 hours to 1 week after the myocardial infarction is completely evolved; they represent necrosis.

Evaluation of arterial circulation to an extremity is accomplished by assessing which of the following? a. Homans sign b. Skin turgor c. Peripheral edema d. Capillary refill

D Capillary refill assessment is a maneuver that uses the patient's nail beds to evaluate both arterial circulation to the extremity and overall perfusion. The severity of arterial insufficiency is directly proportional to the amount of time necessary to reestablish flow and color.

ST segment monitoring for ischemia has gained increasing importance with the advent of thrombolytic therapy. What is the most accurate method for monitoring the existence of true ischemic changes? a. Biomarkers b. Echocardiogram c. 5-lead ECG d. 12-lead ECG

D Cardiac biomarkers are proteins that are released from damaged myocardial cells. The initial elevation of cTnI, cTnT, and CK-MB occurs 3 to 6 hours after the acute myocardial damage. This means that if an individual comes to the emergency department as soon as chest pain is experienced, the biomarkers will not have risen. For this reason, it is clinical practice to diagnose an acute myocardial infarction by 12-lead electrocardiography and clinical symptoms without waiting for elevation of cardiac biomarkers.

The patient has a heart rate (HR) of 84 beats/min and a stroke volume (SV) of 65 mL. Calculate the cardiac output (CO). a. 149 mL b. 500 mL c. 4650 mL d. 5460 mL

D Cardiac output (CO) is the product of heart rate (HR) multiplied by stroke volume (SV). SV is the volume of blood ejected by the heart during each beat (reported in milliliters). 84 × 65 = 5460 mL.

What parameter is used to assess the contractility of the left side of the heart? a. Pulmonary artery occlusion pressure b. Left atrial pressure c. Systemic vascular resistance d. Left ventricular stroke work index

D Contractility of the left side of the heart is measured by the left ventricular stroke work index.

Patient is admitted with heart failure. The patient has developed dyspnea with wheezing, a nonproductive cough, and pulmonary crackles that progress to the gurgling sounds of pulmonary edema. The nurse suspects the patient may be developing with problem? a. Dyspnea b. Orthopnea c. Paroxysmal nocturnal dyspnea d. Cardiac asthma

D Dyspnea with wheezing, a nonproductive cough, and pulmonary crackles that progress to the gurgling sounds of pulmonary edema are symptoms of cardiac asthma. With dyspnea, the patient feels shortness of breath from pulmonary vascular congestion and decreased lung compliance. In orthopnea, the patient has difficulty breathing when lying flat because of an increase in venous return that occurs in the supine position. Paroxysmal nocturnal dyspnea is a severe form of orthopnea in which the patient awakens from sleep gasping for air.

A patient is admitted after a positive exercise treadmill test with a diagnosis of coronary artery disease (CAD) and stable angina. Radiographic tests show that the patient has blockage in the left main coronary artery and four other vessels. The nurse anticipates that the patient's treatment plan will include what treatment or procedure? a. Medical therapy b. PCI c. TAVR d. CABG

D Early studies demonstrated coronary artery bypass graft (CABG) surgery was more effective than medical therapy for improving survival in patients with left main or three-vessel coronary artery disease and at relieving anginal symptoms. Medical therapy is recommended if the ischemia is prevented by antianginal medications that are well tolerated by the patient. Surgical revascularization has been shown to be more efficacious than percutaneous coronary intervention (PCI) in patients with multivessel or left main coronary disease. Transcatheter aortic valve replacement (TAVR) is a transformational therapy for patients who have severe aortic stenosis but who are extremely high-risk surgical candidates or who are inoperable by virtue of associated co-morbidities.

The nurse is developing a patient education plan for a patient with valvular heart disease. Which instruction would be included as part of that plan? a. Increase fluid intake to increase cardiac output. b. Take sodium replacement tablets to replace sodium lost with diuretics. c. Increase daily activity until shortness of breath occurs. d. Take prophylactic antibiotics before undergoing any invasive procedure.

D Education for the patient with acute or chronic heart failure secondary to valvular dysfunction includes (1) information related to diet, (2) fluid restrictions, (3) the actions and side effects of heart failure medications, (4) the need for prophylactic antibiotics before undergoing any invasive procedures such as dental work, and (5) when to call the health care provider to report a negative change in cardiac symptoms.

Which condition can cause an artificial increase in the pulmonary artery occlusion pressure (PAOP)? a. Aortic regurgitation b. Aortic stenosis c. Mitral stenosis d. Mitral regurgitation

D If mitral regurgitation is present, the mean pulmonary artery occlusion pressure reading is artificially elevated because of abnormal backflow of blood from the left ventricle to the left atrium during systole.

A patient's central venous pressure (CVP) reading suddenly increased from 10 to 48 mm Hg. His lungs are clear except for fine rales at the bases. What should the nurse do next? a. Nothing as this reading is still within normal limits. b. Place a STAT call into the physician. c. Administer ordered prn Lasix. d. Check the level of the transducer.

D If the transducer falls below the correct level, the reading would be falsely elevated. This rise is consistent with a transducer having fallen from the correct level on the bed to the floor. Lasix is not indicated. Central venous pressure (CVP) of 45 mm Hg, if true, is severely elevated. Not enough information has been provided to call the physician. If the CVP value is true and the patient's condition is poor, a call to the physician would be appropriate after assessment.

What is the normal resting membrane potential of a myocardial cell? a. 10 to 20 mV b. 30 to 40 mV c. -20 to -30 mV d. -80 to -90 mV

D In a myocardial cell, the normal resting membrane potential is -80 to -90 mV.

Which cardiac biomarker is elevated in decompensated heart failure? a. Triglycerides b. Troponin I c. Troponin T d. B-type natriuretic peptide (BNP)

D In decompensated heart failure, ventricular distension from volume overload or pressure overload causes myocytes in the ventricle to release B-type natriuretic peptide (BNP). With greater ventricular wall stress, more natriuretic peptide is released from the myocardium, reflected as an elevated BNP level. The BNP value is combined with the physical examination, the 12-lead ECG, and a chest radiograph to increase the accuracy of heart failure diagnosis. Troponins are elevated with acute coronary syndrome. Triglycerides are not a biomarker and are reflective of lipids in the bloodstream.

What major clinical finding present in a patient with ventricular fibrillation (VF)? a. Hypertension b. Bradycardia c. Diaphoresis d. Pulselessness

D In ventricular fibrillation (VF), the patient does not have a pulse, no blood is being pumped forward, and defibrillation is the only definitive therapy. No forward flow of blood or palpable pulse is present in VF.

Which laboratory value indicates a heightened risk for the development of coronary artery disease (CAD)? a. Total cholesterol level of 170 mg/dL b. HDL cholesterol level of 30 mg/dL c. Triglyceride level of 120 mg/dL d. LDL cholesterol level >190 mg/dL

D Low-density lipoprotein (LDL) cholesterol is usually described as the "bad cholesterol" because high levels are associated with an increased risk of acute coronary syndrome (ACS), stroke, and peripheral arterial disease (PAD). High LDL levels initiate the atherosclerotic process by infiltrating the vessel wall and binding to the matrix of cells beneath the endothelium. Total cholesterol levels below 200 are considered normal. High-density lipoprotein (HDL) cholesterol levels below 40 are at low risk of coronary artery disease. Triglyceride levels below 150 are considered normal.

An 82-year-old patient is admitted into the critical care unit with a diagnosis of left-sided heart failure related to mitral stenosis. Physical assessment findings reveal tachycardia with an S3 and a 3/6 systolic murmur. Which of the following descriptions best describes the murmur heard with mitral stenosis? a. High-pitched systolic sound b. Medium-pitched systolic sound c. High-pitched diastolic sound d. Low-pitched diastolic sound

D Mitral stenosis describes a narrowing of the mitral valve orifice. This produces a low-pitched murmur, which varies in intensity and harshness depending on the degree of valvular stenosis. It occurs during diastole, is auscultated at the mitral area (fifth ICS, midclavicular line), and does not radiate.

A nurse is obtaining the history of a patient who reveals that he had an myocardial infarction (MI) 5 years ago. When the admission 12-lead electrocardiogram (ECG) is reviewed, Q waves are noted in leads V3 and V4 only. Which conclusion is most consistent with this situation? a. The patient may have had a posterior wall MI. b. The patient must have had a right ventricular MI. c. The admission 12-lead ECG was done incorrectly. d. The patient may have had an anterior MI

D Not every acute myocardial infarction (MI) results in a pathologic Q wave on the 12-lead electrocardiogram (ECG). When the typical ECG changes are not present, the diagnosis depends on symptomatic clinical presentation, specific cardiac biomarkers (eg, cTnI, cTnT, CK-MB), and non-ECG diagnostic tests such as cardiac catheterization. Anterior and posterior wall MIs have ST changes, not Q wave changes.

A nurse admits a patient with a diagnosis of syncope of unknown etiology. Orthostatic vital signs are lying: 110/80 mm/Hg; sitting: 100/74 mm/Hg; standing: 92/40 mm/Hg. Based on this information, what should the nurse monitor? a. Respirations b. Fluid intake c. Peripheral pulses d. Activity

D Postural (orthostatic) hypotension occurs when the systolic blood pressure drops by 10 to 20 mm Hg or the diastolic blood pressure drops by 5 mm Hg after a change from the supine posture to the upright posture. This is usually accompanied by dizziness, lightheadedness, or syncope. If a patient experiences these symptoms, it is important to complete a full set of postural vital signs before increasing the patient's activity level.

Which findings would be reasons to abort an exercise stress test? a. Ventricular axis of +90 degrees b. Increase in blood pressure c. Inverted U wave d. ST segment depression or elevation

D Signs that can alert the nurse to stop the test include ST segment elevation equal to or greater than 1.0 mm (one small box) or ST depression equal to or greater than 2.0 mm (2 small boxes). Blood pressure is expected to rise during exercise, but a systolic blood pressure greater than 250 mm Hg or a diastolic blood pressure greater than 115 mm Hg is considered high enough to stop the test. Parameters for ventricular axis in degrees are -30 to +90. Left-axis deviation is present if the axis falls between -30 and -90 degrees.

Which classification of dysrhythmia is most common with an inferior wall infarction in the first hour after ST segment elevation myocardial infarction (STEMI)? a. Sinus tachycardia b. Multifocal PVCs c. Atrial fibrillation d. Sinus bradycardia

D Sinus bradycardia (heart rate less than 60 beats/min) occurs in 30% to 40% of patients who sustain an acute myocardial infarction (MI). It is more prevalent with an inferior wall infarction in the first hour after ST segment elevation MI. Sinus tachycardia (heart rate more than 100 beats/min) most often occurs with an anterior wall MI. Premature atrial contractions (PACs) occur frequently in patients who sustain an acute MI. Atrial fibrillation is also common and may occur spontaneously or may be preceded by PACs. Premature ventricular contractions (PVCs) are seen in almost all patients within the first few hours after an MI.

A patient is admitted with left-sided heart failure and a blood pressure of 220/118 mm Hg. Which drug will be most effective in decreasing the blood pressure and reducing afterload? a. Dopamine b. Verapamil c. Propranolol d. Sodium nitroprusside

D Sodium nitroprusside (Nipride) is a potent, rapidly acting venous and arterial vasodilator, particularly suitable for rapid reduction of blood pressure in hypertensive emergencies and perioperatively. It also is effective for afterload reduction in the setting of severe heart failure. The drug is administered by continuous intravenous infusion, with the dosage titrated to maintain the desired blood pressure and systemic vascular resistance.

A patient has been admitted in hypertensive crisis. Which medication would the nurse expect the practitioner to order for this patient? a. Digitalis b. Vasopressin c. Verapamil d. Sodium nitroprusside

D Sodium nitroprusside is frequently the first drug used to lower blood pressure in hypertensive emergency. Sodium nitroprusside is useful because of its half-life of seconds. It is not suitable for long-term use because of development of a metabolite that causes cyanide-like toxicity. Short-acting beta-blockers that are effective are labetalol and esmolol. Beta-blockers are especially effective if aortic dissection is present. Digoxin is frequently prescribed for atrial fibrillation.

The nurse is caring for a patient with these vital signs: blood pressure 220/110, pulse 108, respiratory rate 24, temperature 103° F, and oxygen saturation of 94% on oxygen 2L nasal cannula. The patient is responsive and denies chest pain. The physician has ordered a work-up for coronary artery disease (CAD). These findings are suggestive of which diagnosis? a. Silent ischemia b. Prehypertension c. Stage 1 hypertension d. Stage 2 hypertension

D Stage 2 hypertension is defined as a systolic blood pressure of 160 mm Hg or above and a diastolic blood pressure of 100 mm Hg or above.

What is the rationale for administrating a fibrinolytic agent to a patient experiencing acute ST-elevation myocardial infarction (STEMI)? a. Dilation of the blocked coronary artery b. Anticoagulation to prevent formation of new emboli c. Dissolution of atherosclerotic plaque at the site of blockage d. Restoration of blood flow via lysis of the thrombus

D The administration of a fibrinolytic agent results in the lysis of the acute thrombus, thus recanalizing, or opening, the obstructed coronary artery and restoring blood flow to the affected tissue. After perfusion is restored, adjunctive measures are taken to prevent further clot formation and reocclusion.

A patient is admitted with an acute inferior myocardial infarction (MI). A 12-lead electrocardiogram (ECG) is done to validate the area of infarction. Which finding on the ECG is most conclusive for infarction? a. Inverted T waves b. Tall, peaked T waves c. ST segment depression d. Pathologic Q waves

D The changes in repolarization are seen by the presence of new Q waves. These new, pathologic Q waves are deeper and wider than tiny Q waves found on the normal 12-lead ECG

Why do many patients with very high heart rates frequently have chest pain and shortness of breath? a. Patients with heart disease frequently have an anxiety disorder as well. b. The rapid pounding of the heart in the chest wall causes the physical pain. c. The heart muscle gets tired from the increased work. d. The decreased diastolic time decreases oxygen delivery to the myocardium

D The coronary arteries are perfused during diastole. When the heart rate increases, the diastolic time decreases as each contraction has less time to be completed. This decreases the time the coronary arteries have to deliver oxygenated blood to the myocardium. The symptoms described are caused by a lack of oxygen in the myocardium.

Which of the following is most descriptive of the capillary? a. Large diameter, low pressure b. Small diameter, high pressure c. Large diameter, high pressure d. Small diameter, low pressure

D The diameter of a capillary is less than that of an arteriole, but the pressure is relatively low as a result of the large cross-sectional area of the branching capillary bed.

Which blood test standardizes prothrombin time (PT) results among worldwide clinical laboratories? a. aPTT b. ACT c. HDL d. INR

D The international normalized ratio (INR) was developed by the World Health Organization in 1982 to standardize prothrombin time results among clinical laboratories worldwide. High-density lipoproteins (HDLs) are particles of the total serum cholesterol. Activated coagulation time (ACT) is also known as the activated clotting time. The ACT is a point of care test that is performed outside of the laboratory setting in areas such as the cardiac catheterization laboratory, the operating room, or critical care units. The activated partial thromboplastin time (aPTT) is used to measure the effectiveness of intravenous or subcutaneous ultrafractionated heparin therapy.

Which statement regarding the autonomic nervous system's role in the regulation of heart rate is true? a. Parasympathetic influences increase heart rate. b. Sympathetic influences are predominantly present. c. Parasympathetic influences are only compensatory. d. Both sympathetic and parasympathetic influences are normally active.

D The parasympathetic nervous system and the sympathetic nervous system operate to create a balance between relaxation and fight-or-flight readiness. They affect cardiovascular function by slowing the heart rate during periods of calm and increasing it in response to sympathetic stimulation.

A patient is admitted after a femorotibial bypass graft. What nursing action is critical in the immediate postoperative period? a. Frequent assessment of the skin b. Hourly assessment of intake and output c. Monitoring for ST segment changes d. Frequent pulse checks to the affected limb

D The primary focus of nursing care in the immediate postprocedural period is assessment of the adequacy of perfusion to the affected limb and identification of complications. Pulse checks are performed frequently, and the physician is notified of any decrease in the strength of the Doppler signal. Because distal perfusion is compromised in this patient population, nursing measures to prevent skin breakdown are implemented. If the repair was performed above the renal arteries, kidney function may be impaired as a result of interruption of renal blood flow during the procedure. Urine output is therefore assessed hourly and supported with fluids and diuretics as needed. Because patients with peripheral vascular disease are at high risk for cardiac events, ST segment monitoring is performed to detect episodes of myocardial ischemia throughout the perioperative period.

What is the name of the valve that allows blood flow into pulmonary artery? a. Aortic b. Tricuspid c. Mitral valve d. Pulmonic valves

D The pulmonic valve allows blood flow into the pulmonary artery, and the aortic valve allows blood flow into the aorta. The tricuspid (right) and mitral valves (left) are located between the atria and the ventricles.

Which is an example of a physiologic shunt? a. A ventricular septal defect b. Blood returning from the inferior vena cava to the right atrium c. A septal infarct d. The thebesian vessels returning deoxygenated blood to the left ventricle

D The thebesian vessels return blood to the left ventricle. The mixing of unoxygenated blood with freshly oxygenated blood is called a physiologic shunt. A ventricular septal defect (VSD) allows mixing of blood from both ventricles. The clinical impact depends on the size of the intracardiac shunt. A VSD is a congenital opening between the ventricles; a ventricular septal rupture can occur as a complication of a large anterior wall myocardial infarction.

Which intervention should be strictly followed to ensure accurate cardiac output readings? a. Inject 5 mL of iced injectate at the beginning of exhalation over 30 seconds. b. Inject 10 mL of warmed injectate into the pulmonary artery port three times. c. Ensure at least 5° C difference between injectate and the patient temperature. d. Administer the injectate within 4 seconds during inspiration.

D To ensure accurate readings, the difference between injectate temperature and body temperature must be at least 10° C, and the injectate must be delivered within 4 seconds, with minimal handling of the syringe to prevent warming of the solution. This is particularly important when iced injectate is used.

Noninvasive emergency pacing is best achieved via the use of which type of temporary pacing? a. Transvenous (endocardial) b. Epicardial c. Transthoracic d. Transcutaneous

D Transcutaneous cardiac pacing involves the use of two large skin electrodes, one placed anteriorly and the other posteriorly on the chest, connected to an external pulse generator. It is a rapid, noninvasive procedure that nurses can perform in the emergency setting and is recommended for the treatment of symptomatic bradycardia.

A patient returns from the cardiac catheterization laboratory after angioplasty and stent placement (ECG changes had indicated an inferior wall myocardial infarction in progress). Which lead would best monitor this patient? a. Varies based on the patient's clinical condition and recent clinical history b. Lead V3 c. Lead V1 d. Lead II

A The selection of an electrocardiographic monitoring lead is not a decision to be made casually or according to habit. The monitoring lead should be chosen with consideration of the patient's clinical condition and recent clinical history. Lead II is recommended for monitoring of atrial dysrhythmias and would be appropriate in this case as due to inferior wall injuries. Lead V1 is recommended for monitoring of ventricular dysrhythmias. Leads I and aVF are selected to detect a sudden change in ventricular axis.

A patient's arterial line waveform has become damped. What action should the nurse take to correct the situation? a. Check for kinks, blood, and air bubbles in the pressure tubing. b. Prepare for a normal saline fluid challenge for hypotension. c. Discontinue the arterial line as it has become nonfunctional. d. Check the patient's lung sounds for a change in patient condition.

A A damped waveform occurs when communication from the artery to the transducer is interrupted and produces false values on the monitor and oscilloscope. Damping is caused by a fibrin "sleeve" that partially occludes the tip of the catheter, by kinks in the catheter or tubing, or by air bubbles in the system.

A sudden increase in left atrial pressure, acute pulmonary edema, and low cardiac output, caused by the ventricle contracting during systole, are all characteristics of what condition? a. Acute mitral regurgitation b. Aortic insufficiency c. Chronic mitral regurgitation d. Pericardial friction rub

A Acute mitral regurgitation occurs when the ventricle contracts during systole and a jet of blood is sent in a retrograde manner to the left atrium, causing a sudden increase in left atrial pressure, acute pulmonary edema, and low cardiac output (CO) and leading to cardiogenic shock. Chronic mitral regurgitation is auscultated in the mitral area and occurs during systole. It is high pitched and blowing, although the pitch and intensity vary, depending on the degree of regurgitation. As mitral regurgitation progresses, the murmur radiates more widely. Aortic insufficiency is an incompetent aortic valve. If the valve cusps do not maintain this seal, the sound of blood flowing back into the left ventricle during diastole is heard as a decrescendo, high-pitched, blowing murmur. A pericardial friction rub is a sound that can occur within 2 to 7 days after a myocardial infarction. The friction rub results from pericardial inflammation (pericarditis). Classically, a pericardial friction rub is a grating or scratching sound that is both systolic and diastolic, corresponding to cardiac motion within the pericardial sac.

A patient suddenly develops a wide QRS complex tachycardia. The patient's heart rate is 220 beats/min and regular; blood pressure is 96/40 mm Hg; and respiratory rate is 22 breaths/min, and the patient is awake without complaint except for palpitations. Which of the following interventions would be best to try first? a. Adenosine 6 mg rapid IV push b. Lidocaine 1 mg/kg IV push c. Verapamil 5 mg IV push d. Digoxin 0.5 mg IV push

A Adenosine (Adenocard) is an antidysrhythmic agent that remains unclassified under the current system. Adenosine occurs endogenously in the body as a building block of adenosine triphosphate (ATP). Given in intravenous boluses, adenosine slows conduction through the atrioventricular (AV) node, causing transient AV block. It is used clinically to convert supraventricular tachycardias and to facilitate differential diagnosis of rapid dysrhythmias.

Adenosine is an antidysrhythmic agent that is given primarily what reason? a. To convert supraventricular tachycardias b. To suppress premature ventricular contractions (PVCs) c. To treat second and third degree AV blocks d. To coarsen ventricular fibrillation so that defibrillation is effective

A Adenosine occurs endogenously in the body as a building block of adenosine triphosphate (ATP). Given in intravenous boluses, adenosine slows conduction through the atrioventricular (AV) node, causing transient AV block. It is used clinically to convert supraventricular tachycardias and to facilitate the differential diagnosis of rapid dysrhythmias

Which statement made by a patient would indicate the need for further education before an electrophysiology procedure? a. "I need to take all my heart medications the morning of the procedure." b. "The doctor is going to make my heart beat wrong on purpose." c. "I will be awake but relaxed during the procedure." d. "I will be x-rayed during the procedure."

A All antidysrhythmic medications are discontinued several days before the study so that any ventricular dysrhythmias may be readily induced during the electrophysiology procedure (EPS). Anticoagulants, especially warfarin, are also stopped before EPS. Premedication is administered before the study to induce a relaxed state, and during the procedure, the patient is conscious but receives sedative agents (midazolam) at regular intervals.

Which clinical manifestation is usually the first symptom of peripheral arterial disease (PAD)? a. Cramping when walking b. Thrombophlebitis c. Pulmonary embolism d. Cordlike veins

A Arterial occlusion obstructs blood flow to the distal extremity. The lack of blood flow produces ischemic muscle pain known as intermittent claudication. This cramping, aching pain while walking is often the first symptom of peripheral arterial occlusive disease. The pain is relieved by rest and may remain stable in occurrence and intensity for many years.

What two medications are commonly prescribed at discharge for patients who have had a coronary artery stent placed? a. Aspirin and prasugrel b. Aspirin and abciximab c. Clopidogrel and eptifibatide d. Tirofiban and tricagrelor

A Because platelet activation is a complex process involving multiple pathways, combination therapy with two or more agents has proven most effective. The current standard of care for percutaneous coronary intervention typically includes dual antiplatelet therapy with aspirin and a thienopyridine. These oral agents are administered before the procedure and continued at discharge. Abciximab, eptifibatide, and tirofiban are all intravenous antiplatelet agents.

A patient presents with atrial fibrillation, a heart rate of 156 beats/min, and a blood pressure of 124/76 mm Hg. The practitioner orders diltiazem, a calcium channel blocker, to be given slowly by intravenous push. Why did the practitioner choose this medication to treat this patient's atrial tachyarrhythmia? a. Diltiazem decreases the calcium influx into the atrioventricular (AV) nodal tissue and decreases the speed of impulse conduction. b. Diltiazem increases the calcium influx into the AV nodal tissue and decreases the speed of impulse conduction. c. Diltiazem decreases the calcium influx into the myocardial tissue and decreases the strength of heart contraction. d. Diltiazem increases the calcium influx into the myocardial tissue and decreases the strength of heart contraction.

A Calcium channel-blocking drugs, such as verapamil and diltiazem, inhibit the inward Ca++ current into pacemaker tissue, especially the atrioventricular (AV) node. For this reason, they are used therapeutically to slow the rate of atrial tachydysrhythmias and protect the ventricle from excessive atrial impulses.

Which condition is usually associated with clubbing? a. Central cyanosis b. Peripheral cyanosis c. Carbon monoxide poisoning d. Acute hypoxemia

A Clubbing in the nail bed is a sign associated with longstanding central cyanotic heart disease or pulmonary disease with hypoxemia. Peripheral cyanosis, a bluish discoloration of the nail bed, is seen more commonly. Peripheral cyanosis results from a reduction in the quantity of oxygen in the peripheral extremities from arterial disease or decreased cardiac output. Central cyanosis is a bluish discoloration of the tongue and sublingual area. Multiracial studies indicate that the tongue is the most sensitive site for observation of central cyanosis.

Which diagnostic tool can be used to detect structural heart abnormalities? a. Echocardiogram b. Electrocardiogram (ECG) c. Exercise stress test d. 24-hour Holter monitor

A Echocardiography is used to detect structural heart abnormalities such as mitral valve stenosis and regurgitation, prolapse of mitral valve leaflets, aortic stenosis and insufficiency, hypertrophic cardiomyopathy, atrial septal defect, thoracic aortic dissection, cardiac tamponade, and pericardial effusion

An echocardiogram reveals an ejection fraction of 55%. On the basis of this information, how would the patient's cardiac function be described? a. Adequate b. Mildly decreased c. Moderately decreased d. Severely decreased

A Ejection fraction is expressed as a percent, with normal being at least greater than 50%. An ejection fraction of less than 35% indicates poor ventricular function (as in cardiomyopathy), poor ventricular filling, obstruction to outflow (as in some valve stenosis conditions), or a combination of these.