CARDIAC + CCRN Questions cardiac

A shift in the point of maximal impulse (PMI) to the fifth left intercostal space at the anterior axillary line could be caused by any of these conditions except:

Pericardial effusion

Tracheal shift toward the left with diminished or absent breath sounds on the right is indicative to what?

Pneumothorax

CK-MB?

Positive serum isoenzyme - greater than 4% is indicative of MI (highly specific test for MI)

Indicative leads for this cardiac wall are V8 and V9:

Posterior

Leads V8 and V9 are used to evaluate which of the following?

Posterior MI Lead V7 is at the fifth left intercostal space (LICS) at the posterior axillary line, lead V9 is at the fifth LICS at the lateral spine, and lead V8 is halfway between leads V7 and V9. Leads V8 and V9 are used to identify indicative changes of posterior MI as opposed to the traditional method of looking for reciprocal changes in the anterior leads.

Which of the following drugs may increase the QT interval by 50% or more?

Procainomide

The capacity to noninvasively alter one of several aspects of the function of a pacemaker is referred to as:

Programability Programmability is the ability to change one of several aspects of the function of a pacemaker using a device placed over the pulse generator.

Which of the following are two significant adverse effects of angiotensin-converting enzyme (ACE) inhibitors (e.g., captopril [Capoten])?

Proteinuria and hyperkalemia ACE inhibitors may cause hyperkalemia by inhibiting the secretion of aldosterone triggered by angiotensin II. Proteinuria also may occur, even leading to nephrotic syndrome and renal failure. Monitor serum potassium, and monitor urine for proteinuria

Pleuritic pain is described as:

Sharp Pleuritic pain is described as sharp pain that is intensified by a deep breath.

Types of Angina

Stable and Unstable Angina

Acute Coronary Syndrome (definition)

Syndrome of acute myocardial ischemia caused by atherosclerotic plaque rupture and thrombus formation

If a murmur is audible at the same time that the carotid pulse is felt, the murmur is: SYSTOLIC or DIASTOLIC?

Systolic The bolus of blood is ejected from the left ventricle during systole; therefore a murmur audible when the pulse is palpable would be systolic. Systolic murmurs may be functional murmurs related to increased flow through the heart causing turbulence, but they certainly may be pathologic, caused by valve disease or septal defects. Diastolic murmurs are always pathologic.

Complications of Cardiogenic Shock

Tachycardia LVF RVF Hypo perfusion U/O less than 0.5 mL/kg/hr Cool to cold skin Diminished breath sounds

Which of the following diagnostic tests would be most definitive in identifying aortic rupture?

A thoracic aortogram would show leakage of dye with aortic rupture.

Three things tell you that the catheter has flipped back into the right ventricle: ?

drop in diastolic pressure, loss of dicrotic notch, and initiation of ventricular ectopy.

Which of the following would not be associated with a false-positive result for an acute myocardial infarction using the total creatine kinase (CK)? A. Hypothyroidism B. Hemorrhagic stroke C. Cardioversion D. Ulcerative colitis

D. Ulcerative colitis

Angina Pectoris (clinical presentation - subjective)

1. Subjective a. Substernal chest discomfort that usually lasts 1 to 4 minutes and subsides with rest and/or nitro use. 1. Discomfort may be described as burning, squeezing, tightness, pressure, heaviness, indigestion, or aching. 2. Pain may radiate to shoulders, back, arms, jaw, neck, and epigastrium b. Dyspnea c. N/V d. Anxiety e. Weakness

Stable Angina (signs and symptoms)

- Unchanging frequency, duration, and severity - Predictable to the patient - ST segment depression may occur during pain

Pathologic Consequence of Atherosclerosis and Arteriosclerosis

1. Angina pectoris 2. MI 3. Heart failure 4. Dysrhythmias caused ischemia 5. Sudden death

Angina Pectoris (Collaborative Management)

1. Relieve chest pain a. Nitro b. Calcium channel blockers (especially for variant angina) c. Morphine sulfate may be required for unstable angina 2. Increase oxygen demand a. nasal canula 5L/min during ischemic pain unless contraindicated by lung dz. b. Blood transfusion if angina caused by anemia c. Platelet aggregation inhibitors (e.g., aspirin or ticlopidine to prevent platelet aggregation; heparin may be prescribed to prevent clotting or extension of clot d. IABP - may be used in unstable angina; IABP increases coronary artery perfusion pressure (CAPP) 3. Decrease oxygen demand a. Removal of provoking factors 1. Activity cessation immediately when chest pain occurs 2. Bed rest during pain; semi-Fowler position usually most comfortable b. NTG as prescribed 1. NTG in doses less than 1 mcg/kg/min is a predominately venous dilator (decreases after load and preload as well); it decreases myocardial workload and myocardial oxygen consumption by decreasing preload.

CAD (pathophysiology)

1.Arteriosclerosis: a group of diseases characterized by thickening and loss of elasticity (calcification) of arterial walls 2. Atherosclerosis: the most common form of arteriosclerosis. a. A chronic disease process characterized by the build-up of fatty plague along the subintimal layer of arteries leading to a decrease in arterial luman. 3. Decreased blood flow and oxygen supply to the myocardium lead to imbalance between oxygen supply and oxygen demand. a. Gradual or partial occlusion: ischemia causing angina b. Sudden or complete occlusion: necrosis causing MI

A 72-year-old man arrived in the emergency department after 4 hours of substernal pain radiating to the left arm. He has a 100 pack-year history of cigarette smoking, chronic obstructive pulmonary disease, and intermittent claudication. His electrocardiogram on admission shows sinus tachycardia with a rate of 120 beats/min and ST segment elevation in leads I, AVL, and V3 to V6. Vital signs include blood pressure, 150/84 mm Hg; respiratory rate, 15 breaths/min; functional oxygen saturation (SpO2), 95%; and temperature, 38.3° C (100.9° F). An S4 is noted during cardiac auscultation. This sound indicates: A. atrial contraction and propulsion of blood into a noncompliant ventricle. B. inflammation of the pericardium. C. opening of a defective semilunar valve. D. rapid ventricular filling into an already distended ventricle.

A

A patient's digital readout of the pulmonary artery pressure suddenly changes from 22/10 mm Hg to 24/2 mm Hg and remains at this pressure. Which of the following is the most likely cause of this change? A. Proximal movement of the catheter B. Distal movement of the catheter C. Hypoxemia D. Pulmonary artery vasodilation

A

A patient is admitted to the emergency department with chest trauma after a motor vehicle collision. He has had an exploratory thoracotomy and has just arrived in the surgical intensive care unit. Vital signs are blood pressure, 80/42 mm Hg; heart rate, 120 beats/min; and respiratory rate, 32 breaths/min. Hemodynamic parameters are as follows: Right atrial pressure (RAP) 16 mm Hg Pulmonary artery pressure 40/20 mm Hg Pulmonary artery occlusive pressure (PAOP) 18 mm Hg Cardiac index 2 L/min/m2 He has distant heart sounds and distended neck veins. He quickly deteriorates and is pulseless, although the monitor still shows sinus tachycardia. Immediate treatment would include which of the following? A. Cardiopulmonary resuscitation (CPR), epinephrine, pericardiocentesis B. CPR, epinephrine, insertion of needle in second intercostal space at midclavicular line C. Transcutaneous pacemaker and fluid bolus D. Atropine and transcutaneous pacemaker

A History of chest trauma, hypotension, distant heart sounds, distended neck veins, and equalization of pressures (RAP, pulmonary artery diastolic pressure, and PAOP are elevated and within 5 mm Hg of each other) indicate cardiac tamponade. Treatment for pulseless electrical activity (PEA) in this patient includes CPR, epinephrine (for any pulseless situation), and pericardiocentesis. Needle tap would have been appropriate if this were tension pneumothorax. A transcutaneous pacemaker is inappropriate because the patient has a stable electrical rhythm but no mechanical response.

Myocardial ischemia or infarction may cause which of the following? A. Mitral regurgitation B. Aortic stenosis C. Mitral stenosis D. Aortic regurgitation

A Myocardial ischemia or infarction is likely to cause papillary muscle ischemia or infarction, which would cause atrioventricular (AV) valve regurgitation. If left ventricular ischemia occurs, mitral regurgitation occurs. If right ventricular ischemia occurs, tricuspid regurgitation occurs.

An aortic tear commonly is associated with which of the following? A. Acceleration-deceleration injury B. Barotrauma C. Penetrating injury of the chest wall D. Blunt force injury to the chest wall

A Acceleration-deceleration injury may cause a shearing tear of the aorta. This usually occurs with a high-speed motor vehicle collision when the vehicle, the body, and then the heart make a sudden stop.

A patient with heart failure most likely would have which of the following? A. S3 B. Murmur C. S4 D. Pericardial friction rub

A An S3 is an indication of heart failure occurring before crackles in the lung bases. Left ventricular failure causes an S3 heard at the mitral area (fifth left intercostal space at the midclavicular line), whereas right ventricular failure causes an S3 heard at the tricuspid area (fifth left intercostal space at the left sternal border).

Over the past 2 hours, a patient admitted with severe acute heart failure has the following changes in assessment parameters: Admission 2 Hours Later Heart sounds S1, S2 S1, S2, S3 audible at apex Blood pressure 118/60 mm Hg 98/54 mm Hg Heart rate 105 beats/min 126 beats/min Respiratory rate 30 breaths/min 36 breaths/min Goals of therapy in this patient would include: A. decrease preload and increase contractility. B. decrease preload and increase afterload. C. decrease afterload and decrease contractility. D. decrease afterload and increase preload.

A An important clue in the stem is the presence of the S3 at the apex, which indicates left ventricular failure with systolic dysfunction. Remember that systole is contraction, so contraction dysfunction should respond to a drug that improves contractility. The S3 indicates the need to decrease circulating volume. Choose option a, which reads decrease preload and increase contractility

S1 is heard best in which of the following areas? A. Mitral B. Tricuspid C. Pulmonic D. Aortic

A Because S1 is caused by mitral and tricuspid valve closure, the answer logically would be mitral or tricuspid. Consider the higher pressures on the left side and conclude that the mitral valve closure would be louder. Therefore S1 would be loudest over the mitral area.

A 62-year-old man is admitted with chest pain. His electrocardiogram reveals ST segment elevation and T wave inversion in leads V1 to V4. Aspirin has been given, and morphine titration and nitroglycerin infusion are used to relieve his chest pain. The patient suddenly develops a loud holosystolic murmur at the lower left sternal border, chest pain, and hypotension 5 days after his myocardial infarction. A pulmonary artery catheter is inserted. Which of the following parameters would be noted in this patient? A. Increase in venous oxygen saturation (SvO2) C. Decrease in cardiac output D. Increase in systolic blood pressure (BP)

A Consider the flow of blood. The pressure in the left side of the heart normally is greater than the pressure in the right side of the heart in adults, so when there is a ventricular septal defect, there is a left-to-right shunt. This would send oxygenated blood back to the right side of the heart and increase SvO2.

Which of the following is a cause of diastolic dysfunction? A. Cardiac tamponade B. Myocardial infarction

A Diastolic dysfunction is an inability of the heart to fill adequately. Tamponade compresses the chambers so that filling is impaired. If filling is impaired, cardiac output is diminished.

Which of the following is not characteristic of the clinical presentation of dissecting thoracic aortic aneurysm? A. Crushing substernal chest pain B. Hypotension C. Widened mediastinum on chest x-ray film D. Syncope

A Dissecting thoracic aortic aneurysm causes a ripping or tearing chest pain that radiates to the back, neck, or shoulders.

Which of the following is associated with mitral stenosis? A. Pinkish discoloration of the cheeks B. Systolic murmur C. Widened pulse pressure D. Narrow pulse pressure

A Patients with mitral stenosis may exhibit a pinkish discoloration of the cheeks (i.e., malar blush). Mitral stenosis causes a diastolic murmur. Widened pulse pressure is associated with aortic regurgitation. Narrowed pulse pressure is associated with mitral regurgitation.

A patient is admitted with unstable angina. He has a long history of hypertension and coronary artery disease. The nurse notes a split S2 on expiration and a single S2 on inspiration during cardiac auscultation. Blood pressure is 150/88 mm Hg, and heart rate is 88 beats/min. On the electrocardiogram, there is a normal-appearing P wave in front of each QRS complex, the PR interval measures 0.2 second consistently, and the QRS complexes measure 0.14 second. They are positive in V5 and V6 and negative in V1 and V2. These findings most likely indicate which of the following? A. Left bundle branch block (LBBB) B. Right bundle branch block (RBBB) C. Third-degree atrioventricular block D. Ventricular tachycardia

A Features of LBBB described here are a QRS complex greater than 0.12 second in duration and a QRS complex that is positive in leads V5 and V6 (consider these left ventricular leads) and negative in leads V1 and V2 (consider these right ventricular leads). LBBB causes a paradoxical splitting of S2. This means that it is split on expiration but not on inspiration. This is paradoxical because it is opposite of a normal physiologic split of S2, which is split on inspiration but not split on expiration.

Which of the following drugs will NOT reduce both preload and after load? A. Hydralazine (Apresoline) B. Nitroprusside (Nipride) C. Prazosin (Minipress) D. Nifedipine (Procardia)

A Hydralazine is an arterial dilator and will reduce afterload. All other drugs listed dilate arteries and veins so they will decrease preload and afterload.

Which of the following should not be given to a patient with hypertrophic cardiomyopathy? A. Nitroglycerin (Tridil) B. Propranolol (Inderal) C. Diltiazem (Cardizem) D. Amiodarone (Cordarone)

A Hypertropic cardiomyopathy previously was known as idiopathic hypertrophic subaortic stenosis. The left ventricular free wall and the septum are hypertrophied below the aortic valve, creating a subaortic stenosis. Nitrates and diuretics are contraindicated because they decrease venous return needed for adequate cardiac filling. Positive inotropes such as digoxin, dobutamine, and dopamine are contraindicated because they may increase the outflow obstruction.

A 28-year-old man with a long history of intravenous drug abuse arrives in the emergency department and is transferred to the critical care unit. He is complaining of fatigue and right upper quadrant pain. Vital signs are as follows: Blood pressure 110/80 mm Hg Heart rate 124 beats/min Respiratory rate 26 breaths/min Temperature 39.4° C Physical assessment reveals a holosystolic murmur at the lower left sternal border and jugular venous distention. Laboratory data show an elevated sedimentation rate and white blood cell count. What would be the primary goal of therapy in this patient? A. Treat infection. B. Improve contractility. C. Reduce circulating volume. D. Prevent bleeding.

A Murmur and fever in an adult always should be suspected to be caused by bacterial endocarditis. The history of drug abuse augments this suspicion. With a history of intravenous drug abuse or pulmonary artery catheter, the tricuspid valve most likely is affected. In other precipitating causes, mitral and aortic valves more likely are affected. The valve becomes regurgitant as a result of bacterial vegetations and eventually may become stenotic because of scar tissue. Treatment is directed toward controlling fever and treating the infection. The reason for the right ventricular failure (jugular venous distention and right upper quadrant pain, which is indicative of hepatomegaly) is tricuspid regurgitation and not a problem with decreased contractility or increased preload.

A 52-year-old man has undergone coronary artery bypass grafting and has returned to the critical care unit. During the last hour his parameters were as follows: O2 saturation 99% PaO2 with FiO2 0.4 184 mm Hg Hemoglobin 12 gm/dL Serum potassium 3.8 mEq/L Urine output 100 mL/hr Now the patient's venous oxygen saturation (SvO2) monitor shows a rapid decline from a reading of 75% to 62% without any change in arterial oxygen saturation (SaO2). His cardiac rhythm changes from normal sinus rhythm to a sinus rhythm with ventricular bigeminy. The nurse would assess the patient for which of the following? A. Decreased cardiac output B. Internal hemorrhage C. Hypermetabolism D. Hypoxemia

A Of the given options, option a is the correct choice because ventricular dysrhythmias commonly result in a decrease in cardiac output. If you had no idea of a correct answer, cluster options b, c, and d as noncardiac involvement, then select option a. The clinical situation is related to the heart, so that would be a priority assessment.

A patient 5 days after an acute inferior myocardial infarction suddenly complains of severe dyspnea and palpitations. The patient appears anxious and diaphoretic. While completing the assessment of the patient, a loud holosystolic murmur at the apex that radiates to the axilla is noted. The patient also has crackles throughout the lung field but an S3 at the apex is not audible. Which of the following is most likely to be descriptive of the pulmonary artery occlusive pressure (PAOP) in this patient? A. An elevated v wave and an overestimate of the left ventricular end-diastolic pressure (LVEDP) C. A normal v wave and an accurate reflection of the LVEDP D. An elevated v wave and a direct correlation to the pulmonary artery diastolic pressure

A PAOP is an indirect reflection of left atrial pressure (LAP). In mitral regurgitation, there is an increase in LAP during systole because blood regurgitates back into the left atrium. Remember that v waves on the PAOP represent ventricular systole, and because the left atrial pressure would be higher during left ventricular systole, assume elevated v waves, options a and d. Because atrial pressures are mean pressure, any large wave causes an overestimation of the pressure as it reflects LVEDP.

A 66-year-old woman is admitted to the critical care unit in acute respiratory distress. Her respiratory rate is 38 breaths/min, and her ventilations are shallow and labored. Her blood pressure is 96/64 mm Hg, and heart rate is 120 beats/min. The monitor shows atrial fibrillation. Lung auscultation reveals crackles to the scapular level bilaterally. Cardiac auscultation reveals a grade II holosystolic murmur and an S3 at the apex. Which of the following is the most likely diagnosis? A. Pulmonary edema B. Pulmonary embolus

A Pulmonary embolus, pneumothorax, and myocardial infarction are likely to cause chest pain. Because this patient reports dyspnea but no chest pain, the most likely cause is pulmonary edema. S3, crackles, tachycardia, and a mitral regurgitation murmur support that conclusion. Choose option a.

A premature P wave buried in the T wave before a run of wide QRS complex tachycardia indicates that the wide QRS complex tachycardia is most likely which of the following? A. Supraventricular tachycardia with aberrancy B. Ventricular tachycardia C. Bundle branch block D. Wolff-Parkinson-White syndrome

A Remember that a run of wide QRS complex tachycardia triggered by a PAC is likely a supraventricular tachycardia with aberrancy, whereas a run of wide QRS complex tachycardia triggered by a premature ventricular contraction is likely ventricular tachycardia.

In a patient with aortic stenosis, which symptom would indicate an urgent need for valve replacement? A. Syncope B. Pulmonary hypertension C. Left ventricular hypertrophy D. Aortic calcification

A Syncope and chest pain are indications of hypoperfusion. They indicate that not enough blood is getting through the aortic valve to perfuse vital organs. Valve replacement is needed.

Which of the following describes the typical configuration of the QRS complex in lead V1 in a patient with a left bundle branch block? A. rS or QS B. rSR C. qR D. RS

A The QRS complex in left bundle branch block is 0.12 second or greater and predominantly negative in lead V1. Only option a is predominantly negative. Remember that when the waves are written like this, a lowercase letter indicates a small wave and a capital letter indicates a large wave.

Which drug category is used to block the maladaptive sympathetic nervous system (SNS) innervation in heart failure? A. Beta-blockers B. Angiotensin-converting enzyme (ACE) inhibitors C. Vasodilators D. Diuretics

A The first stage of compensation for heart failure is sympathetic nervous system stimulation, which causes tachycardia and vasoconstriction. These effects increase myocardial oxygen consumption and diminish time for diastolic filling. Beta-blockers (e.g., metoprolol) or alpha- and beta-blockers (e.g., carvedilol) are used to block this SNS effect.

A patient is admitted with an acute anterior myocardial infarction. He has a history of pulmonary fibrosis related to occupational lung disease. This evening he is complaining of extreme dyspnea. Fine crackles are heard throughout the lung fields. A pulmonary artery catheter is inserted and reveals pulmonary artery pressure of 42/24 mm Hg and a pulmonary artery occlusive pressure (PAOP) of 10 mm Hg. What is the most likely cause of this patient's dyspnea? A. Pulmonary fibrosis B. Left ventricular failure C. Cardiac tamponade D. Pneumothorax

A The hemodynamic picture (elevated diastolic pulmonary artery pressure [PAd] with normal PAOP) is one of pulmonary hypertension. In this case, it is most likely due to long-standing hypoxemia. Left ventricular failure would elevate PAd and PAOP, maintaining a PAd-PAOP difference of 5 mm Hg or less. Cardiac tamponade would elevate and equalize (within 5 mm Hg) the PAd and PAOP. Pneumothorax would cause pulmonary hypertension, but it also would cause unequal breath sounds, which this patient does not have.

A 48-year-old male patient with a history of inferior myocardial infarction (MI) is admitted with an acute anterolateral MI. He is tachycardic and hypotensive. Cardiac index is 1.9 L/min/m2. Pulmonary artery occlusive pressure (PAOP) is 20 mm Hg, and systemic vascular resistance (SVR) is 2000 dynes/sec/cm−5. Despite emergent percutaneous coronary intervention, Q waves develop, and cardiogenic shock continues. The patient remains significantly hypotensive despite dobutamine infusion. An intraaortic balloon pump (IABP) is inserted via his left femoral artery. Which of the following are the primary functions of the IABP? A. Decrease afterload and improve coronary artery perfusion B. Decrease preload and myocardial oxygen consumption C. Decrease preload and afterload D. Decrease afterload and increase cardiac contractility

A The primary effects of IABP are decreased afterload and improved coronary artery perfusion pressure. IABP does not directly affect preload, and it does not increase cardiac contractility.

In essence, a pulsatile hematoma is what?

A false aneurysm

Which clinical findings are associated with right ventricular myocardial infarction? A. Jugular venous distention (JVD), ST segment in lead V4R, clear breath sounds B. JVD, ST segment in lead V4R, crackles audible in lung bases C. ST segment in lead V4R, crackles audible in lung bases, elevated pulmonary artery occlusive pressure (PAOP) D. JVD, ST segment in lead V4R, elevated PAOP

A Think backward from the fact that the right ventricle is backed up, so there is JVD. Think forward from the fact that the right ventricle is poorly filled, so there are no crackles and decreased PAOP

Which vessel is used as a graft when the minimally invasive direct coronary artery bypass grafting (MIDCABG) procedure is performed? A. Internal thoracic artery B. Radial artery C. Gastroepiploic artery D. Saphenous vein

A Think of the most local option. The internal thoracic is more local than the gastroepiploic artery, the radial artery, or the saphenous vein.

A 47-year-old man was admitted to the critical care unit for complaints of crushing substernal chest pain unrelieved by nitroglycerin or rest. An electrocardiogram reveals the following: ST segment elevation in leads II, III, and aVF and reciprocal changes in leads I and aVL. Vital signs are blood pressure 100/64 mm Hg, heart rate 64 beats/min, and respiratory rate 28 breaths/min. Fibrinolytic therapy is initiated. The nurse closely monitors for successful reperfusion by observation for which for the following? A. Return of the ST segment to the baseline during infusion of the fibrinolytic drug B. Transient atrial dysrhythmias during infusion of the fibrinolytic drug C. Ejection fraction greater than 40% after completion of the infusion D. Electrocardiogram change of T wave inversion within 90 minutes of infusion

A You know that reperfusion occurs when the coronary artery is reopened, so look for the answer that indicates an immediate or early effect. You also know that ST segment elevation occurs with injury and suspect that when the coronary artery occlusion causing that injury is resolved, the ST segments should return to baseline. Choose option a.

Coronary Artery Disease (definition)

A progressive disease of the coronary arteries that results in their narrowing of obstruction

Increasing the dobutamine increases .......further to improve the stroke volume and cardiac index. Dobutamine also causes ..... to decrease preload (PAOP) and afterload (SVRI). Dopamine is inappropriate because it would increase the afterload (SVR) further.

Contractility/Vasodilation

Which drug category is used to block the maladaptive renin-angiotensin-aldosterone (RAA) system in heart failure?

ACE

A postoperative cardiac surgery patient's blood pressure suddenly drops to 70 mm Hg palpable, with a loss of the a wave in the pulmonary artery occlusion pressure (PAOP) waveform. What change in his cardiac rhythm would cause this change in his PAOP waveform?

A-fib The loss of the a wave equals the loss of atrial contraction, which is certain in atrial fibrillation.

Prolongation of the QT interval with predisposition to torsades de pointes occurs in all of these conditions except:

A. hypomagnesemia. B. tricyclic antidepressant toxicity. C. therapeutic levels of Class IA antidysrhythmics. D. hyperkalemia. Remember that low levels of potassium, calcium, and magnesium usually occur together. So hypomagnesemia and hyperkalemia are unlikely to cause torsades de pointes. Remember that magnesium is used to treat torsades de pointes, so hypomagnesemia should be considered as one of the major causes. This question is stated negatively, so choose d as the option that is not a cause of prolonged QT interval and torsades de pointes.

GP IIb/IIIa inhibitor frequently used after PCI:

ABCIXIMAB

Which of the following is an important group of drugs used to block a maladaptive compensatory mechanism in heart failure?

ACE Inhibitors When the heart fails to provide the kidney with an adequate glomerular filtration rate, the kidney secretes renin. This renin causes the conversion of angiotensinogen to angiotensin I, and then angiotensin I is converted to angiotensin II as it passes though the lungs. Angiotensin II is a potent vasoconstrictor that also causes the release of aldosterone from the adrenal cortex. Aldosterone causes the kidney to retain sodium and water and excrete potassium. This compensatory mechanism is adaptive in hypovolemia but maladaptive in heart failure. ACE inhibitors block the conversion of angiotensin I to angiotensin II, preventing the increase in afterload caused by the vasoconstrictive effects of angiotensin and the increase in preload caused by the sodium and water retention effects of aldosterone.

The nurse assesses the client's cardiac status. Which finding requires immediate intervention? a. Swishing sound heard on either side of the neck b. Bounding pulses c. Pulse rate of 90 beats/min d. Blood pressure of 140/90 mm Hg

ANS: A A bruit is a swishing sound that may develop in narrowed arteries. Bruits are usually associated with atherosclerotic disease. This finding may indicate atherosclerotic disease of the carotid arteries and further evaluation is needed. Bounding pulses, a pulse rate of 90 beats/min, and a blood pressure of 140/90 mm Hg are not assessment findings that require immediate interventions.

The charge nurse is supervising the care of four critical care patients being monitored using invasive hemodynamic modalities. Which patient should the charge nurse evaluate first? a. A patient in cardiogenic shock with a cardiac output (CO) of 2.0 L/min b. A patient with a pulmonary artery systolic pressure (PAP) of 20 mm Hg c. A hypovolemic patient with a central venous pressure (CVP) of 6 mm Hg d. A patient with a pulmonary artery occlusion pressure (PAOP) of 10 mm Hg

ANS: A A cardiac output of 2.0 L/min in a patient with cardiogenic shock warrants immediate assessment. A PAP of 20 mm Hg, CVP of 6 mm Hg, and a PAOP of 10 mm Hg are all within normal limits.

On discharge after undergoing an exploratory laparotomy, the nurse teaches the client to monitor for which sign of early shock? a. Decreased urine output b. Low body temperature c. Slow bounding pulse d. Constipation

ANS: A A decrease in urine output is a sensitive indicator of early shock. In severe shock, urine output is decreased (compared with fluid intake) or even absent.

Which client is most at risk for peripheral vascular disease? a. A middle-aged man who smokes b. A middle-aged woman with a sedentary lifestyle c. An older man who is moderately obese d. A young adult with family history of coronary artery disease

ANS: A All these risk factors contribute to the development of cardiovascular disease, but cigarette smoking is a major risk factor for both CAD (coronary artery disease) and PVD (peripheral vascular disease).

The nurse evaluates the results of which laboratory test as diagnostic for acute coronary syndrome in the client with unstable angina? a. Troponin T b. Serum lactate dehydrogenase (LDH) c. Serum myoglobin d. Creatine kinase (CK)-MB isoenzym

ANS: A Although all these laboratory tests are appropriate to confirm or rule out a myocardial infarction, the one most specific for acute coronary syndromes is troponin T. When elevated, it serves to identify the development of unstable angina, subendocardial MI, or MI.

Which client is most at risk of developing left-sided heart failure? a. Middle-aged woman with aortic stenosis b. Middle-aged man with pulmonary hypertension c. Older woman who smokes two packs of cigarettes daily d. Older man who has had a right ventricular myocardial infarction

ANS: A Although most individuals with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, CAD (coronary artery disease), and hypertension.

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

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

The client's urinary output is normal, whereas the respiratory rate and heart rate are slightly elevated from baseline. The nurse correlates these findings to which stage of shock? a. Early b. Compensatory c. Intermediate d. Refractory

ANS: A An increase in heart and respiratory rates (heart rate first) from the client's baseline or a slight increase in diastolic blood pressure may be the only objective manifestations of early shock.

The client with heart failure is prescribed enalapril (Vasotec). What is the nurse's focus for teaching? a. Avoiding salt substitutes b. Taking medication with food c. Avoiding aspirin or aspirin-containing products d. Holding this medication if the pulse rate is below 74 beats/min

ANS: A Angiotensin-converting enzyme (ACE) inhibitors inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride.

A client in the hyperdynamic phase of septic shock has been admitted to the intensive care unit. For which complication will the nurse be alert for as shock progresses from the hyperdynamic to the hypodynamic phase? a. Acute respiratory distress syndrome b. Acute bowel obstruction c. Ventricular tachycardia d. Seizure activity

ANS: A As septic shock progresses to the hypodynamic phase, acute respiratory distress syndrome (ARDS), a potentially fatal complication, can develop. There will be decreased perfusion to the bowel, but a bowel obstruction is usually seen.

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

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

A client admitted with septic shock develops tachycardia and an increase of 20 mm Hg in systolic blood pressure. Which pathophysiologic factors of hyperdynamic shock are responsible for these clinical manifestations? a. Inflammatory reaction of circulating endotoxins b. Vasoconstriction resulting in tissue hypoxia c. Reductions in hematocrit and hemoglobin d. Platelet aggregation

ANS: A Circulating endotoxins interact with white blood cells and blood vessel walls to trigger inflammatory reactions. Some endotoxins exert a direct effect on the heart, causing an initial increase in cardiac output and resulting in tachycardia, with normal to elevated systolic blood pressure. In hyperdynamic shock, vasodilation is present. Reductions in hematocrit and hemoglobin levels are seen late in septic shock accompanying hemorrhage. Platelet aggregation can cause microthrombus formation, leading to disseminated intravascular coagulation (DIC).

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

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

The nurse is caring for a patient following insertion of an intraaortic balloon pump (IABP) for cardiogenic shock unresponsive to pharmacotherapy. Which hemodynamic parameter best indicates an appropriate response to therapy? a. Cardiac index (CI) of 2.5 L/min/m2 b. Pulmonary artery diastolic pressure of 26 mm Hg c. Pulmonary artery occlusion pressure (PAOP) of 22 mm Hg d. Systemic vascular resistance (SVR) of 1600 dynes/sec/cm-5

ANS: A Desired outcomes for a patient in cardiogenic shock with an IABP include decreased SVR, diminished symptoms of myocardial ischemia (chest pain, ST-segment elevation), increased stroke volume, and increased cardiac output and cardiac index. A cardiac index of 2.5 L/min is within normal limits. All other values are high and would not indicate an appropriate response to therapy.

The nurse has administered a drug that causes vasoconstriction. Which finding indicates an expected response? a. Increased diastolic blood pressure b. Decreased heart rate c. Increased systolic blood pressure d. Increased mean arterial pressure

ANS: A Diastolic pressure is determined by the amount of vasoconstriction in the periphery. An increase in peripheral vascular resistance increases diastolic pressure.

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

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

Which medication(s) will the nurse administer to a client in the hyperdynamic phase of septic shock? a. Heparin b. Vitamin K c. Corticosteroids d. Clotting factors, platelets, and plasma

ANS: A During the hyperdynamic phase of septic shock, because of alterations in the clotting cascade, clients begin to form numerous small clots. Heparin is administered to limit clotting and prevent consumption of clotting factors.

Which client statement alerts the nurse to the occurrence of heart failure? a. "I get short of breath when I climb stairs." b. "I see halos floating by." c. "I have trouble remembering things." d. "I have lost my appetite".

ANS: A Dyspnea on exertion (DOE) is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure.

An older adult client is admitted with fluid volume excess. Which diagnostic or laboratory study would best assist in the diagnosis of heart failure? a. Echocardiography b. Chest x-ray c. T4, TSH d. Arterial blood gases

ANS: A Echocardiography is considered the best tool for the diagnosis of heart failure.

After receiving a handoff report from the night shift, the nurse completes the morning assessment of a patient with severe sepsis. Vital sign assessment notes blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32 breaths/min, oxygen saturation (SpO2) 96% on 45% oxygen via Venturi mask, temperature 101.5° F, central venous pressure (CVP/RAP) 2 mm Hg, and urine output of 10 mL for the past hour. The nurse initiates which active physician order first? a. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is < 5 mm Hg. b. Increase supplemental oxygen therapy to maintain SpO2 greater than 94%. c. Administer 40 mg furosemide (Lasix) intravenous as needed if the urine output is less than 30 mL/hr. d. Administer acetaminophen (Tylenol) 650-mg suppository per rectum as needed to treat temperature > 101° F.

ANS: A Fluid volume resuscitation is the priority in patients with severe sepsis to maintain circulating blood volume and end-organ perfusion and oxygenation. A 500-mL IV bolus of 0.9% normal saline is appropriate given the patient's CVP of 2 mm Hg and hourly urine output of 10 mL/hr. There is no evidence to support the need to increase supplemental oxygen. Administration of furosemide (Lasix) in the presence of a fluid volume deficit is contraindicated.

Which intervention reduces the risk of complications in the client with a myocardial infarction who has been treated with thrombolytic therapy? a. Administration of heparin b. Application of ice to the injection site c. Placing the client in Trendelenburg position d. Instructing the client to take slow deep breaths

ANS: A Following clot lysis, large amounts of thrombin are released, increasing the risk of vessel reocclusion. To maintain vessel patency, IV or low-molecular weight heparin and aspirin are prescribed.

Which assessment finding alerts the nurse to the possibility of pulmonary edema in an older adult? a. Confusion b. Dysphagia c. Sacral edema d. Irregular heart rate

ANS: A Impending pulmonary edema is characterized by a change in mental status, disorientation, and confusion, along with dyspnea and increasing fluid levels in the lungs

A patient is admitted to the cardiac care unit with an acute anterior myocardial infarction. The nurse assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields. Following insertion of a pulmonary artery catheter by the physician, which hemodynamic values is the nurse most likely to assess? a. High pulmonary artery diastolic pressure and low cardiac output b. Low pulmonary artery occlusive pressure and low cardiac output c. Low systemic vascular resistance and high cardiac output d. Normal cardiac output and low systemic vascular resistance

ANS: A In cardiogenic shock, cardiac output and cardiac index decrease. Right atrial pressure, pulmonary artery pressures, and pulmonary artery occlusion pressure increase and volume backs up into the pulmonary circulation and the right side of the heart. Pulmonary artery occlusion pressure increases in cardiogenic shock. Systemic vascular resistance is high and cardiac output is low in cardiogenic shock. Cardiac output is low and systemic vascular resistance is high in cardiogenic shock.

The home care nurse is assessing the client receiving antibiotic therapy in the home for infective endocarditis. Which of the following clinical manifestations requires re-evaluation of the treatment regimen? a. Temperature: 101.6° F b. Clubbing of fingers c. Petechiae d. Pulse pressure of 36 mm Hg

ANS: A Persistent or new fever in a client receiving antibiotic therapy for infective endocarditis may indicate inappropriate or ineffective therapy.

How will the nurse position the client in severe heart failure? a. High Fowler's, pillows under arms b. Semi-Fowler's, with legs elevated c. High Fowler's, with legs elevated d. Semi-Fowler's, on their left side

ANS: A Placing the client in a high Fowler's position, with pillows under their arms, allows for maximum chest expansion.

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

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

The client asks the nurse to explain about his heart murmur. Which is the nurse's best response? a. It is the rushing sound that blood makes moving through narrow places. b. It is the sound of the heart muscle stretching in an area of weakness. c. It is a term doctors use to describe how well the blood circulates in the heart. d. It is the sound the heart makes when it has to work too hard.

ANS: A Murmurs reflect turbulent blood flow through normal or abnormal valves. The significance of a murmur depends on its cause. Some murmurs are associated with a healthy heart that ejects blood quickly and turbulently from the left ventricle. Other murmurs may be indicators of severe valve, vessel, or heart problems.

In caring for the client who has suffered a myocardial infarction, the nurse correlates which hemodynamic parameters with cardiogenic shock? a. Decreased cardiac output and decreased MAP b. Increased cardiac output and increased afterload c. Increased cardiac output and increased MAP d. Decreased cardiac output and increased MAP

ANS: A Myocardial infarction (MI) is a major cause of direct pump failure. With MI, cardiac output and MAP are decreased and afterload is increased.

Eight hours after presenting to the emergency department with complaints of substernal chest pain, a client's laboratory results demonstrate that myoglobin levels have not risen. What is the nurse's interpretation of these results? a. The client has not experienced a myocardial infarction. b. The client is experiencing an evolving myocardial infarction. c. The client most likely had a myocardial infarction several days ago. d. The client has experienced a myocardial infarction within the last 24 hours.

ANS: A Myoglobin is a heme protein found in skeletal and cardiac muscle. With myocardial injury, myoglobin levels rise within 3 to 6 hours. If myoglobin levels have not risen within that time, the client has not experienced a myocardial infarction.

A client in severe heart failure is to receive nesiritide (Natrecor). Which intervention is essential prior to starting this medication? a. Insert a separate IV access. b. Prepare a test bolus dose. c. Prepare the piggyback line. d. Administer IV Lasix first.

ANS: A Natrecor should be given through a separate IV access because it is incompatible with many medications, especially heparin.

Which laboratory value is indicative of a myocardial infarction? a. Troponin T = 0.8 ng/mL b. Myoglobin = 85 mcg/L c. CK creatine kinase = 180 units/L d. HDL = 60 mg/dL

ANS: A Normal levels are troponin T <0.2 ng/mL; myoglobin <90 mcg/L; CK = 30-135 units/L (females), 55-170 units/L (males); HDL = 55-60 mg/dL (females), 5-50 mg/dL (males). Troponin T and CK levels are elevated. CK is nonspecific for cardiac damage; CK-MB is specific for cardiac muscle; troponin T is specific for cardiac necrosis and acute myocardial infarction (MI).

A nurse obtains a pulmonary artery pressure reading of 25/12 mm Hg in a client recovering from a myocardial infarction. Which is the nurse's first intervention based on these findings? a. Compares the results with previous readings b. Increases the IV fluid rate because these readings are low c. Immediately notifies the physician of the elevated pressures d. Documents the finding and continues to monitor

ANS: A Normal pulmonary artery pressures range from 15 to 26 mm Hg for systolic and 5 to 15 mm Hg for diastolic. Although these readings are within normal limits, the nurse needs to assess any trends that may indicate a need for medical treatment to prevent complications.

A client with a history of having several myocardial infarctions has excessive filling of the ventricles as a result. Which physiologic response will the nurse expect to see in this client? a. Decreased cardiac output b. Increased blood pressure c. Increased pulse pressure d. Increased mean arterial pressure

ANS: A Overstretching or excessive filling of the ventricles results in excessive end-diastolic volume and decreased cardiac output.

The nurse is caring for a patient admitted with cardiogenic shock. Hemodynamic readings obtained with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac index (CI) of 1.0 L/min/m2. What is the priority pharmacological intervention? a. Dobutamine (Dobutrex) b. Furosemide (Lasix) c. Phenylephrine (Neo-Synephrine) d. Sodium nitroprusside (Nipride)

ANS: A Positive inotropic agents (e.g., dobutamine) are given to increase the contractile force of the heart. As contractility increases, cardiac output and index increase and improve tissue perfusion. Administration of furosemide will assist only in managing fluid volume overload. Phenylephrine administration enhances vasoconstriction, which may increase afterload and further reduce cardiac output. Sodium nitroprusside is given to reduce afterload. There is no evidence to support a need for afterload reduction in this scenario.

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

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

What is the nurse's interpretation of a client's ECG that reveals ST-segment depression and T-wave inversion in leads II, III, and aVF? a. An episode of angina b. Variant angina c. Acute myocardial infarction d. Aortic thrombosis

ANS: A The ECG obtained during an anginal episode reveals ST-segment depression, T-wave inversion, or both. With variant angina, the ECG reveals ST-segment elevation. With acute MI, ECG changes include ST-segment elevation, T-wave inversion, and abnormal Q waves.

The nurse is caring for a patient in cardiogenic shock who is being treated with an intraaortic balloon pump (IABP). The family inquires about the primary reason for the device. What is the best statement by the nurse to explain the IABP? a. "The action of the machine will improve blood supply to the damaged heart." b. "The machine will beat for the damaged heart with every beat until it heals." c. "The machine will help cleanse the blood of impurities that might damage the heart." d. "The machine will remain in place until the patient is ready for a heart transplant."

ANS: A The IABP improves coronary artery perfusion, reduces afterload, and improves perfusion to vital organs. An IABP acts through counterpulsation, augmenting the pumping action of the heart, displacing blood to improve both forward and backward blood flow. It does not "beat" for the damaged heart. An IABP does not filter blood impurities. An IABP is designed as a temporary therapy for use when pharmacological interventions alone are not effective. It is indicated for short-term use, not as a bridge to transplant.

The client presents with a heart rate of 40 beats/min. The nurse expects that an electrophysiological study may determine an alteration in which structure? a. Sinoatrial (SA) node b. Bachmann's bundle c. Bundle of His d. Purkinje fibers

ANS: A The SA node is composed of pacemaker cells that normally initiate electrical impulses at a rate of 60 to 100 beats/min. Altered function of the SA node may result in slow or rapid heart rates

While monitoring a patient for signs of shock, the nurse understands which system assessment to be of priority? a. Central nervous system b. Gastrointestinal system c. Renal system d. Respiratory system

ANS: A The central nervous system experiences decreased perfusion first. The patient will have central nervous system changes early during the course of shock, such as changes in the level of consciousness. Although the gastrointestinal, renal, and respiratory systems also experience changes during shock, changes in the central nervous system provide the earliest indication of decreased perfusion.

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

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

Which laboratory result alerts the nurse that a female client is at high risk for cardiovascular disease? a. Homocysteine = 25 mmol/dL b. Highly sensitive C-reactive protein = 1 mg/dL c. Microalbuminuria, trace d. CK-MB = 1%

ANS: A The homocysteine level is elevated, which is indicative of protein breakdown. Elevation is a significant marker in females.

A client with a stenotic mitral valve has presented to the clinic for further evaluation. Which intervention is the highest priority? a. Assessment of blood pressure b. Assessment of heart rate c. Intravenous fluids d. Administration of digoxin

ANS: A The mitral valve separates the left atrium from the left ventricle. Stenosis of this valve results in a decreased amount of blood entering the left ventricle. This may result in blood pressure changes. Intravenous fluids and administration of digoxin would not be as important as assessing for decreased cardiac output by changes in blood pressure. Heart rate may eventually change as the client compensates for the decreased output.

The nurse is caring for an 18-year-old athlete with a possible cervical spine (C5) injury following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. The patient's skin is warm and flushed. What is the best interpretation of these findings by the nurse? a. The patient is developing neurogenic shock. b. The patient is experiencing an allergic reaction. c. The patient most likely has an elevated temperature. d. The vital signs are normal for this patient.

ANS: A The most profound feature of neurogenic shock is bradycardia with hypotension from the decreased sympathetic activity. There is no evidence to support an allergic reaction in this scenario. Hypothermia, not an elevated temperature, can develop from uncontrolled heat loss associated with vasodilation in neurogenic shock. Vital signs are not normal given the clinical situation.

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

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

The nurse assesses a client and notes the presence of an S3 gallop. Which is the nurse's priority intervention? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the health care provider immediately. d. Transfer the client to the intensive care unit.

ANS: A The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure

The nurse is caring for a patient in septic shock. The nurse assesses the patient to have a blood pressure of 105/60 mm Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on 45% supplemental oxygen via Venturi mask, and a temperature of 102° F. The physician orders stat administration of an antibiotic. Which additional physician order should the nurse complete first? a. Blood cultures b. Chest x-ray c. Foley insertion d. Serum electrolytes

ANS: A Timely identification of the causative organism through blood cultures and the initiation of appropriate antibiotics following obtaining blood cultures improve the survival of patients with sepsis or septic shock. A chest x-ray, Foley insertion, and measurement of serum electrolytes may be included in the plan of care but are not the priority in this scenario.

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

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

A nurse is preparing to measure a client's pulmonary artery wedge pressure (PAWP). In what position will the nurse place the client for the most accurate results? a. Supine, with the head elevated to 45 degrees b. Supine, with the head elevated to 30 degrees c. Reverse Trendelenburg position at 15 degrees d. Supine, flat

ANS: A To measure the PAWP accurately, the client should be placed in supine position, with the head elevated to 45 degrees.

A client brought to the emergency room following a myocardial infarction is found to be hypotensive. Which compensatory change is expected as a result of baroreceptor stimulation? a. Increased heart rate b. Vasodilation c. Hypoxemia d. Decreased respiratory rate

ANS: A When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the SA node. This results in an increase in heart rate.

Which technique will the nurse use to auscultate the second heart sound? a. Bell of the stethoscope at the base of the heart b. Diaphragm of the stethoscope at the base of the heart c. Bell of the stethoscope at the left sternal border of the heart d. Diaphragm of the stethoscope at the left sternal border of the heart

ANS: B The second heart sound reflects closing of the aortic and pulmonic valves. This sound is higher pitched and heard best at the base of the heart. The diaphragm of the stethoscope is better at picking up higher pitched sounds

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

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

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

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

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

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

The nurse correlates which clinical manifestations with the early stages of hypovolemic shock? (Select all that apply.) a. Elevated heart rate b. Elevated systolic blood pressure c. Elevated diastolic blood pressure d. Decreased respiratory rate e. Decreased pulse rate f. Decreased body temperature

ANS: A, C Heart and respiratory rates increased from the client's baseline level or a slight increase in diastolic blood pressure may be the only objective manifestations of this early stage of shock.

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

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

The nurse is caring for a young adult patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.) a. Blood pressure b. Heart rate c. Level of consciousness d. Pupil response e. Respirations f. Urine output

ANS: A, C, F The level of consciousness assesses cerebral perfusion, urine output assesses renal perfusion, and blood pressure is a general indicator of systemic perfusion. Heart rate is not an indicator of perfusion. Pupillary response does not assess perfusion. Respirations do not assess perfusion.

The nurse is preparing to obtain a right atrial pressure (RAP/CVP) reading. What are the most appropriate nursing actions? (Select all that apply.) a. Compare measured pressures with other physiological parameters. b. Flush the central venous catheter with 20 mL of sterile saline. c. Inflate the balloon with 3 mL of air and record the pressure tracing. d. Obtain the right atrial pressure measurement during end exhalation. e. Zero reference the transducer system at the level of the phlebostatic axis.

ANS: A, D, E To obtain an accurate right atrial pressure (RAP/CVP) reading, the transducer system should be zero referenced and leveled with the phlebostatic axis to ensure accurate readings; the value should be obtained during end exhalation, and any obtained measure should be evaluated in light of the patient's physiological parameters and physical assessment. The catheter does not need to be flushed before measurement because continuous saline flush is part of the RAP system. There is no balloon with a right atrial pressure (RAP/CVP) catheter.

Which assessment finding indicates arterial insufficiency? a. Dependent edema b. Dependent rubor c. Bluish discoloration of the toes d. Clubbing of the fingers

ANS: B A dusky redness replacing pallor in a dependent foot is an indication of arterial insufficiency. Edema would be indicative of venous insufficiency, as would bluish discoloration.

The nurse hears an atrial gallop (S4) in an older adult client. Which is the best intervention? a. Administer a diuretic. b. Document the finding. c. Decrease the intravenous flow rate. d. Evaluate the client's medications.

ANS: B An atrial gallop may be heard in older adult clients because of a stiffened ventricle. The nurse should document the finding, but no other intervention is needed at this time.

In monitoring a client receiving a dopamine hydrochloride drip for the treatment of shock, the nurse correlates which symptom as an indication of a possible overdose of this medication? a. Pallor b. Hypertension c. Palmar erythema d. Increased pulse deficit

ANS: B An overdose of dopamine hydrochloride is manifested by hypertension.

The nurse has just completed administration of a 1000-L bolus of 0.9% normal saline. The nurse assesses the patient to be slightly confused, with a mean arterial blood pressure (MAP) of 50 mm Hg, a heart rate of 110 beats/min, urine output of 10 mL for the past hour, and a central venous pressure (CVP/RAP) of 3 mm Hg. What is the best interpretation of these results by the nurse? a. Patient response to therapy is appropriate. b. Additional interventions are indicated. c. More time is needed to assess response. d. Values are normal for the patient condition.

ANS: B Assessed vital signs and hemodynamic values indicate decreased circulating volume. The patient has not responded appropriately to therapy aimed at increasing circulating volume. Additional intervention is needed because response to therapy is not appropriate, values are abnormal, and timely intervention is critical for a patient with low circulating blood volume.

The nurse is preparing to measure the thermodilution cardiac output (TdCO) in a patient being monitored with a pulmonary artery catheter. Which action by the nurse best ensures the safety of the patient? a. Ensure the transducer system is zero referenced at the level of the phlebostatic axis. b. Avoid infusing vasoactive agents in the port used to obtain the TdCO measurement. c. Maintain a pressure of 300 mm Hg on the flush solution using a pressure bag. d. Limit the length of the noncompliant pressure tubing to a maximum 48 inches.

ANS: B Avoiding infusing vasoactive agents into the port used to obtain the thermodilution cardiac output (TdCO) measurement prevents the patient from receiving a bolus of these agents during rapid infusion of the injectate solution. Ensuring zero referencing of the transducer, maintaining 300 mm Hg pressure of the system pressure bag, and limiting the length of the pressure tubing help to ensure the obtained measures are accurate and do not influence safety.

A client post-myocardial infarction is placed on a beta blocker. Which statement best indicates that the client understands the action of this medication? a. "It will decrease my blood pressure." b. "It will make me urinate more." c. "I will take this medication at the first indication of chest pain." d. "This will help prevent cardiac disease."

ANS: B Beta blockers slow the heart rate and decrease blood pressure. Beta blockers will not make the client urinate more, and they will not prevent cardiac disease.

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

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

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

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

The nurse is caring for a patient with severe sepsis who was resuscitated with 3000 mL of lactated Ringer solution over the past 4 hours. Morning laboratory results show a hemoglobin of 8 g/dL and hematocrit of 28%. What is the best interpretation of these findings by the nurse? a. Blood transfusion with packed red blood cells is required. b. Hemoglobin and hematocrit results indicate hemodilution. c. Fluid resuscitation has resulted in fluid volume overload. d. Fluid resuscitation has resulted in third spacing of fluid.

ANS: B Fluid resuscitation with large volumes of crystalloid results in hemodilution of red blood cells and plasma proteins. Hemoglobin and hematocrit results indicate hemodilution. Given the clinical scenario, there is no evidence to support the need for a blood transfusion and no evidence of fluid overload. Although administration of large volumes of crystalloid can result in hemodilution of plasma proteins leading to third spacing of fluid, this fact does not support the hemoglobin and hematocrit results.

A client with systolic dysfunction has an ejection fraction of 38%. The nurse expects to observe which physiologic change? a. An increase in stroke volume b. A decrease in tissue perfusion c. An increase in oxygen saturation d. A decrease in arterial vasoconstriction

ANS: B In systolic dysfunction, the ventricle is unable to contract with enough force to eject blood effectively during systole. As the ejection fraction decreases (50% to 70% is normal), tissue perfusion decreases and the client develops activity intolerances.

The emergency department nurse assesses for which clinical manifestation in the client suspected to be in the nonprogressive stage of shock? a. Decreased heart rate and decreased urinary output b. Increased heart rate and decreased urinary output c. Increased pulse pressure and increased heart rate d. Decreased pulse pressure and decreased heart rate

ANS: B In the nonprogressive stage of shock, both kidney and cardiovascular compensations, in addition to chemical compensatory mechanisms, are needed. These result in an increase in heart rate and decrease in urinary output to maintain MAP (mean arterial pressure) and volume in the central blood vessels.

Which assessment finding does the nurse expect in the client with mitral insufficiency? a. A systolic click on auscultation b. A high-pitched holosystolic murmur c. Angina with exertion d. A cough with hemoptysis

ANS: B Incomplete closure of the mitral valve allows backflow of blood into the left atrium when the ventricle contracts, resulting in a holosystolic, high-pitched murmur

The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action? a. Creatinine 1.0 mg/dL b. Lactate 6 mmol/L c. Potassium 3.8 mEq/L d. Sodium 140 mEq/L

ANS: B Lactate level has been used as an indicator of decreased oxygen delivery to the cells, adequacy of resuscitation in shock, and as an outcome predictor. All other listed values are within normal limits and do not require additional follow-up.

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

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

Which therapy will the nurse administer to the client in the late phase of septic shock? a. Anticoagulation therapy b. Clotting factors, platelets, and plasma c. Corticosteroids d. Protamine sulfate

ANS: B Therapy during the second (late) phase of septic shock is aimed at increasing the blood's ability to clot. This consists of administering clotting factors, plasma, platelets, and other blood products.

The client with heart failure has been ordered to receive a daily nitroglycerin transdermal patch. Which is the priority nursing intervention? a. Placing an occlusive dressing over the patch b. Removing the patch overnight c. Rotating the skin site of nitroglycerin administration d. Administering a larger loading dose before the initiation of therapy

ANS: B Providing a 12-hour nitrate-free period out of every 24 hours helps prevent the development of tolerance to the vasodilating effects of nitrates.

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

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

A nurse is caring for a client admitted with tachycardia, a pericardial friction rub, and the development of a murmur. Which finding in the client's history leads the nurse to suspect rheumatic carditis? a. The client was vacationing in the tropics 2 weeks ago. b. The client has had a sore throat for 1 week. c. The client is currently taking antibiotics. d. The client has a history of alcoholism.

ANS: B Rheumatic carditis is a sensitivity response occurring after infection with group A beta-hemolytic streptococci. The client's history of a sore throat is suspicious for rheumatic carditis because of the clinical manifestations at admission.

A client with acidosis resulting from hypovolemic shock has been ordered to receive intravenous fluid replacement. Which fluid preparation will the nurse administer? a. Normal saline b. Ringer's lactate c. 5% dextrose in water d. 5% dextrose in 0.45% normal saline

ANS: B Ringer's lactate is an isotonic solution that acts as a volume expander. Also, the lactate acts as a buffer in the presence of acidosis.

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

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

The nurse is administering intravenous norepinephrine (Levophed) at 5 mcg/kg/min via a 20-gauge peripheral intravenous (IV) catheter. What assessment finding requires immediate action by the nurse? a. Blood pressure 100/60 mm Hg b. Swelling at the IV site c. Heart rate of 110 beats/min d. Central venous pressure (CVP) of 8 mm Hg

ANS: B Swelling at the IV site is indicative of infiltration. Infusion of norepinephrine (Levophed) through an infiltrated IV site can lead to tissue necrosis and requires immediate intervention by the nurse. A blood pressure of 100/60 mm Hg, heart rate of 110 beats/min, and a CVP of 8 mm Hg are adequate and do not require immediate intervention.

The nurse notes that the client's apical pulse is displaced to the left. What conclusion can be drawn from this assessment? a. This is a normal finding. b. The heart is hypertrophied. c. The left ventricle is contracted. d. The client has pulsus alternans.

ANS: B The client with heart failure typically has an enlarged heart that displaces the apical pulse to the left.

Which assessment finding does the nurse expect in a client with pericarditis? a. An irregular heart rate that speeds up and slows down b. A friction rub at the left lower sternal border c. The presence of a gallop rhythm d. A substernal lift at the apex

ANS: B The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together.

What clinical manifestation alerts the nurse to the possibility that the client's mitral stenosis has progressed? a. The client's oxygen saturation is 92%. b. The client has dyspnea on exertion. c. The client has a systolic crescendo-decrescendo murmur. d. The client experiences a loss of strength in the upper extremities.

ANS: B The development of dyspnea on exertion occurs as the mitral valvular orifice narrows and pressure in the lungs increases.

A client's cardiac catheterization has shown an 80% blockage of the right coronary artery (RCA). While waiting for bypass surgery, what is essential to have on hand? a. Furosemide (Lasix) b. External pacemaker c. Lidocaine d. Central venous catheter

ANS: B The right coronary artery supplies the right atrium, the right ventricle, the inferior portion of the left ventricle, and the atrioventricular (AV) node. It also supplies the SA node in 50% of people. If the client occludes the RCA totally, the AV node would not function and the client would go into heart block, so emergency pacing should be available for the client.

Which assessment finding does the nurse expect in the client with mitral valve prolapse? a. Rumbling apical diastolic murmur b. Midsystolic click and late systolic murmur c. An S3 coupled with a high-pitched systolic murmur d. Continuing, loud diastolic murmur radiating to the left axilla

ANS: B The mitral valve separates the left atrium from the left ventricle. The prolapse permits backflow of blood during mid- to late systole, resulting in a midsystolic click and a late systolic murmur at the heart apex.

A client has had a recent myocardial infarction involving the left ventricle. Which assessment finding is expected? a. Faint S1 and S2 sounds on auscultation b. Decreased cardiac output c. Increased blood pressure d. Increased strength of peripheral pulses

ANS: B The myocardium is the layer responsible for the contractile force of the heart. Damage to this layer can result in decreased cardiac output. This would most likely result in a decreased blood pressure and strength of peripheral pulses. S1 and S2 would most likely not be affected.

The nurse is caring for a patient in cardiogenic shock experiencing chest pain. Hemodynamic values assessed by the nurse include a cardiac index (CI) of 2.5 L/min/m2, heart rate of 70 beats/min, and a systemic vascular resistance (SVR) of 2200 dynes/sec/cm-5. Upon review of physician orders, which order is most appropriate for the nurse to initiate? a. Furosemide (Lasix) 20 mg intravenous (IV) every 4 hours as needed for CVP > 20 mm Hg b. Nitroglycerin infusion titrated at a rate of 5-10 mcg/min as needed for chest pain c. Dobutamine (Dobutrex) infusion at a rate of 2-20 mcg/kg/min as needed for CI < 2 L/min/m2 d. Dopamine (Intropin) infusion at a rate of 5-10 mcg/kg/min to maintain a systolic BP of at least 90 mm Hg

ANS: B The patient is complaining of chest pain and has an elevated systemic vascular resistance (SVR). To reduce afterload, ease the workload of the heart, and dilate the coronary arteries, improving oxygenation to the heart muscle, initiation of a nitroglycerin infusion is most appropriate. Assessment data do not support the initiation of other listed physician order options.

Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips, hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36 breaths/min. What is the priority intervention? a. Diphenhydramine (Benadryl) 50 mg intravenously b. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously c. Methylprednisolone (Solu-Medrol) 125 mg intravenously d. Ranitidine (Zantac) 50 mg intravenously

ANS: B The patient is exhibiting signs of anaphylaxis. For anaphylaxis with hypotension, epinephrine 0.3 to 0.5 mg (3 to 5 mL of 1:10,000 solution) is administered intravenously. Diphenhydramine (Benadryl) will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension. Corticosteroids, such as methylprednisolone (Solu-Medrol), are used to reduce inflammation, but epinephrine is the drug of choice for anaphylaxis with hypotension. Ranitidine (Zantac) will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension.

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

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

A client brought to the emergency room has been diagnosed with an acute myocardial infarction and is ordered thrombolytic therapy with reteplase. The nurse correlates which rationale with the administration of this medication? a. Reversing any myocardial damage if given within 2 hours of the event b. Restoring perfusion to the injured area, reducing the size of the infarct c. Restoring coronary reperfusion without risk of internal bleeding d. Decreasing the necessity of percutaneous transluminal coronary angioplasty (PTCA)

ANS: B Thrombolytic therapy is indicated in MI to restore perfusion to the injured area, thereby limiting the size of the infarct. Establishing sustained reperfusion in the first few hours after an MI has resulted in a decreased incidence of mortality.

The nurse is caring for a 70-kg patient in hypovolemic shock. Upon initial assessment, the nurse notes a blood pressure of 90/50 mm Hg, heart rate 125 beats/min, respirations 32 breaths/min, central venous pressure (CVP/RAP) of 3 mm Hg, and urine output of 5 mL during the past hour. Following physician rounds, the nurse reviews the orders and questions which order? a. Administer acetaminophen (Tylenol) 650-mg suppository prn every 6 hours for pain. b. Titrate dopamine (Intropin) intravenously for blood pressure < 90 mm Hg systolic. c. Complete neurological assessment every 4 hours for the next 24 hours. d. Administer furosemide (Lasix) 20 mg IV every 4 hours for a CVP > 20 mm Hg.

ANS: B Vasoconstrictive agents should not be administered for hypotension in the presence of circulation fluid volume deficit. The nurse should question the use of the dopamine (Intropin) infusion. All other listed orders are appropriate and have potential for use in the treatment of a hypovolemic shock.

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

ANS: B When the pacemaker generates an electrical impulse (pacer spike) and no depolarization is noted, it is described a failure to capture. On the ECG, a pacer spike is noted, but it is not followed by a P wave (atrial pacemaker) or a QRS complex (ventricular pacemaker). Common causes of failure to capture include output (milliamperes) set too low, or displacement of the pacing lead wire from the myocardium (transvenous or epicardial leads). Other causes of failure to capture include battery failure, fracture of the pacemaker wire, or increased pacing threshold as a result of medication or electrolyte imbalance.

A client with coronary artery disease is scheduled for a minimally invasive direct coronary artery bypass (MIDCAB). Which is the nurse's best response to the client's questions about how this procedure is different? a. "The sternotomy incision is smaller." b. "Cardiopulmonary bypass is not required." c. "There is far less incisional pain with a MIDCAB." d. "There is no risk of graft closure after this procedure."

ANS: B With a MIDCAB procedure, cardiopulmonary bypass is not required. It uses a thoracotomy incision rather than a sternotomy. Clients who have a MIDCAB report more incisional pain as compared with a traditional CABG. There is a risk of graft closure, as with a CABG.

Which of the following situations may result in a low cardiac output and low cardiac index? (Select all that apply.) a. Exercise b. Hypovolemia c. Myocardial infarction d. Shock

ANS: B, C, D Hypovolemia, myocardial infarction, and shock often result in a decreased cardiac output. Cardiac output is usually increased with exercise.

A female client is admitted to rule out ischemic heart disease. Which symptoms are indicative of heart disease? (Select all that apply.) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal fullness e. Anxiety f. Feeling of choking g. Abdominal pain

ANS: B, C, D, E, F Women may not have chest pain but may feel discomfort or indigestion. They often present with a triad of symptoms—indigestion or feeling of abdominal fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch the breath. Frequently, women are not diagnosed and therefore not treated adequately.

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

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

In monitoring a client in hypovolemic shock who has been placed on a dopamine hydrochloride drip, the nurse recognizes which parameter as the desired response to this drug? a. Hypotension b. Tachycardia c. Increased cardiac output d. Decreased mean arterial pressure

ANS: C Dopamine hydrochloride causes vasoconstriction that in turn increases cardiac output and mean arterial pressure, thereby improving tissue perfusion and oxygenation.

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

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

A client with heart failure develops an increase in preload. Which mechanism contributes to this increase? a. A reduction in sympathetic stimulation b. Stimulation of coronary baroreceptors c. Activation of the renin-angiotensin-aldosterone system d. Arterial vasodilation and subsequent increase in oxygen consumption

ANS: C Activation of the renin-angiotensin-aldosterone system increases preload by contributing to vasoconstriction and fluid retention, which in turn reduce the force of contraction and cardiac output.

The nurse prioritizes which assessment in the older client who has had CABG surgery? a. Skin assessment b. Otoscopic assessment c. Mental status assessment d. Gastrointestinal assessment

ANS: C Assessment of mental status is important, because older adults are more likely to experience transient neurologic deficits as compared with younger adults.

The nurse recognizes which laboratory test as most specific in diagnosing an acute myocardial infarction? a. Myoglobin b. Serum LDH c. CK-MB isoenzyme d. Troponin T

ANS: C CK-MB isoenzyme is found in myocardial muscle. CK-MB activity is most specific for myocardial infarction (MI) and shows a predictable rise and fall over 3 days.

A client's heart disease has resulted in a reduction of stroke volume. Which compensatory mechanism is expected? a. Increased blood pressure b. Decreased mean arterial pressure c. Increased heart rate d. Decreased respiratory rate

ANS: C Cardiac output is equal to stroke volume multiplied by the heart rate. When stroke volume decreases, the heart rate increases to compensate.

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

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

What assessment finding will the nurse expect as the client's mean arterial blood pressure decreases below 60 mm Hg? a. Increased cardiac output b. Hypertension c. Chest pain d. Decreased heart rate

ANS: C Coronary artery blood flow occurs primarily during diastole. A mean arterial pressure (MAP) of 60 mg Hg is necessary for adequate blood flow to coronary arteries and a MAP of 60 to 70 mm Hg is necessary for adequate perfusion to major body organs. If the MAP decreases below 60 mm Hg, the client with cardiac disease may have chest pain. The cardiac output would most likely decrease, and the blood pressure would also decrease. Heart rate may increase as the body initiates compensatory mechanisms.

The nurse monitors for which responses as indicative of improvement in the client receiving dobutamine for management of heart failure? a. Decreased heart rate, increased pulse quality b. Decreased heart rate, decreased pulse quality c. Increased heart rate, increased pulse quality d. Increased heart rate, decreased pulse quality

ANS: C Dobutamine is a positive inotropic agent that works by stimulating beta-adrenergic receptor sites. The result of this stimulation is an increase in the rate and force of the myocardial contraction.

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

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

Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock? a. A patient admitted with abdominal pain and an elevated white blood cell count b. A patient with a temperature of 102° F and a general dermal rash c. A patient with a 2-day history of nausea, vomiting, and diarrhea d. A patient with slight rectal bleeding from inflamed hemorrhoids

ANS: C Excessive external loss of fluid may occur through the gastrointestinal tract via vomiting and diarrhea, which may lead to hypovolemia. There is no evidence to support significant fluid loss in the remaining patient scenarios.

The nurse is starting to administer a unit of packed red blood cells (PRBCs) to a patient admitted in hypovolemic shock secondary to hemorrhage. Vital signs include blood pressure 60/40 mm Hg, heart rate 150 beats/min, respirations 42 breaths/min, and temperature 100.6° F. What is the best action by the nurse? a. Administer blood transfusion over at least 4 hours. b. Notify the physician of the elevated temperature. c. Titrate rate of blood administration to patient response. d. Notify the physician of the patient's heart rate.

ANS: C Given the acute nature of the patient's blood loss, the nurse should titrate the rate of the blood transfusion to an improvement in the patient's blood pressure. Administering the transfusion over 4 hours can lead to a prolonged state of hypoperfusion and end-organ damage. The heart rate will normalize as circulating blood volume is restored. A mildly elevated temperature does not take priority over restoring circulating blood volume.

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

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

The nurse is caring for a patient in spinal shock. Vital signs include blood pressure 100/70 mm Hg, heart rate 70 beats/min, respirations 24 breaths/min, oxygen saturation 95% on room air, and an oral temperature of 96.8° F. Which intervention is most important for the nurse to include in the patient's plan of care? a. Administration of atropine sulfate (Atropine) b. Application of 100% oxygen via facemask c. Application of slow rewarming measures d. Infusion of IV phenylephrine (Neo-Synephrine)

ANS: C Hypothermia can develop in neurogenic shock from uncontrolled heat loss; therefore, a patient should be rewarmed slowly to avoid further vasodilation. In shock, a drop in systolic blood pressure to less than 90 mm Hg is considered hypotensive. Atropine is used for symptomatic bradycardia. The patient's oxygen saturation is 95% on room air with an adequate respiratory rate. The application of 100% oxygen via facemask is not indicated. The patient's heart rate is adequate to support a normal blood pressure.

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

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

Which assessment finding does the nurse expect in a client diagnosed with aortic stenosis? a. Bounding arterial pulse b. Slow, faint arterial pulse c. Narrowed pulse pressure d. Elevated systolic and diastolic pressures

ANS: C In aortic stenosis, the client presents with a narrowed pulse pressure when the blood pressure is assessed.

A client is admitted with early-stage heart failure. Which immediate compensatory response would the nurse expect to see in this client? a. Decreased stroke volume, causing decreased urinary output b. Arterial vasodilation, resulting in pooling of blood in the extremities c. Stimulation of adrenergic receptors, causing an increase in heart rate d. Myocardial hypertrophy, resulting in an initial increase in oxygen saturation

ANS: C In heart failure, stimulation of the sympathetic nervous system represents the most immediate response. Adrenergic receptor stimulation causes an increase in heart rate and respiratory rate.

A client is admitted with early-stage heart failure. Which assessment finding does the nurse expect? a. A drop in blood pressure and urine output b. An increase in creatinine and lower extremity edema c. An increase in heart rate and respiratory rate d. An increase in oxygen saturation

ANS: C In heart failure, stimulation of the sympathetic nervous system represents the most immediate response. Adrenergic receptor stimulation causes an increase in heart rate and respiratory rate. The blood pressure will remain the same or elevate slightly.

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

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

An older adult client with heart failure has developed atrial fibrillation. What diagnostic or laboratory test would the nurse expect to be ordered? a. Serum anion gap b. Serum sodium level c. T4 (thyroxine) and TSH (thyroid-stimulating hormone) d. Serum creatinine

ANS: C In older adults with atrial fibrillation, T4 and TSH levels should be checked because hypo- or hyperthyroidism can cause or aggravate heart failure.

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

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

The nurse is caring for a patient admitted to the critical care unit 48 hours ago with a diagnosis of severe sepsis. As part of this patient's care plan, what intervention is most important for the nurse to discuss with the multidisciplinary care team? a. Frequent turning b. Monitoring intake and output c. Enteral feedings d. Pain management

ANS: C Initiation of enteral feedings within 24 to 48 hours of admission is critical in reducing the risk of infection by assisting in maintaining the integrity of the intestinal mucosa. Monitoring intake and output, frequent turning, and pain management are important aspects of care but are not a critical priority during the first 24 to 48 hours following admission.

A nurse is performing an admission assessment on an older adult client with multiple chronic diseases. The nurse finds the heart rate to be 48 beats/min. What will the nurse do first? a. Document the finding as normal. b. Evaluate the client for a pulse deficit. c. Assess the client's medications. d. Administer atropine.

ANS: C Pacemaker cells in the conduction system decrease in number as a person ages, resulting in bradycardia. The nurse should check the medication reconciliation for medications that might cause such a drop in the heart rate and then inform the health care provider.

A client who had a stroke 1 month ago presents with an acute MI. The nurse recognizes which statement as correct regarding the administration of thrombolytic therapy to this client? a. No effect on administration of this therapy b. Relative contraindication to administration of this therapy c. Absolute contraindication for administration of this therapy d. Increased risk for an extension of the current MI

ANS: C Recent stroke (within 2 months) is an absolute contraindication to thrombolytic therapy.

Which illness in the client's history would alert the nurse to the possibility of an abnormality of the heart valves? a. Tuberculosis b. Recurrent viral pneumonia c. Rheumatic fever d. Asthma

ANS: C Rheumatic fever is an inflammatory disease that is typically caused by infection with group A beta-hemolytic streptococci that can affect the endocardium.

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

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

The nurse correlates which rationale with the administration of aspirin plus nitroglycerin to the client experiencing angina-like chest pain? a. Analgesic properties without sedation b. Vasoconstriction and improved blood flow c. Inhibition of platelet aggregation and clot formation d. Cardiotonic properties and improved contraction

ANS: C Taking aspirin at the first sign of chest pain can disrupt blood clotting and reduce the risk of a coronary thrombosi

Which instructions are essential in a teaching plan for a client with hypertrophic cardiomyopathy (HCM)? a. "Take your digoxin at the same time every day." b. "You should begin an aerobic exercise program." c. "You should report episodes of dizziness or fainting." d. "You may have a maximum of two alcoholic drinks weekly."

ANS: C The client with HCM is instructed to notify the health care provider if episodes of fainting, dizziness, or palpitations occur, because these may signal the onset of deadly dysrhythmias. Clients with HCM are instructed to avoid strenuous exercise and alcohol. Cardiac glycosides are contraindicated in obstructive HCM.

Which nursing diagnosis would be considered a priority for the client with heart failure? a. Anxiety related to hospitalization b. Altered Health Maintenance c. Impaired Gas Exchange d. Altered Comfort

ANS: C The client with heart failure experiences impaired gas exchange related to inadequate cardiac pump function. Although all other diagnoses presented here may be manifested, Impaired Gas Exchange is the priority because it is the most life-threatening.

A client brought to the emergency room after a motor vehicle accident is suspected of having internal bleeding. Which initial clinical manifestation of hypovolemic shock would the nurse expect to find in this client? a. Increased respiratory rate b. Decreased urinary output c. Increased heart rate d. Cool pale skin

ANS: C The first manifestations of hypovolemic shock result from compensatory mechanisms. Signs of shock are first evident as changes in cardiovascular function. As shock progresses, changes in skin, respiration, and kidney function progress.

A nurse notes that the cardiac output, systolic blood pressure, and pulse pressure are beginning to decrease rapidly in a client being treated for septic shock. Which conclusion can the nurse draw from these changes? a. Respiratory acidosis will follow quickly. b. Compensatory mechanisms are being activated. c. The client is in the hypodynamic phase of septic shock. d. The therapy for septic shock is beginning to demonstrate effectiveness.

ANS: C The hypodynamic phase of septic shock is characterized by a rapid decrease in cardiac output, systolic blood pressure, and pulse pressure.

A patient is admitted after collapsing at the end of a summer marathon. She is lethargic, with a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg. The nurse anticipates administering which therapeutic intervention? a. Human albumin infusion b. Hypotonic saline solution c. Lactated Ringer's bolus d. Packed red blood cells

ANS: C The patient is experiencing symptoms of hypovolemic shock. Isotonic crystalloids, such as normal saline and lactated Ringer's solutions, are the priority intervention. Albumin and plasma protein fraction (Plasmanate) are naturally occurring colloid solutions that are infused when the volume loss is caused by a loss of plasma rather than blood, such as in burns, peritonitis, and bowel obstruction. Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema and are not used for fluid resuscitation. There is no evidence to support a transfusion in the given scenario.

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

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

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

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

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

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

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

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

During the initial stages of shock, what are the physiological effects of decreased cardiac output? a. Arterial vasodilation b. High urine output c. Increased parasympathetic stimulation d. Increased sympathetic stimulation

ANS: D A reduction in blood pressure leads to an increase in catecholamine release, resulting in an increase in heart rate and contractility to improve cardiac output. Decreased cardiac output leads to arterial vasoconstriction in an effort to increase blood pressure. Low urine output results, as decreased cardiac output reduces blood flow to the kidneys. There is an increase in sympathetic stimulation in response to a decrease in cardiac output.

he nurse is administering both crystalloid and colloid intravenous fluids as part of fluid resuscitation in a patient admitted in severe sepsis. What findings assessed by the nurse indicate an appropriate response to therapy? a. Normal body temperature b. Balanced intake and output c. Adequate pain management d. Urine output of 0.5 mL/kg/hr

ANS: D Adequate urine output of at least 0.5 mL/ kg/hr indicates adequate perfusion to the kidneys following administration of fluid to enhance circulating blood volume. Normal body temperature and adequate pain management are not assessment findings indicating an adequate response to fluid therapy. During fluid resuscitation in severe sepsis, intake and output will not be balanced as circulating fluid volume deficit is restored.

For which manifestations will the nurse monitor when caring for the client with distributive shock resulting from an anaphylactic event? a. Increased heart rate and blood pressure b. Increased blood pressure and cardiac output c. Decreased blood pressure and respiratory rate d. Decreased blood pressure and edema

ANS: D Anaphylaxis damages cells and causes release of large amounts of histamine and other inflammatory chemicals. This results in massive blood vessel dilation and increased capillary leak.

The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the nurse most likely to assess? a. High pulmonary artery occlusive pressure and high cardiac output b. High systemic vascular resistance and low cardiac output c. Low pulmonary artery occlusive pressure and low cardiac output d. Low systemic vascular resistance and high cardiac output

ANS: D As a consequence of the massive vasodilation associated with septic shock, in the early stages, cardiac output is high with low systemic vascular resistance. In septic shock, pulmonary artery occlusion pressure is not elevated. In the early stages of septic shock, systemic vascular resistance is low and cardiac output is high. In the early stages of septic shock, cardiac output is high.

The nurse is caring for a patient admitted with the early stages of septic shock. The nurse assesses the patient to be tachypneic, with a respiratory rate of 32 breaths/min. Arterial blood gas values assessed on admission are pH 7.50, CO2 28 mm Hg, HCO3 26. Which diagnostic study result reviewed by the nurse indicates progression of the shock state? a. pH 7.40, CO2 40, HCO3 24 b. pH 7.45, CO2 45, HCO3 26 c. pH 7.35, CO2 40, HCO3 22 d. pH 7.30, CO2 45, HCO3 18

ANS: D As shock progresses along the continuum, acidosis ensues, caused by metabolic acidosis, hypoxia, and anaerobic metabolism. A pH 7.30, CO2 45 mm Hg, HCO3 18 indicates metabolic acidosis and progression to a late stage of shock. All other listed arterial blood gas values are within normal limits.

For which client should the nurse remain alert for the possible development of septic shock? a. 25-year-old man with irritable bowel syndrome b. 52-year-old man taking beta blockers for hypertension c. 37-year-old woman who is 20% above ideal body weight d. 68-year-old woman with cancer being treated with chemotherapy

ANS: D Certain conditions or treatments that can cause immunosuppression, such as having cancer and being treated with chemotherapeutic agents, aspirin, and certain antibiotics, can predispose a person to septic shock.

The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102° F, and a right atrial pressure (RAP) of 1 mm Hg. Assuming physician orders, which intervention should the nurse carry out first? a. Acetaminophen suppository b. Blood cultures from two sites c. IV antibiotic administration d. Isotonic fluid challenge

ANS: D Early goal-directed therapy in severe sepsis includes administration of IV fluids to keep RAP/CVP at 8 mm Hg or greater (but not greater than 15 mm Hg) and heart rate less than 110 beats/min. Fluid resuscitation to restore perfusion is the immediate priority. Broad-spectrum antibiotics are recommended within the first hour; however, volume resuscitation is the priority in this scenario.

The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-directed therapy protocols in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? a. Breath sounds and capillary refill b. Blood pressure and oral temperature c. Oral temperature and capillary refill d. Right atrial pressure and urine output

ANS: D Early goal-directed therapy includes administration of IV fluids to keep central venous pressure at 8 mm Hg or greater. Combined with urine output, fluid therapy effectiveness can be adequately assessed. Evaluation of breath sounds assists with determining fluid overload in a patient but does not evaluate the effectiveness of fluid therapy. Capillary refill provides a quick assessment of the patient's overall cardiovascular status, but this assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems. Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in shock. Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in shock. Capillary refill provides a quick assessment of the patient's overall cardiovascular status, but this assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems.

Which intervention is essential to teach the client starting on digoxin therapy? a. "Avoid taking aspirin or aspirin-containing products." b. "Increase fluid intake to at least 3000 mL/day." c. "Do not take this medication if your pulse rate is below 80 beats/min." d. "Do not take this medication within 1 hour of taking an antacid.

ANS: D Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption.

Which client is at highest risk for the development of high-output heart failure? a. Young woman taking oral contraceptives b. Middle-aged man who broke an ankle while training for a marathon c. Older adult with dehydration 5 years after having a myocardial infarction d. Young woman taking large doses of Synthroid to promote weight loss

ANS: D Hyperthyroidism, whether caused by increased synthesis of thyroid hormones or overdose of exogenous thyroid hormone, increases heart rate and contractility. This can increase the workload of the heart without allowing sufficient time for perfusion and oxygenation.

A client is taking triamterene-hydrochlorothiazide (Dyazide) and furosemide (Lasix). Which assessment finding alerts the nurse to a serious side effect? a. Cough b. Headache c. Bradycardia d. Hypokalemia

ANS: D Hypokalemia is a side effect of both thiazide and loop diuretics. The client loses electrolytes with fluid. Coughing is not a typical side effect of this medication. Headaches may occur with any medication, and is not a serious side effect. Bradycardia is not likely to occur with this medication.

The nurse monitors for which complication in the client who had PTCA 1 hour ago? a. Hypertensive crisis b. Hyperkalemia c. Infection d. Bleeding

ANS: D In the first few postprocedure hours, the nurse monitors for complications, such as bleeding from the insertion site, hypotension, acute closure of the vessel, dye reaction, hypokalemia, and dysrhythmias.

Which assessment finding supports a diagnosis of impaired tissue perfusion in the client with heart failure? a. Carotid bruit b. A dry hacking cough c. A positive Allen's test d. Dyspnea on exertion

ANS: D Indications of poor tissue perfusion are activity intolerance, which includes dyspnea on exertion.

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

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

A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. Which primary collaborative intervention should the nurse perform? a. Maintain the head of the bed in a high Fowler's position. b. Keep the client on bedrest, with passive range of motion. c. Limit visitors and activity to a minimum. d. Administer loop diuretics.

ANS: D The client with worsening heart failure is most at risk for pulmonary edema as a consequence of fluid retention. Administering the diuretics will decrease the fluid overload, thereby decreasing the incidence of pulmonary edema.

The client has all the following clinical manifestations. Which assessment finding alerts the nurse to the probability of septic shock? a. Hypotension b. Pale clammy skin c. Anxiety and confusion d. Oozing of blood at the IV site

ANS: D The late phase of sepsis-induced distributive shock is characterized by most of the same cardiovascular manifestations as any other type of shock. The distinguishing feature is the lack of ability to clot blood, causing the client to bleed from areas of minor trauma and to bleed spontaneously

The client is being given a drug that blocks the action of the sympathetic nervous system. Which assessment finding does the nurse expect? a. Increased blood pressure b. Increased heart rate c. Increased cardiac output d. Decreased heart rate

ANS: D The sympathetic nervous system directly stimulates the ventricles, increasing heart rate. It also causes vasoconstriction, increasing blood pressure. Agents that block sympathetic impulses decrease heart rate and blood pressure.

A client admitted with a gastrointestinal ulcer is NPO and has a nasogastric tube connected to low suction. The nurse monitors the client for which type of shock? a. Distributive shock b. Obstructive shock c. Cardiogenic shock d. Hypovolemic shock

ANS: D This client is at risk for hypovolemic shock caused by bleeding from gastrointestinal ulcers, leading to fluid volume loss, and from nasogastric suction, which can compound the situation if the client is not sufficiently hydrated with IV fluids.

A nurse is monitoring a client undergoing exercise electrocardiography (stress test). Which assessment finding necessitates that the test be stopped? a. The client's heart rate reaches 140 beats/min. b. The client's blood pressure is 100/80 mm Hg. c. The client's respiratory rate exceeds 36 breaths/min. d. The client's electrocardiogram (ECG) indicates significant ST segment depression.

ANS: D This electrocardiographic finding is associated with myocardial ischemia and could signal a possible myocardial infarction if the physical activity is continued or increased. The other findings do not indicate emergent assessments.

A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse? a. The assessed values are within normal limits. b. The patient is at risk for developing cardiogenic shock. c. The patient is at risk for developing fluid volume overload. d. The patient is at risk for developing hypovolemic shock.

ANS: D Vital signs and hemodynamic values assessed collectively include classic signs and symptoms of hypovolemia. Both urine output and chest drainage values are high, contributing to the hypovolemia. Assessed values are not within normal limits. A cardiac output of 4 L/min is not indicative of cardiogenic shock. The patient is at risk for hypovolemia, not volume overload, as evidenced by excessive hourly chest drainage and urine output.

What changes in the electrocardiogram (ECG) tracing would the nurse monitor for in the client with a myocardial infarction? a. ST-segment depression, flattened T wave, normal Q wave b. ST-segment depression, T-wave inversion, normal Q wave c. ST-segment inversion, T-wave elevation, abnormal Q wave d. ST-segment elevation, T-wave inversion, abnormal Q wave

ANS: D When myocardial infarction occurs, the changes usually seen on an ECG tracing are ST-segment elevation, T-wave inversion, and an abnormal Q wave.

A patient has had an inferior myocardial infarction. He now has a new holosystolic murmur at apex, acute severe dyspnea, decreased cardiac index, and a normal cardiac silhouette on x-ray film. Which of the following complications most likely is occurring in this patient?

Acute Mitral Regurgitation With an inferior myocardial infarction, the risk of the papillary muscles being affected is greater than in other types of myocardial infarction. The papillary muscles of the left ventricle maintain normal mitral valve function. If damaged, acute mitral regurgitation occurs and is manifested by a new holosystolic murmur at the apex, acute pulmonary edema, and decreased cardiac output/index.

A patient with chronic atrial fibrillation has sudden, continuous, localized pain, pallor, and pulselessness of her right arm. Which of the following is most likely occurring?

Acute arterial occlusion Acute arterial occlusion may result from thrombus, embolus, or swelling compressing an artery (e.g., compartment syndrome or burn injury). Clinical indications of acute arterial occlusion include pain, pallor, pulselessness, paresthesia, paralysis, and polar (cold).

Acute chest pain and/or ST segment elevation after PCI may indicate acute?

Acute closure

A 36-year-old man arrives in the emergency department with complaints of "fluttering" in his chest. The following pattern is seen on the electrocardiogram monitor (V-TACH). Which drug would be administered first? Amio or Adenosine

Amio This is a wide QRS complex tachycardia that is assumed to be ventricular tachycardia. The first drug for a wide QRS complex tachycardia is amiodarone. If the rhythm does not respond to amiodarone, synchronized cardioversion is indicated.

A sound occurring in early diastole caused by a rapid opening of a stenotic mitral valve is which of the following?

An opening snap Mitral stenosis causes a low-pitched rumbling diastolic murmur with an opening snap and a closing snap (a loud S1). An S4 is a late diastolic sound. Stenosis means that the mitral valve will not open well, so the murmur occurs when the valve should be open, thus diastolic murmur. An ejection click is associated with semilunar valve disease.

Indicative leads for this cardiac wall are V3 and V4?

Anterior

A 72-year-old man arrived in the emergency department after 4 hours of substernal pain radiating to the left arm. He has a 100 pack-year history of cigarette smoking, chronic obstructive pulmonary disease, and intermittent claudication. His electrocardiogram on admission shows sinus tachycardia with a rate of 120 beats/min and ST segment elevation in leads I, AVL, and V3 to V6. Vital signs include blood pressure, 150/84 mm Hg; respiratory rate, 15 breaths/min; functional oxygen saturation (SpO2), 95%; and temperature, 38.3° C (100.9° F). Electrocardiogram findings indicate that this patient is having a myocardial infarction in which wall of the heart?

Anterolateral left ventricle Leads I, AVL, V5, and V6 show the lateral wall of the left ventricle. Leads V3 and V4 show the anterior wall of the left ventricle. ST segment elevation in the identified leads indicates acute injury of the anterolateral wall of the left ventricle. Infarction will occur if prompt reperfusion is not achieved.

Which of the following conditions would not cause backward failure of the right ventricle (increased right ventricular end-diastolic volume) and forward failure of the left ventricle (decreased left ventricular end-diastolic volume)?

Aortic Regurgitation

When specific to mitral valve prolapse, a midsystolic click usually is heard at the ........., and the murmur follows the click such as S1, click, murmur, S2.

Apex

Which of the following drugs prescribed for a patient with stable angina does not decrease myocardial oxygen consumption?

Aspirin The goal of medical management in angina is to decrease myocardial oxygen consumption and to prevent progression of the disease. Beta-blockers decrease myocardial oxygen consumption by decreasing heart rate and contractility. Nitrates decrease myocardial oxygen consumption by decreasing preload primarily and may decrease afterload also, depending on the dosage. Calcium channel blockers decrease myocardial oxygen consumption by decreasing preload and afterload. Aspirin is used for primary and secondary prevention of a myocardial infarction by inhibiting platelet aggregation.

PCI procedure that opens an occluded artery using a shaving device?

Atherectomy

The most likely cause of acute MI?

Atherosclerosis

MI (patho)

Atherosclerosis with unstable plaque Plaque rupture may be caused by inflammation and/or infection C-reactive protein (CRP) rises rapidly following an inflammatory response Inadequate oxygenation causes anaerobic metabolism - which causes lactic acidoses Prolonged ischemic causes electrical and mechanical death of myocardium Ischemia, injury, and acidosis causes electrical irritability; this potentially leads to PVCs, VT, VF

A blood pressure difference of 25 mm Hg between the left and right arm indicates which of the following? A. Subclavian thrombosis B. Aortic dissection C. Myocardial infarction

B

The presence of which of the following is a contraindication for percutaneous transluminal coronary angioplasty in this patient? A. Double-vessel disease with 80% occlusion B. Left main coronary artery disease C. A discrete, noncalcific and proximal lesion D. A coronary artery bypass graft with saphenous vein grafts

B

What is the nurse's interpretation of a large wide Q wave on the ECG of the client undergoing preadmission testing for surgery? a. The client is experiencing angina. b. The client has had a myocardial infarction in the past. c. The client's atria are enlarged and failing. d. The client's ECG pattern is a common variation of normal sinus rhythm.

B

Which of the following accurately describes the normal difference between the pulmonary artery diastolic pressure (PAd) and the pulmonary artery occlusive pressure (PAOP)? A. The difference should be 5 mm Hg or less with the PAOP higher. B. The difference should be 5 mm Hg or less with the PAd higher. C. They should be the same. D. The difference between these pressures is irrelevant.

B

The most common cause of death after vascular surgery is: A. stroke. B. myocardial infarction. C. pulmonary embolism. D. dysrhythmia.

B Because atherosclerosis does not occur in one vessel, patients requiring vascular surgery are likely also to have coronary artery disease.

A patient is admitted to the emergency department with complaints of severe headache. She states that she has been out of her blood pressure pills for 3 weeks and cannot afford to buy more. Her blood pressure ranges from 250/128 mm Hg to 200/110 mm Hg. Nitroprusside (Nipride) is being titrated, and the patient is receiving oxygen by nasal cannula. Which of the following describes the appropriate drug therapy and goal for this patient? A. Diuretics to decrease preload B. Arterial vasodilators to decrease afterload C. Venous vasodilators to decrease preload D. Beta-blockers to decrease contractility

B Blood pressure is the most significant component of systemic vascular resistance and afterload. Afterload reduction is needed. Arterial vasodilators reduce afterload.

Which of the following statements is true regarding a patient who comes to the emergency department with chest pain and has a negative myoglobin level 3 hours after the onset of chest pain? A. Myocardial infarction (MI) cannot be ruled out. B. MI can be ruled out. C. The myoglobin level test should be repeated in 4 hours. D. A troponin level is necessary to rule out MI.

B Myoglobin elevates early in MI (within 3 hours) and has a very high sensitivity, so a negative myoglobin 3 hours after the onset of chest pain rules out MI.

The skin changes associated with chronic peripheral arterial disease are: A. thickened with brownish discoloration at the ankles. B. pale and shiny. C. ulcerations at the sides of the ankles. D. rubor when in dependent position.

B Peripheral arterial disease causes shiny, pale skin with hair loss, ulceration at pressure points, and diminished or absent pulses. Options a, c, and d are descriptions of venous disease.

The reciprocal changes of a posterior myocardial infarction (MI) are evident in which leads? A. II, III, aVF B. V1, V2 C. V5, V6 D. I, aVL

B The reciprocal leads are the leads on the wall opposite the MI. The anterior, especially anteroseptal, leads are V1 and V2. The indicative leads for a posterior MI are V8 and V9.

A patient has had an inferior myocardial infarction. He now has a new holosystolic murmur at apex, acute severe dyspnea, decreased cardiac index, and a normal cardiac silhouette on x-ray film. An intraaortic balloon pump is inserted. Which of the following would indicate a beneficial effect of afterload reduction in this patient? A. An increase in the height of the v wave during catheter occlusion (pulmonary artery occlusive pressure [PAOP]) B. A decrease in the height of the v wave during catheter occlusion (PAOP) C. No change in the PAOP waveform D. A damping of the PAOP waveform

B A decrease in the afterload facilitates the increase in systolic ejection volume and decreases regurgitation back through the mitral valve. The v wave height decreases as the volume of regurgitation diminishes, which causes a decrease in the pressure. Think as follows: a decrease in afterload equals a decrease in regurgitation equals a decrease in the amplitude of the v wave.

A 62-year-old man is admitted with chest pain. His electrocardiogram reveals ST segment elevation and T wave inversion in leads V1 to V4. Aspirin has been given, and morphine titration and nitroglycerin infusion are used to relieve his chest pain. Five days after a myocardial infarction (MI), the patient suddenly develops a loud holosystolic murmur at the lower left sternal border, chest pain, and hypotension. Which complication of acute MI should the nurse suspect? B. Ventricular septal rupture C. Extension of MI

B A new murmur indicates rupture of some intracardiac structure. Remember that this patient has electrocardiogram changes in leads V1 to V4, and leads V1 and V2 show the septum. Choose option b because ventricular septal rupture is more likely in anteroseptal MI. Papillary muscle rupture is more likely in inferior MI, the murmur is loudest at the apex, and the clinical presentation is related to acute pulmonary edema.

Which of the following antidysrhythmic agents is associated with serious adverse effects when used long term? A. Verapamil (Calan) B. Amiodarone (Cordarone) C. Procainamide (Pronestyl) D. Propranolol (Inderal)

B Amiodarone potentially causes severe adverse effects such as pulmonary fibrosis, peripheral neuropathies and extrapyramidal symptoms, and hepatotoxicity. The adverse effects of verapamil, procainamide, and propranolol are mild compared with the adverse, potentially life-threatening effects of amiodarone.

In which quadrant is the mean QRS complex axis located if the QRS complex is predominantly positive in lead I and negative in lead aVF? A. Normal quadrant B. Left axis deviation quadrant C. Right axis deviation quadrant D. Indeterminant quadrant

B Because the positive of lead I is the left arm, if the QRS complex is upright in lead I, the mean QRS axis is to the left. Because the positive of lead aVF (a unipolar lead) is at the foot, if the QRS complex is negative in lead aVF, the mean QRS axis is upward away from the foot. This axis would be in the upper left quadrant, described as left axis deviation.

n determining readiness to wean a patient from the intraaortic balloon pump, which parameters are most important? A. Cardiac index and heart rate B. Cardiac index and systemic vascular resistance (SVR) C. Pulmonary artery occlusive pressure (PAOP) and SVR D. Mean arterial pressure (MAP) and SVR

B Cardiac index and SVR are two of the primary factors affected by the balloon pump. Though MAP sounds like a good answer, remember that it equals cardiac output multiplied by SVR, so cardiac index and SVR are more specific indicators.

Drug therapy for chronic heart failure is most likely to include which of the following drug combinations? A. Digoxin and furosemide B. Carvedilol and enalapril

B Digoxin and furosemide were important in heart failure in the past, but inotropes are now used late if at all because they increase myocardial oxygen consumption and mortality. Eliminate option a. Nitroprusside and nitroglycerin are more likely to be used acutely, and the question says chronic, so eliminate options c and d.

Over the past 2 hours, a patient admitted with severe acute heart failure has the following changes in assessment parameters: Admission 2 Hours Later Heart sounds S1, S2 S1, S2, S3 audible at apex Blood pressure 118/60 mm Hg 98/54 mm Hg Heart rate 105 beats/min 126 beats/min Respiratory rate 30 breaths/min 36 breaths/min Which of the following combinations of drugs are indicated for the achievement of the therapeutic goals of this patient? A. Nitroprusside (Nipride) and furosemide (Lasix) B. Dobutamine (Dobutrex) and furosemide (Lasix) C. Dobutamine (Dobutrex) and nitroprusside (Nipride) D. Morphine sulfate and furosemide (Lasix)

B Dobutamine has positive inotropic effects on the heart that optimize cardiac output by increasing contractility. Diuretics should be used with a positive inotropic agent in this patient to decrease cardiac workload through the reduction of preload. A venous vasodilator such as nitroglycerin also could be used but would require careful titration to prevent further decrease in blood pressure. An arterial vasodilator such as nitroprusside would result in too great of a reduction in systemic vascular resistance and blood pressure in this patient.

A 57-year-old man was admitted to the critical care unit with a diagnosis of anteroseptal myocardial infarction. A pulmonary artery catheter was inserted, and initial readings were within normal limits. Vital signs were blood pressure 140/92 mm Hg, heart rate 110 beats/min and regular, and respiratory rate 24 breaths/min. Breath sounds are equal and clear to auscultation. Three hours after admission, the patient becomes restless with cool, pale skin. Vital signs are now blood pressure 110/72 mm Hg, heart rate 120 beats/min, and respiratory rate 28 breaths/min and labored. Breath sounds are still equal, but crackles are audible at the lung bases bilaterally. Which medication would reduce this patient's preload most effectively? A. Nitroprusside (Nipride) B. Nitroglycerin (Tridil)

B Dopamine is an inotropic agent at doses of about 5 mcg/kg/min and primarily a vasoconstrictor at higher doses, so eliminate option b. Hydralazine is an arterial vasodilator, and nitroprusside is a mixed vasodilator with predominantly arterial effects, so eliminate options d and a. Nitroglycerin is a predominantly venous vasodilator. Remember, veins are before (i.e., pre) the heart, and to decrease preload, you must dilate veins. Select option c.

Which patient activities are most likely to cause myocardial ischemia and ST segment elevation? A. Taking medications, using the bedpan, having the bed changed B. Using the bedpan, having the bed changed, having an intravenous catheter inserted C. Taking medications, eating breakfast, being weighed on an overbed scale D. Using the bedpan, having the bed changed, having visitors

B In a question like this you need to choose the option with all three activities that significantly increase myocardial oxygen consumption. For instance, in option c, even though being weighed on an overbed scale does significantly increase myocardial oxygen consumption, taking medications does not.

A patient has a history of rheumatic fever and mitral stenosis. She has decided to have a mitral valve replacement because her symptoms of dyspnea, orthopnea, and paroxysmal nocturnal dyspnea have become severe and unmanageable. These symptoms result from which of the following? A. Right ventricular failure B. Pulmonary hypertension C. Left ventricular failure D. Pericardial effusion

B In mitral stenosis, the left atrium engorges and causes a backup of blood into the pulmonary vascular bed and pulmonary hypertension. These symptoms result from that pulmonary hypertension. Right ventricular failure does occur, but it is associated with jugular venous distention, peripheral edema, and hepatomegaly. Left ventricular filling is compromised in mitral stenosis. This is an example of backward failure of the right ventricle and forward failure of the left ventricle. The pericardium is not involved.

A 63-year-old woman is 2 days past a myocardial infarction (MI). She now is complaining of dyspnea. Her respiratory rate is 26 breaths/min, and ventilation is labored. She has cool, clammy skin, S3 at the apex, and crackles bilaterally over lung bases. She is receiving oxygen therapy, and arterial oxygen saturation is 95%. A pulmonary artery catheter has been inserted. Blood pressure 104/82 mm Hg Heart rate 118 beats/min Right atrial pressure 12 mm Hg Pulmonary artery pressure 42/30 mm Hg Venous oxygen saturation 55% Pulmonary artery occlusive pressure (PAOP) 26 mm Hg Cardiac output 2.9 L/min Cardiac index 1.4 L/min/m2 Systemic vascular resistance (SVR) 2100 dynes/sec/cm−5 Oxygen therapy is initiated. What additional immediate measures would be anticipated? A. Vasopressors and beta-blockers B. Vasodilators and positive inotropic agents C. Beta-blockers and tissue plasminogen activator D. Positive inotropes and fluids

B Inotropes are needed to improve contractility because clinical assessment and hemodynamic parameters suggest right and left ventricular failure. Vasodilators are needed to decrease preload and afterload.

The term P mitrale often is used to designate which type of P wave? A. P waves that are more than 2.5 mm in height in lead II B. A notched P wave that is more than 0.11 second in duration C. A notched P wave D. A P wave that is more than 0.11 second in duration

B Left atrial enlargement is common in mitral stenosis. Left atrial enlargement is manifested by a wide (greater than 0.11 second), notched P wave in lead II, and a dominant terminal component of the biphasic P wave in lead V1. Think mitral valve + P wave → left atrium; now you need to know the electrocardiogram characteristics of left atrial enlargement.

Which of the following is an advantage of nesiritide over other vasodilators such as nitroglycerin? A. Nesiritide may be used with hypotensive patients. B. Nesiritide has a diuretic effect. C. Other vasodil

B Nesiritide is a brain-type natriuretic peptide (BNP), and a natriuretic causes the excretion of sodium and water.

STUDY MODEOptionsRationaleTest-Taking StrategyQuestion 297 of 372 Home Help Back Next A 52-year-old man is admitted to the critical care unit with a diagnosis of an acute myocardial infarction (MI). His electrocardiogram shows ST segment elevation and T wave inversion in leads V2, V3, and V4. His history includes hypertension, 80 pack-years of smoking, chronic obstructive pulmonary disease, and hypercholesteremia. An IV and fibrinolytic therapy were initiated in the emergency department. Which of the following would not be an indication of successful reperfusion? A. Pain cessation B. Absence of creatine kinase (CK) enzyme elevation C. Reversal of ST segment elevation with return of ST segment to baseline D. Short runs of ventricular tachycardia

B Note that ST segment and T wave inversion are present, but Q waves have not developed. This indicates acute injury or evolving MI. If the fibrinolytic drugs are successful, the ST segments will come back to baseline and pathologic (wide and deep) Q waves will not develop. Though short runs of ventricular tachycardia sound bad, they actually are an indication of reperfusion. These reperfusion dysrhythmias are thought to be caused by oxygen free radicals. Pain cessation occurs because as blood flow to the ischemic area is reestablished, anaerobic metabolism and production of lactic acid ceases. The CK enzymes still will be elevated even with reperfusion. CK enzymes actually elevate earlier and sometimes higher with reperfusion. This is referred to as CK washout.

A 55-year-old man with a long history of alcoholism continues to drink alcohol and now has alcoholic cardiomyopathy, a form of dilated cardiomyopathy. Which of the following would this patient not be expected to receive? A. Angiotensin-converting enzyme inhibitors B. Cardiac transplant referral C. Diuretics D. Inotropes

B Options a, c, and d are appropriate treatments. Cardiac transplantation is the definitive treatment for dilated cardiomyopathy, but this patient is not a candidate for transplantation as long as he continues to consume alcohol.

Oxygen delivery (DO2) is the product of which of the following? A. PaO2, hemoglobin, mean arterial pressure B. SaO2, hemoglobin, cardiac output C. SvO2, cardiac index, SaO2 D. PaO2, mean arterial pressure, SvO2

B Oxygen is delivered from the arterial end, so choose an option that has SaO2 instead of SvO2. Also remember that most oxygen is carried on hemoglobin. Look for SaO2 (not PaO2) and hemoglobin. The only option with both of these is option b.

A 61-year-old man is admitted to the critical care unit from the cardiac catheterization laboratory. He has just had a percutaneous coronary angioplasty and stent insertion to the right coronary artery. His leg is immobilized, and the head of his bed is at 30 degrees. Six hours later the patient is restless and complaining of back pain. The femoral sheath is intact in the right femoral area, and there is no evidence of bleeding or hematoma. Neck veins are flat with the head of the bed at 30 degrees, and heart sounds are normal. Vital signs are blood pressure 80/50 mm Hg, heart rate 120 beats/min, and respiratory rate 24 breaths/min. What should the nurse suspect? A. Cardiac tamponade B. Retroperitoneal bleeding C. Coronary artery dissection D. Acute closure of the right coronary artery

B Patients who have had interventional cardiologic procedures may bleed externally from the groin or retroperitoneally. Early clinical indications of retroperitoneal bleeding are subtle. The patient is frequently in frank shock before it is suspected. Note the patient's restlessness, indicative of decreased perfusion to the brain. Back pain is a common symptom in patients after percutaneous coronary intervention because they must lie relatively flat.

A 78-year-old man is admitted to the coronary care unit with a diagnosis of an acute myocardial infarction. He has a history of chronic obstructive pulmonary disease (COPD). He now is complaining of shortness of breath. An S3, a grade II/VI systolic murmur, and crackles bilaterally are noted. His blood pressure is 100/60 mm Hg, heart rate is 112 beats/min, pulmonary artery pressure is 38/24 mm Hg, pulmonary artery occlusive pressure (PAOP) is 20 mm Hg, right atrial pressure (RAP) is 12 mm Hg, and cardiac index is 2 L/min/m2. Which of the following is the most likely cause of the patient's dyspnea? A. Right ventricular failure (RVF) B. Left ventricular failure (LVF) C. Acute exacerbation of COPD D. Primary pulmonary hypertension

B The hemodynamic profile is one of left and right ventricular failure and shock (i.e., cardiogenic shock). The left ventricular failure would cause pulmonary edema, whereas right ventricular failure would cause systemic edema. Remember to focus on the question being asked. Even though there is evidence of RVF (RAP 12 mm Hg), the most likely cause of the patient's dyspnea is the LVF.

A 65-year-old woman was admitted yesterday for an acute anterior myocardial infarction (MI). She denies chest pain but complains of dyspnea. The monitor shows sinus tachycardia with a rate of 120 beats/min with no changes in her 12-lead electrocardiogram. Her blood pressure is 100/60 mm Hg, respiratory rate is 28 breaths/min, and functional oxygen saturation (SpO2) is 88%. Chest x-ray films show pulmonary venous congestion. A pulmonary artery catheter is inserted, and initial pressures indicate the following: right atrial pressure, 6 mm Hg; pulmonary artery pressure, 35/26 mm Hg; pulmonary artery occlusive pressure (PAOP), 22 mm Hg; cardiac output, 4 L/min; and cardiac index, 2.2 L/min/m2. Which of the following is the most likely cause of these clinical findings? A. Pericarditis B. Left ventricular failure C. Extension of MI D. Acute respiratory distress syndrome (ARDS)

B Pericarditis would cause pleuritic-type chest pain and diffuse ST segment changes across the precordium. Extension of the MI would cause ischemic pain and ST segment elevation in leads adjacent to the leads initially changed by the MI. ARDS would cause an increase in the diastolic pulmonary artery pressure (PAd) with a normal PAOP and a difference between PAd and PAOP of more than 5 mm Hg (indication of pulmonary hypertension). The clinical presentation is consistent with left ventricular failure and cardiac pulmonary edema.

A patient is admitted to the critical care unit with tachycardia, tachypnea, dyspnea, and crackles to the scapula. A loud holosystolic murmur is audible at the apex radiating to the axilla. A pulmonary artery catheter is inserted to evaluate fluid status and cardiac function. Prominent v waves are seen on the pulmonary artery occlusive pressure waveform. This clinical presentation is indicative of pulmonary edema associated with which of the following? A. Mitral stenosis B. Mitral regurgitation C. Aortic stenosis D. Aortic regurgitation

B Prominent v waves are associated with mitral regurgitation, whereas prominent a waves are associated with mitral stenosis. Mitral regurgitation causes a holosystolic murmur loudest at the apex and radiating to the axilla. First consider the murmur. Mitral stenosis and aortic regurgitation cause diastolic murmurs, so eliminate options a and d. Because the murmur is loudest in the mitral area, mitral regurgitation is the most likely cause. The presence of prominent v waves is further support for option b as the correct answer.

A 63-year-old woman is 2 days past a myocardial infarction. She now is complaining of dyspnea. Her respiratory rate is 26 breaths/min, and ventilation is labored. She has cool, clammy skin, S3 at the apex, and crackles bilaterally over lung bases. She is receiving oxygen therapy, and arterial oxygen saturation is 95%. A pulmonary artery catheter has been inserted. Blood pressure 104/82 mm Hg Heart rate 118 beats/min Right atrial pressure 12 mm Hg Pulmonary artery pressure 42/30 mm Hg Venous oxygen saturation 55% Pulmonary artery occlusive pressure (PAOP) 26 mm Hg Cardiac output 2.9 L/min Cardiac index 1.4 L/min/m2 Systemic vascular resistance (SVR) 2100 dynes/sec/cm−5 Oxygen therapy is initiated. What parameter would best indicate improvement? A. Increase in cardiac index B. Increase in stroke volume C. Decrease in PAOP D. Decrease in SVR

B Remember that cardiac output is equal to stroke volume multiplied by heart rate. Stroke volume is affected by preload, afterload, and contractility. An increase in cardiac output and index could be caused by an increase in stroke volume or an increase in heart rate. Because an increase in heart rate increases oxygen consumption, an improvement in stroke volume would be more specific to improvement.

A 48-year-old man with an acute inferior myocardial infarction (MI) is admitted to the critical care unit. He is receiving oxygen at 3 L/min via a nasal cannula, and his arterial oxygen saturation (SaO2) is 95%. His vital signs and hemodynamic parameters are as follows: Blood pressure 88/60 mm Hg Heart rate 118 beats/min Respiratory rate 26 breaths/min Right atrial pressure (RAP) 20 mm Hg Pulmonary artery pressure 34/8 mm Hg Pulmonary artery occlusive pressure 4 mm Hg Cardiac index 1.8 L/min/m2 He has jugular venous distention, and breath sounds are clear. Cardiac auscultation reveals an S3 at the lower sternum. What additional assessment would be most helpful? A. Echocardiography B. Repeat electrocardiogram with right ventricular leads C. Carotid Doppler flow studies D. Arterial blood gases

B Right ventricular failure, indicated by the elevated RAP, right-sided S3, and jugular venous distention, in the presence of inferior MI is most likely due to concurrent right ventricular MI. Lead V4R is the most helpful, but leads V4R, V5R, and V6R should be all be done

A 28-year-old man with a long history of intravenous drug abuse arrives in the emergency department and is transferred to the critical care unit. He is complaining of fatigue and right upper quadrant pain. Vital signs are as follows: Blood pressure 110/80 mm Hg Heart rate 124 beats/min Respiratory rate 26 breaths/min Temperature 39.4° C Physical assessment reveals a holosystolic murmur at the lower left sternal border and jugular venous distention. Laboratory data show an elevated sedimentation rate and white blood cell count. This patient is at particular risk for: B. pulmonary emboli. D. myocardial infarction.

B The clinical presentation is descriptive of endocarditis. With a history of intravenous drug abuse or pulmonary artery catheter, the tricuspid valve is most likely affected. Vegetation from the tricuspid valve would go to the pulmonary arterial system and cause symptoms of pulmonary emboli and possibly pulmonary infarction.

If a patient's jugular neck veins are distended 6 cm above the angle of Louis with his bed elevated 45 degrees, his right atrial pressure is approximately: A. 4 mm Hg. B. 8 mm Hg. C. 10 mm Hg. D. 12 mm Hg.

B The jugular neck veins are normally only 1 to 2 cm above the angle of Louis with the patient at 45-degree elevation. The right atrial pressure (RAP) can be estimated by adding the 5 cm that the angle of Louis is above the right atrium. Therefore the RAP is 11 cm H2O. To convert to millimeters of mercury, you must remember that 1 mm Hg is equal to 1.36 cm H2O. Divide the 11 cm H2O by 1.36 to arrive at 8 mm Hg.

A patient is admitted to the emergency department with complaints of severe headache. She states that she has been out of her blood pressure pills for 3 weeks and cannot afford to buy more. Her blood pressure ranges from 250/128 mm Hg to 200/110 mm Hg. Nitroprusside (Nipride) is being titrated, and the patient is receiving oxygen by nasal cannula. In considering the risk for cardiac failure and pulmonary edema, consideration should be made to the physiologic principle that the majority of myocardial oxygen consumption occurs during which phase of the cardiac cycle? B. Isovolumetric contraction D. Isovolumetric relaxation

B The majority of myocardial oxygen consumption occurs during isovolumetric contraction. During this phase the cardiac valves are closed and muscular contraction occurs without a change in volume, in order to generate a pressure high enough to overcome the resistance in the arterial (pulmonary or systemic) circulation, to open the semilunar valves (pulmonic or aortic), and to propel blood into the great vessels (pulmonary artery or aorta). In the hypertensive crisis described, the left ventricle must work harder to generate a pressure to exceed the excessive pressure in the systemic arterial system.

A 72-year-old woman arrives in the emergency department with syncope. The electrocardiogram monitor shows third-degree AV heart block with a rate of 42 beats/min. She is transferred to the cardiac catheterization laboratory for insertion of a temporary transvenous pacemaker and is scheduled for a permanent pacemaker insertion in 2 days. When she arrives in the critical care unit and is being moved into the bed from the transport cart, the following rhythm is seen on the electrocardiogram monitor. The electrocardiogram monitor strip indicates failure to capture. Which of the following would be the most appropriate action? A. Change the batteries. B. Turn the patient to the left side. C. Increase the sensitivity. D. Check the electrode connections.

B The most appropriate immediate treatment for failure to capture is to turn the patient on his or her left side. Ideally, this allows the lead to float toward the heart wall so that the electrodes will be in contact with the endocardium and capture can be regained. If this does not work, then turn up the milliamperage. Checking connections and changing the battery are the appropriate actions for failure to pace. Increasing the sensitivity is an appropriate action for failure to sense.

If the esophagus is intubated accidentally during cardiopulmonary arrest, which of the following is the priority? A. Removal of the malpositioned tube and intubation of the trachea B. Ventilation with a bag-valve-mask with 100% oxygen C. Placement of a nasogastric tube D. Emergency tracheostomy

B The priority is to hyperoxygenate before another intubation attempt.

With which pathophysiologic changes does the nurse correlate the acidosis associated with hypovolemic shock? a. Poor respiratory effort secondary to skeletal muscle weakness caused by the hydrogen ion excess b. Lactic acid production resulting from decreased oxygen delivery to the tissues and increased anaerobic metabolism c. Failure of the kidneys to excrete hydrogen ions and reabsorb bicarbonate ions as a result of renal hypertension d. Increased sensitivity of the central chemoreceptors, enhancing the rate and depth of ventilation

B The syndrome of hypovolemic shock results in inadequate tissue perfusion and oxygenation; thus, some cells are metabolizing anaerobically. Such metabolism increases the production of lactic acid, resulting in an increase in hydrogen ion production and acidosis

On a pulmonary artery waveform, the dicrotic notch represents closure of which valve? A. Aortic valve B. Pulmonic valve C. Tricuspid valve D. Mitral valve

B The waveform from the pulmonary artery cannot reflect what is in front of it. Choose the chamber or vessel immediately behind the pulmonary artery. Choose option b. Also, remember that the dicrotic notch on the arterial waveform represents closure of the aortic valve.

Which of the following is associated with a loud S1, an opening snap, and a diastolic murmur? A. Mitral regurgitation B. Mitral stenosis C. Aortic regurgitation D. Aortic stenosis

B This is the description of mitral stenosis. Mitral regurgitation is a blowing pansystolic murmur. Aortic stenosis is a harsh systolic murmur. Aortic regurgitation is a diastolic murmur but usually described as blowing.

A 20-mm S wave in lead V1 and a 25-mm R wave in lead V6 are noted on a patient's 12-lead electrocardiogram. This would indicate which of the following? A. Right bundle branch block (RBBB) B. Left ventricular hypertrophy C. Posterior wall myocardial infarction (MI) D. Right ventricular hypertrophy

B When the depth of the S wave in lead V1 or V2 plus the height of the R wave in lead V5 or V6 is 35 mm or greater, this constitutes voltage criteria for left ventricular hypertrophy.

Class II antidysrhythmics block:?

Beta RECEPTORS The Vaughn-Williams antidysrhythmic classification system categorizes agents by their effect on the action potential. Class I antidysrhythmics block the movement of sodium during phase 0 of the action potential (i.e., depolarization). Class II antidysrhythmics block beta receptors and so affect automaticity. Class III antidysrhythmics block the movement of potassium during phase 3 of the action potential (i.e., late repolarization). Class IV antidysrhythmics block the movement of calcium during phase 2 of the action potential (i.e., early repolarization)

Which of the following correlates with brain natriuretic peptide (BNP) levels?

BNP is correlated with PAOP and left ventricular end-diastolic pressure because it is released in response to increased intravascular volume.

Hypovolemic Shock values:

BP: Decreased RAP: Decreased PAP: Decreased PAOP: Decreased CO/CI: Decreased SV/SI: Decreased SVR: Increased

Septic Shock (early) values:

BP: Decreased RAP: Decreased PAP: Decreased PAOP: Decreased CO/CI: Increased SV/SVI: Increased SVR: Decreased PVR: n/a

Increased or Decreased: BP/RAP/PAP/PAOP/CO/CI/SV/SVR and PVR in Cardiogenic Shock?

BP: Decreased RAP: Increased PAP: Increased PAOP: Increased CO/CI: Decreased SV/SI: Decreased SVR/PVR: Increased

IABP (assessment paramaters)

BP: decreases in systolic BP, and increase in diastolic BP, and an increase in MAP is desirable. CO/CI: an increase in cardiac output/index is desirable PAP/PAOP: a decrease in PAP and PAOP is desirable

A 65-year-old man was admitted 2 hours ago after coronary artery bypass grafting. He has had the following vital sign changes: Admission 2 Hours Later Blood pressure (mm Hg) 110/80 96/76 Heart rate (per minute) 85 100 Right atrial pressure (RAP; mm Hg) 6 2 Pulmonary artery pressure (PAP; mm Hg) 24/12 18/6 Pulmonary artery occlusive pressure (PAOP; mm Hg) 10 5 Cardiac output (L/min) 6 4 Cardiac index (L/min/m2) 3.5 2.5 Systemic vascular resistance index (SVRI; dynes/sec/cm−5) 1920 2590 What is the most likely cause of these changes?

Blood Loss You need to know hemodynamic profiles such as this one. This is classic hypovolemic shock in the compensatory stage.

A patient arrived in the emergency department with complaints of chest pain. The 12-lead electrocardiogram shows ST segment elevation in leads V3 and V4. Occlusion of the affected coronary artery most likely would affect perfusion to which portion of the conduction system?

Bundle of His ST segment elevation in leads V3 and V4 indicates injury to the anterior wall, which would occur with occlusion of the left anterior descending (LAD) artery. In most persons, the SA node, Bachmann's bundle, and AV node are supplied by the right coronary artery. The bundle of His is supplied by the left anterior descending artery. This is why an anterior myocardial infarction may cause type II second-degree AV block or third-degree AV heart block at the level of the bundle of His.

A patient with an acute inferior wall myocardial infarction was admitted to the critical care unit. He is receiving dobutamine at 10 mcg/kg/min and nitroglycerin at 50 mcg/min. A pulmonary artery catheter is inserted, and the following parameters are obtained: Heart rate 112 beats/min Blood pressure 90/46 mm Hg Mean arterial pressure 60 mm Hg Right atrial pressure (RAP) 16 mm Hg Pulmonary artery pressure 26/10 mm Hg Pulmonary artery occlusive pressure (PAOP) 5 mm Hg Cardiac index 2 L/min/m2 Which of the following interventions most likely will improve this patient's cardiac output? A. Decrease the dobutamine drip to 10 mcg/kg/min and infuse 50 mL of normal saline. B. Give milrinone (Primacor) bolus and start drip at 0.5 mcg/kg/min. C. Discontinue nitroglycerin and infuse 250 mL of normal saline. D. Discontinue nitroglycerin and give furosemide (Lasix) 40 mg IV.

C

Which technique is recommended to minimize the effect of fluctuation caused by ventilation on the measurement of pulmonary artery occlusive pressure (PAOP)? C. Record the measurement at the end of expiration. D. Record the measurement at the full inspiration

C

A patient with an acute inferior wall myocardial infarction was admitted to the critical care unit. He is receiving dobutamine at 10 mcg/kg/min and nitroglycerin at 50 mcg/min. A pulmonary artery catheter is inserted, and the following parameters are obtained: Heart rate 112 beats/min Blood pressure 90/46 mm Hg Mean arterial pressure 60 mm Hg Right atrial pressure (RAP) 16 mm Hg Pulmonary artery pressure 26/10 mm Hg Pulmonary artery occlusive pressure (PAOP) 5 mm Hg Cardiac index 2 L/min/m2 The patient exhibits jugular venous distention in a semi-Fowler position. Tall P waves are seen in lead II of the 12-lead electrocardiogram. These findings indicate which of the following physiologic changes? A. Right ventricular dysfunction with decreased right ventricular end-diastolic pressure B. Right ventricular dysfunction with increased left atrial and ventricular end-diastolic pressure C. Increased right ventricular end-diastolic pressure and right atrial enlargement D. Increased right atrial pressure and pulmonic valve regurgitation

C Approximately one third of patients with inferior wall infarction have associated right ventricular (RV) infarction. Necrosis of the RV muscle decreases right ventricular contractility and ejection of blood, causing dilation and failure of the right ventricle with the backup of blood volume and pressure into the right atrium and central venous system. Remember that the right side of the heart delivers blood to the left side of the heart. This clinical and hemodynamic profile shows a patient with right ventricular backward failure and left ventricular forward failure. Note the elevated RAP, indicative of right ventricular failure and back pressure. Note the low PAOP, indicative of left ventricular forward failure. The RAP correlates to the right ventricular end-diastolic pressure (RVEDP), and it is not decreased, so eliminate option a. The PAOP correlates to the left ventricular end-diastolic pressure, and it is not increased, so eliminate option b. There are no indications of pulmonic valve regurgitation (e.g., diastolic murmur at pulmonic area), so eliminate option d. Option c is correct because the RAP correlates with increased RVEDP, and the tall, peaked P waves correlate with right atrial enlargement.

Which vasodilator would be best for a patient with a pulmonary artery occlusive pressure (PAOP) of 24 mm Hg and a systolic vascular resistance (SVR) of 2100 dynes/sec/cm−5? A. Hydralazine (Apresoline) B. Nitroglycerin (Tridil) C. Nitroprusside (Nipride) D. Morphine sulfate

C Left ventricular preload (as measured by PAOP) and left ventricular afterload (as measured by SVR) are increased, so venous vasodilation is needed to decrease preload and arterial vasodilation is needed to decrease afterload. Hydralazine dilates arteries only, morphine sulfate dilates veins only, and nitroglycerin dosages must be above 1 mcg/kg/min to achieve arterial dilating effects. Nitroprusside is a mixed vasodilator. It dilates arteries and veins to decrease afterload and preload.

Which of the following is not a therapeutic effect of nifedipine (Procardia) when used for angina? A. Decreased preload B. Decreased afterload C. Decreased contractility D. Relieve vasospasm

C Nifedipine decreases myocardial oxygen consumption by dilating veins and arteries, thereby decreasing preload and afterload. Nifedipine also decreases vasospasm and potential for vasospasm. Unlike diltiazem and verapamil, nifedipine does not significantly decrease contractility.

A 43-year-old man is admitted with chest pain lasting 2 days. His electrocardiogram shows ST segment elevation and pathologic Q waves in leads V1 to V4. The day before he is to be discharged, he develops S3, crackles in bases, and extreme dyspnea. He is transferred back to the critical care unit. Assessment reveals a loud holosystolic murmur at the lower left sternal border. An oximetric (venous oxygen saturation [SvO2]) pulmonary artery catheter is inserted. Which of the following measured hemodynamic parameters supports the suspicion that the patient has sustained a ventricular septal rupture (VSR)? A. Decreased cardiac output, decreased SvO2 B. Decreased cardiac output, increased SvO2 C. Increased cardiac output, increased SvO2 D. Increased cardiac output, decreased SvO2

C Thermodilution cardiac output is actually a measurement of right ventricular cardiac output (injection port in right atrium and thermistor in pulmonary artery). The right ventricular cardiac output is increased as it continues to send back the blood that has been through the pulmonary circuit to the left ventricle through the septal defect back to the right ventricle. The left ventricular cardiac output is actually decreased, and the patient shows clinical signs of hypoperfusion. Because some of the blood that the right ventricle sends to the pulmonary artery has been through the lungs and come back again, the fiberoptic sensor at the distal end of the catheter in the pulmonary artery senses higher-than-normal saturation.

A 57-year-old man with an acute anterior myocardial infarction has the following vital signs and hemodynamic parameters: Blood pressure 102/60 mm Hg Heart rate 116 beats/min Respiratory rate 24 breaths/min Right atrial pressure 8 mm Hg Pulmonary artery occlusive pressure 22 mm Hg Cardiac index 1.6 L/min/m2 Systemic vascular resistance index 3300 dynes/sec/cm−5 He has crackles at his lung bases and an S3 at his apex. He is pain free at this time but continues to be dyspneic. He is having premature ventricular contractions and short runs of ventricular tachycardia. Which of the following did not occur by sympathetic nervous system (SNS) innervation in an attempt to compensate for the decreased cardiac output and index? A. Increased heart rate B. Increased afterload C. Increased contractility D. Increased ectopy

C Alpha receptors of the SNS cause vasoconstriction and shift blood from nonessential (skin, bowel, kidney) to essential (heart and brain) organs. Beta1 receptors increase heart rate (positive chronotropic effect), increase contractility (positive inotropic effect), and increase conductivity (positive dromotropic effect). The dromotropic effect increases the propensity for ventricular ectopy. Beta2 receptors cause bronchodilation and vasodilation. In this case, the increase in heart rate and ectopy potential is caused by stimulation of the beta1 receptors. The increase in afterload is caused by stimulation of the alpha receptors. Contractility would have been increased by beta1 stimulation, but the patient's myocardium is unable to respond, and contractility remains decreased.

A patient is in cardiogenic shock and requires careful volume titration to enhance contractility. Which of the following ranges describes the most likely optimal pulmonary artery occlusive pressure (PAOP) in this patient? A. 0-5 mm Hg B. 10-15 mm Hg C. 15-20 mm Hg D. 20-25 mm Hg

C Although 8-12 mm Hg is considered a normal PAOP, this does not cause optimal stretch, especially in a patient with a dilated left ventricle. The theoretical optimal PAOP is 15-20 mm Hg. Consider a PAOP of under 8 mm Hg as understretched (needs fluid), a PAOP of 8-12 mm Hg as normal but suboptimally stretched (many patients need more fluid so that an optimal stretch can be achieved), and a PAOP of 12-20 as optimally stretched depending on the degree of ventricular dilation. Consider a PAOP of more than 20 mm Hg excessive for anyone (needs diuretics and/or venous vasodilators).

Which of the following types of block are most likely after an anterior wall myocardial infarction (MI)? B. Second-degree atrioventricular (AV) block, type I C. Second-degree AV block, type II

C Anterior MI is caused by a left anterior descending (LAD) artery lesion. The LAD artery supplies the bundle of His and bundle branches, so anterior MIs may cause blocks of the bundle of His or bundle branches. Second-degree AV block type II is a block at the level of the bundle of His. If this patient does develop a third-degree AV block, it would be at the level of the bundle of His, and the only escape rhythm available below the bundle of His is a ventricular escape rhythm.

Which of the following is the most likely cause of a systolic murmur that is heard best at the second right intercostal space and radiates to the neck? A. Mitral regurgitation B. Mitral stenosis C. Aortic stenosis D. Aortic regurgitation

C Aortic stenosis causes a harsh systolic murmur that is heard best in the aortic area (second right intercostal space at the sternal border) that radiates to the neckBecause the second right intercostal space at the sternal border is the aortic area, exclude the mitral conditions.

A 52-year-old man is admitted to the coronary care unit to rule out a myocardial infarction (MI). Two hours after admission to the unit, he complains of crushing substernal chest pain. His blood pressure is 90/58 mm Hg. The 12-lead electrocardiogram shows type I, second-degree atrioventricular (AV) block and ST segment elevation in leads II, III, and aVF. The physician orders a fluid challenge in addition to therapies to provide pain relief and improve the balance between myocardial oxygen supply and demand. Therapies are effective in stabilizing the patient. Which of the following would indicate right ventricular failure as a complication of inferior MI? A. Reflex tachycardia with an irregular pulse B. Diffuse crackles with shortness of breath C. ST elevation in right precordial leads, especially V4R D. Reduced central venous pressure

C Associate fluid challenge in the patient with MI with right ventricular infarction. The changes on a multiple-lead electrocardiogram logically would be in the right precordial leads.

A 52-year-old man is admitted to the coronary care unit to rule out a myocardial infarction. Two hours after admission to the unit, he complains of crushing substernal chest pain. His blood pressure is 90/58 mm Hg. The 12-lead electrocardiogram shows type I second-degree atrioventricular (AV) block and ST segment elevation in leads II, III, and aVF. Which vessel is most likely occluded? A. Left main coronary artery B. Left anterior descending coronary artery C. Right coronary artery D. Circumflex coronary artery

C Because leads II, III, and aVF have their positive leads at the foot, they look at the heart from the bottom and therefore view the inferior wall of the left ventricle. The inferior wall of the left ventricle is supplied by the right coronary artery. This is consistent with the conduction defect that the patient has developed because the right coronary artery supplies the AV node in 90% of people. Occlusion of the right coronary artery causes conduction disturbances such as first-degree and second-degree AV block, type I (also called Wenckebach).

Why must beta-blockers be started at low dosage and then titrated upward for patients with systolic heart failure? A. Starting at high dosages lessens the overall effect of the beta blockade. B. Profound fatigue occurs. C. A profound negative inotropic effect worsens the degree of failure. D. A profound effect on the renin-angiotensin-aldosterone (RAA) system causes hypovolemia.

C Beta-blockers block the beta receptors and decrease contractility. This may precipitate worsening of the heart failure unless started at a low dosage and carefully titrated upward.

A 67-year-old woman with unstable angina is admitted to the cardiac unit. She has a history of diabetes mellitus and reports having had chest pain intermittently for 4 days. The electrocardiogram shows nonspecific ST changes. Which of the following studies is most diagnostic in identifying a myocardial infarction in this patient? A. Elevated creatine kinase-myocardial bound (CK-MB) B. Elevated creatine kinase-muscle type (CK-MM) C. Elevated troponin I D. Lactate dehydrogenase 1 (LDH-1) greater than LDH-2

C CK isoenzymes include the MM, MB, and BB (brain type) bands. CK-MB and CK-MM elevate within hours of injury and peak within 24 hours. The CK-MB band is the most specific for cardiac muscle, but it may have returned to normal levels by the time this patient arrives at the hospital. Elevation of LDH-1 higher than LDH-2 is also indicative of a myocardial infarction. LDH is not as specific as CK-MB, but although it rises more slowly, it stays elevated longer than CK-MB. Levels of troponin I, a cardiac-specific protein, are even more specific than CK-MB for cardiac injury and stay elevated as long as LDH-1. One essential parameter to identify in the stem is the time component. Look for the most specific study and one that will stay elevated at least 4 days after the onset of pain. Choose option c. Another approach is to note that CK-MB, CK-MM, and LDH-1 are isoenzymes. Troponin I is a contractile protein. If you just do not know, choose the option that is different from the others. Choose option c.

Which of the following may affect adversely the ability of pulmonary artery occlusive pressure (PAOP) to reflect preload? A. Measuring the PAOP at the end of inspiration B. Changes in the patient's afterload C. Changes in the compliance of the patient's ventricle

C If you answered option a, remember that the end of expiration was decided as an arbitrary point to avoid inconsistency in measurement. The issue in this question is really: "When does the PAOP not reflect preload?"

Which of the following is the preferred lead for ST segment monitoring for a patient with a suspected right coronary artery occlusion? A. I B. aVR C. III D. V1

C Leads III and V3 are recommended for ST segment monitoring for patients with acute coronary syndrome unless available information from a previous 12-lead electrocardiogram obtained during an ischemic event indicates that another lead is more sensitive. Lead III is likely to be the most specific (ischemic footprint) for the patient with occlusion of the right coronary artery.

A patient is receiving low-molecular-weight dextran after an aortofemoral bypass graft. What is the purpose of this therapy for this patient? A. Increase circulating volume B. Increase blood thrombogenicity C. Decrease platelet aggregation D. Decrease inflammation

C Low-molecular-weight dextran, also called dextran 40, is used after vascular surgery to decrease platelet aggregation. Dextran frequently is given as 500 mL over a 24-hour period after surgery. Because the surgery has caused intimal trauma, the intrinsic clotting pathway has been activated and clotting at the surgical site may occur. Other platelet aggregation inhibitors include aspirin, abciximab (ReoPro), clopidogrel (Plavix), and nonsteroidal antiinflammatory agents (e.g., ibuprofen). Note that these agents affect platelet aggregation as long as platelets live, approximately 9 to 12 days.

Unstable angina that presents as pain at rest is likely to be due to progression of coronary artery disease or which of the following? A. Dysrhythmias B. Hypertension C. Coronary artery spasm D. Anxiety

C Prinzmetal's, vasospastic, and variant angina are names for myocardial ischemia caused by coronary artery spasm. Angina is a cause of pain at rest and frequently responds to nitroglycerin or calcium channel blockers.

Reciprocal changes in leads V1 and V2 in a patient with indicative changes in leads II, III, and aVF indicate which of the following? A. Expected reciprocal changes of the inferior myocardial infarction (MI) B. A concurrent right ventricular infarction C. A concurrent posterior infarction D. Extension to the anteroseptal wall

C Reciprocal changes in leads V1 and V2 indicate MI on the posterior wall along with the indicative changes in leads II, III, and aVF, which indicate inferior MI. Reciprocal changes of an inferior MI may be seen in leads I and aVL, but reciprocal changes in the anterior leads indicate a concurrent posterior MI. An anteroseptal MI would cause indicative changes in leads V1 and V2. A right ventricular MI would be indicated by indicative changes in lead V4R. Ask what is reciprocal (opposite) the anterior wall—the posterior wall.

A 68-year-old man with a history of emphysema is scheduled for a colon resection. A pulmonary artery catheter is inserted before surgery and is to be used to guide fluid replacement during and after surgery. Postoperatively his vital signs are blood pressure 104/64 mm Hg, heart rate 116 beats/min, and respiratory rate 32 breaths/min. Which of the following parameters would be most helpful in guiding fluid replacement for this patient? B. Pulmonary artery diastolic pressure (PAd) C. Pulmonary artery occlusive pressure (PAOP)

C Remember that fluid equals preload, atrial pressure reflects respective ventricle preload (assuming normal AV valve function and ventricular compliance), and so PAOP (i.e., indirect left atrial pressure) reflects left ventricular preload. Avoid parameters that reflect pulmonary pressures and chambers behind the lungs (e.g., right atrium). Select option c.

A 72-year-old man arrived in the emergency department after 4 hours of substernal pain radiating to the left arm. He has a 100 pack-year history of cigarette smoking, chronic obstructive pulmonary disease, and intermittent claudication. His electrocardiogram on admission shows sinus tachycardia with a rate of 120 beats/min and ST segment elevation in leads I, AVL, and V3 to V6. Vital signs include blood pressure, 150/84 mm Hg; respiratory rate, 15 breaths/min; functional oxygen saturation (SpO2), 95%; and temperature, 38.3° C (100.9° F). This patient is at particular risk for which of the following? A. Sinoatrial (SA) blocks B. Type I second-degree AV block C. Type II second-degree AV block D. Third-degree AV heart block with junctional escape rhythm

C The anterolateral wall is supplied by the left coronary artery. The portions of the conduction system supplied by the left anterior descending coronary artery include the bundle of His and the bundle branches. The SA node and the atrioventricular (AV) node are supplied by the right coronary artery in most hearts. So this patient should be monitored for blocks of the bundle of His and the bundle branches. Type I is located anatomically at the AV node. Type II is located anatomically at the bundle of His. A third-degree AV heart block would have to be blocked above the bundle of His to have a junctional escape rhythm.

Deflation of the intraaortic balloon pump should occur at what point in the cardiac cycle? A. During ventricular systole B. During ventricular diastole C. Immediately before ventricular systole D. Immediately before ventricular diastole

C The balloon is deflated immediately before systole because to have the balloon inflated at all during systole would cause an increase in afterload. The balloon is inflated during diastole.

A patient comes to the emergency department with vague chest discomfort. Her electrocardiogram is unchanged from 6 months ago. Which of the following would be most appropriate for ruling out an acute myocardial infarction (MI)? A. Cardiac catheterization B. Intravascular ultrasonography C. Creatine kinase-myocardial bound (CK-MB) and troponin I D. Transesophageal echocardiography

C The only blood test here is option c. It would be the quickest and easiest test to rule out MI.

A patient 5 days after an acute inferior myocardial infarction (MI) suddenly complains of severe dyspnea and palpitations. The patient appears anxious and diaphoretic. While completing the assessment of the patient, a loud holosystolic murmur at the apex that radiates to the axilla is noted. The patient also has crackles throughout the lung field but an S3 at the apex is not audible. What is the most likely cause of this patient's deterioration? A. Right ventricular failure related to right ventricular MI B. Acute pulmonary embolus C. Acute mitral regurgitation related to papillary muscle dysfunction D. Left ventricular failure related to extension of MI

C The patient has acute mitral regurgitation related to papillary muscle dysfunction or rupture following inferior MI. Inferior MI may cause ischemia or infarction of the posterior leaflet of the mitral valve, causing acute mitral regurgitation and pulmonary edema without the typical left ventricular failure signs (e.g., lateral PMI or S3 at the apex). This causes a new holosystolic murmur at the apex that radiates to the axilla. Mitral regurgitation causes backward failure of the right ventricle and acute pulmonary edema. Forward failure of the left ventricle also occurs because left ventricular filling is decreased.

A patient who was admitted with an acute myocardial infarction (MI) has just returned to the coronary care unit after a percutaneous coronary intervention (PCI) and begins complaining of chest pain. His ST segments now are elevated. Which of the following is the most likely cause? A. Cardiac tamponade B. New MI C. Acute closure D. Retroperitoneal hematoma

C These symptoms would indicate acute closure of the dilated vessel and reocclusion. Although a new MI also would cause chest pain, the timing suggests something related to the procedure. Cardiac tamponade causes a feeling of fullness in the chest but not usually pain, and the electrocardiogram changes are of low voltage across the precordium and electrical alternans. Retroperitoneal hematoma causes back pain unrelieved by the oral narcotics that typically are used for the back pain caused by the immobilization after PCI.

A 78-year-old man is admitted to the coronary care unit with a diagnosis of an acute myocardial infarction. He has a history of chronic obstructive pulmonary disease. He now is complaining of shortness of breath. An S3, a grade II/VI systolic murmur, and crackles bilaterally are noted. His blood pressure is 100/60 mm Hg, heart rate is 112 beats/min, pulmonary artery pressure is 38/24 mm Hg, pulmonary artery occlusive pressure (PAOP) is 20 mm Hg, right atrial pressure is 12 mm Hg, and cardiac index (CI) is 2 L/min/m2. If dobutamine therapy is initiated, which of the following would NOT be an indication of effectiveness? A. Decrease in PAOP B. Increase in CI C. Increase in heart rate

C You would not want the heart rate to go up because this would decrease the time for diastolic filling and increase myocardial oxygen consumption. That would not be an indication of effectiveness.

f the ventricles are depolarized before the atria in a junctional rhythm, the P wave will be: A. before the QRS complex with a PR interval of less than 0.12 second. B. lost in the QRS complex. C. after the QRS complex. D. in the T wave

C. The P wave in junctional rhythms may be before the QRS complex (with a PR interval of less than 0.12 second), lost in the QRS complex, or after the QRS complex. If the atria are depolarized after the ventricles, the P wave would be after the QRS complex Think of the identified timing. If the ventricles are depolarized before the atria, then the QRS complex would be before the P wave. Choose option c.

Normal Values: CO/CI STROKE VOLUME STROKE INDEX

CO/CI : 4-8L/min - 2.5 - 4.0L/min Stroke Volume: 50 - 100 ml/beat Stroke Index: 25-45 ml/beat

A patient has arrived back in the critical care unit after coronary artery bypass graft. Mediastinal tube drainage is minimal, but the patient is hypotensive with a blood pressure of 80/68 mm Hg. Right atrial pressure (RAP) is 15 mm Hg, pulmonary artery pressure is 35/18 mm Hg, and pulmonary artery occlusive pressure (PAOP) is 17 mm Hg. The PAOP waveform shows large a waves and large v waves. What is the most likely cause of these changes?

Cardiac Tamponade Note the equalization of pressures. RAP, diastolic pulmonary artery pressure (PAd), and PAOP are elevated and within 5 mm Hg of each other. Large a waves and large v waves (sometimes referred to as M pattern) are seen. The patient is hypotensive. All of these are seen in cardiac tamponade, and cardiac surgery is a major predisposing factor for cardiac tamponade. Hemorrhage would cause the pressures to be decreased. Pulmonary hypertension would cause the PAd to be elevated disproportionately to the PAOP, so PAd would be elevated but PAOP would be normal. Acute mitral regurgitation would cause large v waves but not large a waves.

Patients with pericarditis are especially susceptible to?

Cardiac Tamponade as pericardial effusion develops to the point that the heart chambers are compressed and cannot fill.

Which shock has an Increased RAP? Cardio Septic Neuro Hypo

Cardiogenic shock

A patient has a cardiac index of 1.8 L/min/m2, right atrial pressure (RAP) of 15 mm Hg, pulmonary artery pressure (PAP) of 40/24 mm Hg, pulmonary artery occlusive pressure (PAOP) of 20 mm Hg, blood pressure of 80/60 mm Hg, and heart rate of 120 beats/min. What do these findings indicate?

Cardiogenic shock A cardiac index of less than 2 L/min/m2 with increased volume indicators (RAP, PAP, PAOP) indicates cardiogenic shock. RAP would be elevated, but PAP and PAOP would be normal or decreased in right ventricular myocardial infarction. Pulmonary embolism would cause the RAP and PAP to be elevated, but the PAOP would be normal or decreased. RAP, PAP, and PAOP would be decreased in early septic shock, whereas the cardiac index would be increased.

Which of the following drugs is an alpha- and noncardioselective beta-blocker?

Carvedilol is an alpha- and noncardioselective beta-blocker that is used for heart failure. Labetalol is another alpha- and noncardioselective beta-blocker used most often for hypertension. Propranolol is a noncardioselective beta blocker, but it does not block alpha receptors. Esmolol and metoprolol are cardioselective beta-blockers, but neither of these drugs blocks alpha receptors

Central cyanosis indicates what?

Central cyanosis is cyanosis in central areas such as mucous membranes and occurs when 5 g of hemoglobin is desaturated. This means that central cyanosis is a late or even impossible sign in anemia and early sign in polycythemia.

A patient continues to have severe chest pain after 25 mg of IV morphine over the past hour. The blood pressure in the one arm is significantly lower than in the other arm. The femoral pulses are faint with mottling of the feet bilaterally. Based on these findings, what test should be expedited for completion?

Chest x-ray The first diagnostic test should be a chest x-ray film for the probable diagnosis of dissecting aortic aneurysm. The chest x-ray film would reveal a widening mediastinum. An additional, more indicative finding would be calcified aortic knob with extension of the aortic wall.

HF (patho)

Compensation > decompensation in the short-term these mechanisms compensate for the failing heart, but in the long-term, all of these factors trigger a process of pathologic growth and remodeling: 1. SNS - increase in heart rate, contractility, and increases cardiac output which causes reduced coronary artery blood flow. 2. Vasoconstriction increases preload and afterload and therefore BP a. Renin-angiotensin -aldosterone system: Sodium and water retention and peripheral vasoconstriction increases blood volume and preload.

A 78-year-old man is being treated for heart failure. He has been taking digoxin (Lanoxin), furosemide (Lasix), and captopril (Capoten). His blood urea nitrogen and creatinine are moderately elevated. During the morning assessment, the nurse notes that the patient is hypotensive and dyspneic. The electrocardiogram monitor shows junctional escape rhythm with a rate of 40 beats/min. Which of the following would be the most appropriate initial action? A. Prepare the patient for a pacemaker. B. Hold the digoxin. C. Administer an as-needed dose of nitroglycerin sublingual. D. Administer atropine 0.5 mg IV

D

An extra heart sound preceding S1 is most likely an S4 if the stethoscope's: A. diaphragm is over the apex. B. bell is over the aortic area. C. diaphragm is over the aortic area. D. bell is over the apex.

D S3 and S4 are low pitched, so choose options with the bell being used. S3 and S4 are heard at the mitral area (i.e., apex) unless the right ventricular is affected, and then they are heard in the tricuspid area. Remember that normal heart sounds (S1, S2) are high-pitched and so heard best with the diaphragm, whereas S3 and S4 are low-pitched and heard best with the bell. Most extra sounds (e.g., S3, S4, pericardial friction rub, and click) are heard best at the apex rather than at the base of the heart.

A 45-year-old man arrives at the emergency department with chest pain. Deep T wave inversion is noted on the electrocardiogram in leads V2 and V3 and persists even after the pain is relieved. Enzymes and troponin are negative for an acute myocardial infarction. Which of the following is most appropriate at this time? A. Initiate beta-blocker therapy. B. Continue nitroglycerin intravenously. C. Administer tissue plasminogen activator. D. Make preparations for an urgent cardiac catheterization

D This clinical presentation describes Wellens syndrome, which is associated with proximal left anterior descending artery disease and a high risk of sudden cardiac death. This patient should be taken to the cardiac catheterization laboratory immediately for evaluation of the degree and location of coronary artery disease. Percutaneous coronary intervention (i.e., percutaneous transluminal coronary angioplasty or atherectomy with or without the placement of coronary artery stents) may be performed to reestablish patency of the stenosed coronary artery.

Which of the following describes the ST-T wave change associated with left ventricular hypertrophy? A. Strain pattern in V1 and V2 B. ST segment elevation with tombstone-shaped T wave in V3 and V4 C. Symmetric T wave inversion in V1 to V4 D. Strain pattern in V5 and V6

D A strain pattern is an asymmetric T wave inversion seen in leads V1 and V2 in right ventricular hypertrophy and in leads V5 and V6 in left ventricular hypertrophy. ST segment elevation with a tombstone appearance would indicate myocardial injury. Symmetric T wave inversion would indicate ischemia. Consider that left ventricular hypertrophy likely would be manifested in the leads most reflective of the left ventricle. Choose option d.

While auscultating the patient's heart, an S3 is noted. What does this heart sound indicate? A. Atrial contraction and propulsion of blood into a noncompliant ventricle B. Inflammation of the pericardium C. Opening of a defective semilunar valve D. Rapid ventricular filling into an already distended ventricle

D An S3 is an indication of heart failure. S3 occurs early in diastole (the rapid filling phase) when the ventricle is already distended. Option a describes the cause of an S4. Option b describes the cause of a pericardial friction rub. Option c describes the cause of an opening snap.

A patient is admitted with a diagnosis of myocardial contusion. Which finding is most consistent with this diagnosis? A. S3 at apex B. Crackles throughout the lung fields C. Tachycardia D. Jugular venous distention

D Because the right ventricle lies immediately behind the sternum, myocardial contusion affects the right ventricle more than the left ventricle. Look for clinical indications of right ventricular failure (e.g., jugular venous distention, S3 at sternum, hepatomegaly, and peripheral edema).

Which of the following should be suspected if ST segment elevation occurs in the anterior leads and the inferior leads? A. Pneumothorax B. Posterior myocardial infarction C. Hypothermia D. Pericarditis

D Diffuse ST segment elevation is associated with pericarditis.

Which of the following would not be used for hypertensive crisis in the presence of acute heart failure? A. Hydralazine (Apresoline) B. Nitroglycerin (Tridil) C. Nitroprusside (Nipride) D. Esmolol (Brevibloc)

D Esmolol is a beta-blocker and would decrease contractility and so would be contraindicated in acute heart failure.

Which of the following does not predispose the patient to digitalis toxicity? A. Hypokalemia B. Hypercalcemia C. Hypomagnesemia D. Hyponatremia

D Hypokalemia, hypercalcemia, and hypomagnesemia increase sensitivity to digitalis toxicity

A 48-year-old man with an acute inferior myocardial infarction (MI) is admitted to the critical care unit. He is receiving oxygen at 3 L/min via a nasal cannula, and his arterial oxygen saturation is 95%. His vital signs and hemodynamic parameters are as follows: Blood pressure 88/60 mm Hg Heart rate 118 beats/min Respiratory rate 26 breaths/min Right atrial pressure (RAP) 20 mm Hg Pulmonary artery pressure 34/8 mm Hg Pulmonary artery occlusive pressure (PAOP) 4 mm Hg Cardiac index 1.8 L/min/m2 He has jugular venous distention, and breath sounds are clear. Cardiac auscultation reveals an S3 at the lower sternum. Which of the following would be the most appropriate therapeutic interventions? C. Dobutamine, nitrates D. Dobutamine, saline

D Important points to note are inferior MI; clinical and hemodynamic indications of right ventricular failure; dry lungs; and low PAOP. This pinpoints that the problem is the right ventricle. Right ventricular MI is treated with volume and inotropes and avoidance of diuretics and venous vasodilators. Choose option d.

A 47-year-old man was admitted to the critical care unit for complaints of crushing substernal chest pain unrelieved by nitroglycerin or rest. An electrocardiogram reveals the following: ST segment elevation in leads II, III, and aVF and reciprocal changes in leads I and aVL. Vital signs are blood pressure 100/64 mm Hg, heart rate 64 beats/min, and respiratory rate 28 breaths/min. These electrocardiogram changes are consistent with an evolving myocardial infarction of which wall of the heart? A. Anterior wall B. Posterior wall C. Lateral wall D. Inferior wall

D Recall that the precordial or chest leads, the V leads, have anterior, posterior, and lateral views. Eliminate options a and b. Also recall that the 12-lead electrocardiogram begins and ends in the lateral leads and that AVL views the left lateral heart. Eliminate option c. AVF should stimulate the thought of f for foot; the electrode for this lead is at the foot, which is inferior to the heart.

A patient develops atrial fibrillation after abdominal surgery. Her blood pressure falls from 110/70 mm Hg to 92/68 mm Hg. The hypotension is related to which of the following? A. Decrease in ventricular contractility B. Hypovolemia D. Decrease in ventricular filling

D Relate recent changes in patient status to recent occurrences. The patient had a change in atrial function, so select an option that results in loss of atrial contraction or "kick." Choose option d.

A patient has just returned from the cardiac catheterization laboratory. She had an angioplasty for occlusion of her right coronary artery. She still has femoral artery and vein sheaths in place. Which of the following categories of drugs would not be routinely used for this patient? A. Platelet aggregation inhibitors B. Nitrates C. Anticoagulants D. Inotropic agents

D The balloon dilation traumatizes the intima of the artery. This triggers the intrinsic clotting pathway. Platelet aggregation inhibitors and anticoagulants are used to block this clotting process and prevent reocclusion. Nitrates are used primarily as antispasmodics in this patient. Inotropic agents are not used routinely after percutaneous coronary interventions

A 90-year-old patient is admitted with acute respiratory distress. Vital signs are blood pressure 92/66 mm Hg, heart rate 132 beats/min and regular rhythm, and respiratory rate 36 breaths/min and labored. Auscultation of breath sounds reveals crackles to the scapular level bilaterally. Which of the following is the most likely pathophysiologic problem in this patient? A. Acute myocardial infarction B. Mild heart failure C. Massive pulmonary embolus D. Acute pulmonary edema

D The findings are classic manifestations of pulmonary edema. The absence of chest discomfort makes pulmonary embolus and acute myocardial infarction (MI) less likely. Mild heart failure does not cause such acute changes. In addition, a MI would cause these symptoms only with acute left ventricular dysfunction and pulmonary edema.

A woman, age 35 years, reports the feeling that her heart is racing out of her chest, shortness of breath, and dizziness on admission to the critical care unit. The patient reports a history of a "floppy valve" for the past 10 years. Which of the following is true regarding the murmur of mitral valve prolapse? A. Early systolic with a low-pitched, blowing quality B. Radiates to the carotid arteries C. Loudest at the lower left sternal border D. Usually accompanied by a midsystolic click

D The murmur of mitral valve prolapse is caused by mitral regurgitation. Mitral regurgitation murmurs are high-pitched, blowing, systolic murmurs that are loudest at the apex and radiate to the axilla. When specific to mitral valve prolapse, a midsystolic click usually is heard at the apex, and the murmur follows the click such as S1, click, murmur, S2.

A 72-year-old woman has been complaining of chest pain for 30 minutes. Her medical history includes vaginal hysterectomy and angina. She was initially alert but is now drowsy. Her skin is cool and moist. Vital signs are blood pressure, 84/60 mm Hg; heart rate, 42 beats/min and regular; and respiratory rate, 28 breaths/min. Electrocardiogram monitor shows sinus bradycardia. Which of the following treatments is indicated? B. Atropine 0.5 mg IV C. Isoproterenol IV infusion at 2 mcg/min D. Transcutaneous pacemaker

D This case describes symptomatic bradycardia. Treatment usually would start with atropine 0.5 mg IV, but the ischemic chest pain means that caution must be exercised to prevent tachycardia and the increased myocardial oxygen consumption. The advantage to a transcutaneous pacemaker is that the rate can be controlled without the potential for tachycardia.

A 70-year-old woman, weighing 50 kg, comes to the emergency department complaining of chest pain and shortness of breath. The electrocardiogram monitor shows ventricular tachycardia at a rate of 150 beats/min. Which treatment is appropriate in this situation? A. Amiodarone (Cordarone) IV B. Verapamil HCl (Calan) IV C. Defibrillation beginning at 200 J D. Synchronized cardioversion beginning at 100 J

D Treatment for an unstable ventricular tachycardia is sedation and synchronized cardioversion beginning at 100 J. Amiodarone would be used in stable ventricular tachycardia. Verapamil is used for supraventricular tachycardias and would be inappropriate for ventricular tachycardia. Defibrillation is indicated if the patient is pulseless.

Which of the following may be useful in systolic dysfunction but may be detrimental in diastolic dysfunction? A. Beta-blockers D. Vasodilators

D Vasodilators are used for preload and afterload reduction in systolic dysfunction but may detrimentally decrease diastolic filling in diastolic dysfunction.

Myocardial Infarction

Death of a portion of the myocardium

Do you want to increase or decrease Preload/afterload in HF?

Decrease preload and afterload

The S3 indicates the need to decrease circulating volume, decrease...... and increase .......

Decrease preload and increase contractility

A patient has just returned from aortofemoral bypass grafting. He has bilateral audible pulses. How is the ankle-brachial index (ABI) calculated?

Divide the ankle pressure by the brachial pressure on the same side. ABI is ankle-brachial index, or ankle artery pressure divided by brachial artery pressure. The pressure at the ankle normally is higher than the pressure at the brachial artery, and the normal ABI is 1 or greater. This measurement is more quantitative than the presence or absence of audible Doppler pulses. If an occlusion is developing, the ankle artery pressure (measured with a blood pressure cuff and a Doppler stethoscope) will decrease and the calculated ABI will decrease long before the pulses are no longer audible.

Inotropic agent most likely to be used for cariogenic shock?

Dobutamine

Left Ventricular failure does occur, but it is associated with jugular venous distention, peripheral edema, and hepatomegaly. T/F?

False - right ventricular failure has these symptoms

Wedge pressure should always be higher than PAD? T/F

False - wedge should never be higher than the PAD

Following percutaneous transluminal coronary angioplasty (PTCA) of the left anterior descending artery, a patient has developed a PULSATILE HEMATOMA at the groin site. Her hemoglobin and hematocrit have decreased steadily over the last 4 hours. Which of the following should be suspected?

False aneurysm

S3, dyspnea, crackles indicate what complication of what acute MI:

EVF

RAP, PAP, and PAOP would be decreased in early............, whereas the cardiac index would be increased.

Early septic shock

Which of the following terms is used to describe an early systolic heart sound associated with aortic or pulmonic stenosis?

Ejection clicks Semilunar valve stenosis may cause a click as the valve opens (i.e., ejection).

Cardiac tamponade, pneumothorax, and pulmonary emboli are possible complications of ?

Electrophysiology testing and radio frequency ablation

Septic (late) values:

Everything the same except: PAOP: Increased CO/CI: Decreased SV/SI: Decreased SVR: Increased

Left main coronary artery Location: ECG leads: Complications:

Extensive anterior V1 - V6 Sudden Cardiac death HF Cariogenic shock

Angina Pectoris (etiology)

Factors that decrease supply a. Arteriosclerosis/atherosclerosis b. Coronary artery spasm c. Aortitis d. Dysrhythmias e. Anemia f. Shock Factors that increase demand: a. HTN b. Aortic valve dz c. Tachydysrhythmias d. HF e. Hyperthyroidism

More burning with biphasic waveform defibrillation? T/F

False There is actually less risk of burning of the skin with biphasic waveform defibrillation. All other statements are correct.

Mitral regurgitation and aortic stenosis are DIATOLIC murmurs? T/F

False - Systolic

While monitoring the patient's pulmonary artery pressure, a damped waveform is noted. Which of the following would not be an appropriate action?

Fast flush the distal lumen A damped pulmonary artery waveform may be caused by air or blood in the pressure monitoring system, a clot in the catheter, or the catheter being advanced distally enough that the catheter diameter occludes the pulmonary arteriole in which the catheter is located (referred to as a spontaneous wedge).

Pericarditis

Fever Chest pain that worsens with deep breath and lessens with sitting up and leaning forward Pericardial friction rub Elevated WBC count and sedimentation rate Diffuse ST segment elevation across the precordial leads Tx: NSAIDs/Discontinue of anticoagulants/monitor for cardiac tamponade

Bacterial Endocarditis is indicated by?

Fever and new murmur

Pulmonary edema

Fluid in the alveolus Impairs gas exchange and causes hypoxemia by impairing the diffusion between alveolus and capillary (side notes) Cardiac pulmonary edema: Caused by acute LVF/elevated PAOP - Fluid is PUSHED from the interstitium and finally into the alveolus because of increased pulmonary capillary hydrostatic pressure Non cardiac pulmonary edema: Most common cause is ARDS; may be caused by drowning/elevated PAOP Fluid LEAKS from the pulmonary capillary into the interstitium and alveolus because of increased permeability of the damaged membrane.

Heart Failure

HF condition in which one or both ventricles cannot pump sufficient blood to meet the metabolic needs of the body - characterized by one or both of the following: Intravascular and interstitial volume overload (e.g., dyspnea, crackles, and edema) Hypo-perfusion Pulmonary edema

The chance of regaining a pulse after cardiac arrest depends most on which of the following?

How quickly defibrillation occurred The longer the ventricle fibrillates, the less likely is successive conversion, so timely defibrillation is crucial.

Device used to decrease after load and increase myocardial perfusion?

IABP

A 48-year-old male patient with a history of inferior myocardial infarction (MI) is admitted with an acute anterolateral MI. He is tachycardic and hypotensive. Cardiac index is 1.9 L/min/m2. Pulmonary artery occlusive pressure (PAOP) is 20 mm Hg, and systemic vascular resistance (SVR) is 2000 dynes/sec/cm−5. Which of the following is a priority in this patient?

Increase myocardial perfusion Note the term priority. Remember that time is muscle, so reperfusion is the priority. Also remember an actual problem (decreased contractility) takes priority over a potential problem (dysrhythmias). Choose option b.

A 55-year-old man has had an anterior myocardial infarction. He developed a third-degree AV heart block and required insertion of a temporary transvenous pacemaker. The pacemaker is functioning in VVI mode. The rhythm strip shows pacing spikes landing indiscriminately in relation to the patient's inherent rhythm. Which of the following would be the best action to correct the situation?

Increase the Sensitivity

A patient is in cardiac and respiratory arrest. The selection of medications to reestablish cardiac function would stimulate the sympathetic nervous system beta1 receptors. This stimulation would result in increased automaticity and which of the following?

Increased myocardial contractility

Which of the following are therapeutic goals for drug therapy for dilated cardiomyopathy?

Increasing contractility, decreasing afterload and preload

Fibrinolytic Therapy (indications and contraindications)

Indications: Hx strongly suggestive of MI ST segment in elevation of more than 1 mm in at least two continuous leads or new LBBB Pain of less than 6 hours or still having pain. Contraindications: Active internal bleeding Hx of stroke, intracranial neoplasm, AV malfunction, or aneurysm Trauma within two months BP greater than or equal to 200 and/or diastolic greater than or equal to 120 Pregnancy

Indicative leads for this cardiac wall are II, III, and aVF?

Inferior

Right coronary artery Location: ECG Leads: Complications:

Inferior II, III, aVF Sinus Brady Junctional Rhythms Blocks (First degree AV block, Second degree type I) Papillary muscle rupture Posterior Reciprocal changes in V1 and V2 indicative of changes in V7-V9 (especially V8-V9 Papillary muscle rupture with acute mitral regurgitation Right Ventricular V4r - V6r (especially V4r)

Pleural and pericardial friction rubs are signs of which of the following?

Inflammation

Evidenced on ECG by T wave inversion?

Ischemia

A patient sustains a myocardial contusion as a result of a motor vehicle collision. Which of the following signs and symptoms would be most likely?

JVD

S3 at the Apex usually means what?

LVF with systolic dysfunction

LVF vs RVF

LVF: Dyspnea, cough, orthopnea S3 Crackles in lung bases Displaced PMI, heave at apex Cough, frothy sputum, hemoptysis Diaphoresis ABGs: decreased PaO2, SaO2 Elevated PA, PAOP Decreased CO/CI RVF: JVD Right sided S3 Hepatomegaly Splenomegaly Peripheral edema Increases RAP, PAP, and PAOP (PAOP usually greater than 20 mm Hg)

Indicative leads for this cardiac wall are I and aVL and/or v5 and v6:

Lateral

Left Circumflex Artery Location: ECG Leads: Complications:

Lateral High: I, aVL Low: V5, V6 Dysrhythmias HF

Which leads are most helpful in differentiating ventricular tachycardia from a supraventricular tachycardia with aberrancy?

Leads V1 and V6 Looking at the heart from either side helps to identify whether the impulse originated in one ventricle or the other. Inferior, lateral, and anterior leads have a predominantly positive QRS complex because the wave of depolarization through the heart is downward and to the left. Lead V1 is the single most helpful lead to differentiate ventricular ectopy from aberrancy. Leads V1 and V6 together are the two most helpful leads.

The mean QRS axis of ventricular tachycardia is most likely to be:

Left axis deviation or intermediate axis

PCI (contraindications)

Left main CAD (unless there is a patent bypass around it, referred to as protected) Stenosis of coronary artery at orifice Variant angina

Aortic stenosis would elevate which of the following?

Left ventricular systolic pressure The left ventricle must generate a high pressure to get the stiff valve open. Arterial systolic pressure will be decreased because of the gradient across the valve

Which of the following causes a murmur that is heard best with the bell of the stethoscope?

Mitral Stenosis The bell is used to hear low-pitched sounds. All murmurs are high pitched except the murmurs of atrioventricular valve stenosis.

Which of the following would cause an increase in the amplitude of the v wave with a normal amplitude a wave on the pulmonary artery occlusive pressure (PAOP) waveform?

Mitral Stenosis The PAOP waveform is a reflection of the left atrium. Mitral regurgitation causes the pressure in the left atria to go up when the ventricle is in systole (i.e., large v waves).

Prominent A and V waves are associated with what ?

Mitral Stenosis and Mitral Regurgitation

Which of the following is not a complication associated with electrophysiology testing and radiofrequency ablation?

Mitral stenosis

A wide and abnormally notched P wave may be seen in patients with:

Mitrale Stenosis

A wide, notched P wave is an indication of left atrial enlargement. The only condition that specifically would affect an atrium is...........

Mitrale Stenosis

While placing a patient on the monitor during admission, a wide-notched P wave is noted in lead II. What does this most likely indicate?

Mitrale Valve Disease A wide notched P wave in lead II is called a P mitrale and is an indication of left atrial enlargement. A normal P wave is approximately 2½ blocks wide and tall. In right atrial enlargement (P pulmonale), the P wave is taller than 2½ blocks tall. In left atrial enlargement (P mitrale), the P wave is wider than 2½ blocks wide. Pulmonary embolism and COPD may cause right atrial enlargement and P pulmonale. Mitral valve disease, especially mitral stenosis, may cause left atrial enlargement and P mitrale. Myocardial infarction does not affect the size of the atria.

Which of the following describes the pulse pressure of a patient with aortic regurgitation?

More than 40 Aortic regurgitation causes a wide pulse pressure and water-hammer pulse, which is a rapid upstroke and downstroke and shortened peak.

MI (etiology)

Most are caused by arteriosclerosis and thrombosis Arteriosclerosis/atherosclerosis Coronary artery thrombosis Coronary artery spasm Cocaine-induced: excessive sympathetic stimulation causes tachycardia, HTN, arterial vasoconstriction, and spasm; coronary artery spasm may cause MI, especially non-Q wave infarction

Manifestation of hypertrophic cardiomyopathy?

Murmur that increases with squatting

Muscle protein sensitive but not specific for MI: Cardiac muscle protein measured in diagnosing MI:

Myoglobin Troponin

Which of the following is the major disadvantage of the use of serum myoglobin for the diagnosis of an acute myocardial infarction (MI)?

Myoglobin has a high sensitivity and low specificity. Therefore myoglobin is an excellent test for ruling out MI but not good for ruling in MI because of its high risk of false positives.

NTG is a what and decreases what? Nitroprusside is a what and decreases what?

NTG is a venous vasodilator and it decreases Preload NTP is a arterial vasodilator and it decreases Afterload

Which drug is NOT used specifically to block a maladaptive compensatory system in heart failure?

Nesiritide

Papillary muscle dysfunction

New holosystolic murmur loudest at apex Clinical indications of LVF and hypo perfusion Increased PAP and PAOP Large V waves on PAOP waveform Echo shows mitral regurgitation Tx: Vasodilators/IABP/CABG

Where do most abdominal aortic aneurysms (AAAs) occur?

Ninety percent of AAAs are infrarenal.

Which medication is associated with thiocyanate toxicity?

Nitroprusside You may remember having sodium nitrate at the bedside of patients receiving a nitroprusside infusion or concurrently running sodium thiosulfate IV in patients receiving a nitroprusside infusion. These are antidotes for thiocyanate toxicity.

HF (etiology)

No. 1 cause is CAD especially with a hx of MI HTN Obesity Alcoholism Smoking New or worsening ischemia Worsening of anemia Renal insufficiency

If a junctional impulse reaches the atria and the ventricles at the same time, how will the P wave appear?

Not visible If the impulse reaches the atria and the ventricles at the same time, the P wave is obscured by the QRS complex and will not be visible. If the impulse reaches the atria before the ventricle, an inverted P wave will be visible immediately before the QRS complex. If the impulse reaches the atria after the ventricle, an inverted P wave will be visible immediately after the QRS complex. The QRS complex width is normal in junctional rhythms because the impulse originates above the ventricle and travels through the ventricle normally (unless there is a bundle branch block).

Tx for Cariogenic Shock

Oxygen Sodium and fluid restrictions ACE/Diuretics/Vasodilators/Inotropic agents (e.g., dobutamine, milrinone or digoxin)

Which of the following is the best hemodynamic parameter for assessing left ventricular function?

PAOP The left atrium is immediately behind the left ventricle. The PAOP is an indirect measurement of left atrial pressure.

Which is preload and after load ? PAOP and SVR

PAOP is preload SVR is after load

What part of the electrocardiographic waveform represents conduction through the atrioventricular node?

PR segment

Percutaneous Coronary Intervention (procedures)

PTCA (percutaneous transluminal coronary angioplasty): inflation of a balloon-tipped catheter in an area of coronary artery stenosis from plague; plague is pushed back against the wall of vessel and fractured (controlled trauma) Coronary Artery Stent: Use of a metal that acts as a scaffolding device to support a coronary artery and maintain potency after PTCA Brachytherapy: use of intracoronary irradiation to reduce risk of restenosis Coronary atherectomy: removal of plaque from coronary artery by a high-speed diamond tipped (rotational) or shaving (directional) device

Fibrinolytic Therapy (indications of reperfusion)

Pain cessation ST segment return to baseline CK washout

MI (clinical presentation)

Pain: 75% to 85% with MI have pain (knifelike, stabbing, burning, or indigestion). Radiates to left arm, left elbow, left shoulder, or jaw. (if pain is radiating to back, consider dissecting aortic aneurysm). May have diminished breath sounds r/t decreased contractility. May have murmur of systolic murmur of mitral regurgitation (holosystolic murmur loudest at apex that radiates to axilla). Palliation: not relieved by oxygen, rest and/or nitrates. Pain is relieved by narcotics and/or reperfusion (e.g., fibrinolytic drugs or PCI).

Rupture of the ....... muscle causes acute mitral regurgitation

Papillary

....... is associated with left bundle branch block, right ventricular premature ventricular contraction, transvenous endocardial pacemaker, or valvular problem.

Paradoxical split of S2

........ would cause the RAP and PAP to be elevated, but the PAOP would be normal or decreased?

Pulmonary Embolism

When pulmonary arterial diastolic pressure (PAd) is more than 5 mm Hg higher than pulmonary artery occlusive pressure (PAOP), it signals which abnormal condition?

Pulmonary HTN

When the pulmonary artery diastolic pressure (PAd) is more than 5 mm Hg greater than the PAOP, it indicates what?

Pulmonary HTN

A patient is admitted with acute chest pain and dyspnea. Pulse oximetry indicates an arterial oxygen saturation (SaO2) of 88%. Readings after insertion of the pulmonary artery catheter included a normal pulmonary artery occlusive pressure (PAOP), an elevated pulmonary artery, and an elevated right atrial pressure (RAP). The nurse suspects that these findings are most indicative of what acute problem?

Pulmonary embolism

Which of the following evaluates right ventricular preload?

RAP (right atrial pressure) Preload is the stretch on the myofibrils that determines the force of the next contraction, according to Starling's law of the heart. Preload is evaluated by the volume in the ventricle at the end of diastole (end-diastolic volume). The volume is reflected by pressure (ventricular end-diastolic pressure). Atrial pressure reflects end-diastolic pressure for the respective ventricle (in the absence of atrioventricular valve disease). Therefore right ventricular preload and right ventricular end-diastolic pressure are evaluated by RAP. Left ventricular end-diastolic pressure is evaluated by LAP, and PAOP is an indirect evaluation of LAP

Which of the following hemodynamic parameters is likely to be elevated with right ventricular infarction?

RAP (right atrial pressure) RAP is elevated because of right ventricular failure and back pressure. PAs actually may be decreased because of the inability of the right ventricle effectively to propel blood into the pulmonary artery. PAd and PAOP usually are decreased as a reflection of poor filling caused by decreased right ventricular contractility. The filling of the left side of the heart (preload) is low because of the poor pumping ability of the right side of the heart. Remember that the right side of the heart sends blood to fill the left side of the heart. This is an example of backward failure of the right ventricle and forward failure of the left ventricle.

Cardiac tamponade would cause an increase in what?

RAP/PAP/ and PAOP

RAP (Right atrial pressure): PAP (Pulmonary artery pressure): PAOP (Pulmonary artery occlusive wedge pressure): SVR (Systemic vascular resistance): PVR (Pulmonary vascular resistance):

RAP: 2-6 mmHg PAP: 20/8 - 30/15 PAOP: 8-12mmHg SVR: 800-1200 dynes PVR: 50-250 dynes

Inferior cardiac wall is supplied by............, and.....................

RCA and Leads II, III, and AVF

Artery sometimes used for CABG that has a high spasm potential ?

Radial

Which of the following is the most likely mechanism for atrial tachycardias?

Reentry Enhanced automaticity, usually associated with catecholamines, is the most common cause of ectopic beats. Triggered activity, related to repolarization problems, is the cause of torsades de pointes. Accessory pathways are a cause of atrial tachycardias, but reentry is the most common cause of atrial tachycardias.

Evidenced by cessation of pain, ST segment return to baseline, dysrhythmias:

Reperfusion

Describe the shape of ventricular remodeling which may be seen in heart failure?

Reshaping of the ventricle into a more spherical shape

This coronary artery supplies RA,RV,and the inferior wall of LV:

Right Coronary Artery

RAP is elevated, but PAP and PAOP is normal or decreased in what?

Right ventricular myocardial infarction.

A patient has just arrived in the emergency department with complaints of severe dyspnea. His medical history includes an inferior myocardial infarction approximately 1 week ago. Physical assessment reveals a loud, blowing holosystolic murmur that is loudest at the apex and radiates to the axilla. Crackles are audible throughout the lung fields, and pulse oximetry reveals hypoxemia. What is the most likely cause of the patient's deterioration?

Ruptured papillary muscle

Which of the following would be the earliest auscultatory finding in left ventricular failure (LVF)?

S3 LVF would cause crackles, S3, and possibly a murmur of mitral regurgitation. So pericardial friction rub, associated with pericarditis, can be eliminated. S3 is the earliest of the remaining three.

Atrial contraction is at the end of diastole, which is when you hear what?

S4

Myocardial ischemia/Infarction/and Hypertrophy are associated with what heart sound?

S4

Which of the following is a clinical indication of diastolic dysfunction?

S4 Although you probably associate an S3 with failure, it is associated with systolic dysfunction (pump failure). An S4 is associated with poor compliance and diastolic dysfunction. Eliminate options c and d as not being directly related to heart failure.

A patient with severe hypertension most likely would have which of the following? S3 or S4

S4 An S4 is associated with ventricular noncompliance. A patient with severe hypertension would develop ventricular hypertrophy, which makes the ventricle noncompliant.

Prinzmetal's angina is associated with which of the following electrocardiogram changes?

ST segment elevation during pain Prinzmetal's angina, also called variant or vasospastic angina, causes ST segment elevation during pain but the ST segment comes back down to baseline after the pain has ceased.

Typical criteria for prompt reperfusion therapies (e.g., PCI and fibrinolytic drugs) in acute MI include either of the following?

ST segment elevation of greater than 1mm in at least two continuous leads New left bundle branch block (LBBB)

Acute Coronary Syndrome (etiology)

Same as Coronary Artery Dz, Angina Pectoris, and Myocardial Infarction

Indicative leads for the cardiac wall are V1 and V2?

Septal

Left anterior descending artery Location: ECG leads: Complications:

Septal V1 - V2 Sinus Tachy AF Anterior V3 - V4 Ventricular aneurysm HF Cariogenic Shock

New holosystolic murmur at lower sternum, increase SVo2 and shock indicated rupture of the?

Septum

IABP deflates and inflates when?

The balloon is inflated during diastole to increase myocardial oxygen supply. Balloon is deflated immediately before systole to decrease myocardial oxygen demand (decreases left ventricular after load by decreasing systolic BP)

A patient has a pulmonary artery catheter (PAC). There is a change in the waveform from the distal tip of the PAC. It now shows a high-voltage wave with a pressure of 25/2 mm Hg, and no dicrotic notch is visible. Premature ventricular contractions are now evident on the electrocardiogram. What should be done?

The catheter tip is now in the right ventricle, and the catheter must be advanced distally into the pulmonary artery. Notify the physician immediately because ventricular ectopy is likely as the catheter tip irritates the endocardium of the left ventricle.

Which of the following cardiac biomarkers most likely would be elevated within 3 hours of an acute myocardial infarction (MI)?

The earliest cardiac biomarker is myoglobin. Myoglobin is very sensitive for MI but has very low specificity. This means that it is effective for ruling out MI but has a lot of false positives.

QT interval of 0.48 second is?

The normal QT interval is between 0.32 and 0.44 second, depending on heart rate. Longer QT intervals are associated with the form of polymorphic ventricular tachycardia called torsades de pointes.

Which one of the following structures is at greatest risk for trauma in myocardial contusion?

The right ventricle is at greatest risk in chest trauma because it is the most directly anterior, located directly beneath the sternum. Right ventricular infarction and failure may occur in severe cases.

Which of the following risk factors quadruples the risk of heart failure in women?

The vascular effects of diabetes mellitus cause this significant increase in the risk of heart failure in women.

Which of the following cardiac biomarkers most likely would be elevated within 4-6 hours of an acute myocardial infarction and stay elevated for several days?

Troponin rises early and stays elevated for several days. Troponin is like the combination of CK-MB (which is the earliest enzyme) and LDH (which is the enzyme that stays elevated for the longest time). Remember that troponin is a muscle protein, not an enzyme, but we can group all of the options in this question under the heading of cardiac biomarkers.

A variation of up to 15 mm Hg between the arms is normal. This much difference is indicative of aortic dissection? True/False

True

Afterload is pressure, and preload is volume. Pressure is the problem in hypertensive crisis, with cardiac output being reduced because of the increased work of pumping against high systemic vascular resistance (afterload). If pressure is afterload, and afterload is after the ventricle, and arteries are after the ventricle, then arterial vasodilators must decrease after load? T/F

True

Aortic regurgitation is a diastolic murmur but would not cause a loud S1 because S1 is due to closure of the mitral and tricuspid valves? T/F

True

Aortic stenosis is not an acute situation that develops with acute myocardial infarctions. Ventricular septal rupture occurs with septal myocardial infarctions and causes a murmur at the lower left sternal border. T/F?

True

Classic manifestations of hypertrophic cardiomyopathy are chest pain, syncope, and an aortic stenosis type of murmur that decreases when the patient is in a squatting position. The first manifestation of this condition is occasionally sudden cardiac death during exercise? T/F

True

Dilated cardiomyopathy causes heart failure and is treated like heart failure. Contractility should be increased, and preload and afterload should be decreased? T/F

True

Events of the left side of the heart are first and loudest, so the S1 would be heard best at the mitral area? T/F

True

Heart failure causes increase AFTERLOAD and PRELOAD? T/F

True

In VSR some of the oxygenated blood from the left ventricle comes back to the right ventricle and mixes with unoxygenated blood, increasing the oxygen saturation of the blood in the pulmonary artery (SvO2)? T/F

True

Leads II and aVF look at the inferior wall, whereas lead V6 looks at the lateral wall of the left ventricle. Only lead V3 is an anterior lead? T/F

True

Leads V1 and V2 show the septum, and leads V3 and V4 show the anterior left ventricle. ST segment elevation indicates acute injury, which may progress to death and necrosis (infarction) if not reversed promptly. T/F?

True

Mitral stenosis and aortic regurgitation cause diastolic murmurs? T/F

True

Remember that dilated cardiomyopathy previously was called congestive cardiomyopathy. It looks like and is treated like heart failure. T/F?

True

Rupture of the left ventricular free wall causes cardiac tamponade and pulseless electrical activity. T/F?

True

Stunned myocardium and intraoperative myocardial infarction more likely would cause an increase in PAOP because of heart failure? T/F

True

The contribution that atrial contraction makes to ventricular filling volume is approximately 15% to 30%. T/F

True

Ventricular fibrillation is the most frequently identified primary mechanism of cardiac arrest. T/F?

True

When the PAd is more than 5 mm Hg higher than the PAOP, look for a pulmonary cause of the dyspnea? T/F

True

A midsystolic click is associated with mitral valve prolapse? T/F

True - Mitral valve prolapse.

An S4 occur in ......,......,....... Most patients with an acute myocardial infarction have an S4 for the first 48 hours? T/F

True - Myocardial ischemia, Infarction, and hypertrophy

PCI (indications)

Unstable or chronic angina Acute or post acute MI Post-CABG with postoperative angina Patient must be surgical candidate (in case of coronary artery dissection)

Which single lead is the most valuable for the diagnosis of ventricular tachycardia?

V1 Because ventricular tachycardia is most likely to originate in the left ventricle, lead V1, which is normally predominantly negative, would be predominantly positive in ventricular tachycardia.

Which of the following is the preferred lead for ST segment monitoring for a patient with a suspected left anterior descending (LAD) artery occlusion?

V3 Lead V3 would look at the anterior wall, which would be affected by occlusion of the LAD artery.

Why does nitroprusside (Nipride) cause tachycardia?

Vasodilators cause stimulation of the baroreceptors (pressure receptors). This stimulation causes a reflex tachycardia.

Brain natriuretic peptide (BNP) is secreted in response to which of the following?

Ventricular Wall stretch BNP is a hormone that is secreted by the ventricular myocytes in response to ventricular wall stretch.

Which of the following is used to evaluate changes in amplitude on the electrocardiogram?

Vertical axis The horizontal axis represents time, and the vertical axis represents amplitude. The duration of the QRS complex or the PR interval would be horizontal axis and represent time.

Which medication is most important in decreasing the risk of complications from chronic atrial fibrillation?

Warfarin Chronic atrial fibrillation causes stasis in the atria, and this stasis causes mural (wall) thrombi. These thrombi may cause pulmonary, cerebral, coronary, or systemic arterial emboli. About 30% of all strokes are estimated to be the result of atrial fibrillation. Warfarin prevents the development of the mural thrombi that may become cerebral emboli.

Deep T wave inversion is noted on the electrocardiogram in leads V2 and V3 and persists even after the pain is relieved. Enzymes and troponin are negative for an acute myocardial infarction. Which syndrome does this describe?

Wellens syndrome

Which of the following is a manifestation of left atrial enlargement on the electrocardiogram?

Wide, notched P waves in lead II on 12-lead electrocardiogram P waves represent atrial contraction, so look for changes in the P waves as an indication of atrial enlargement. Leads II and V1 are the two best P wave leads.

Atrial fibrillation and supraventricular tachycardia are associated with this dysrhythmia?

Wolff-Parkinson-White syndrom

Give diuretics for HF?

Yes - eliminate symptoms and physical signs of fluid retention, such as JVD and/or edema

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

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

4 things PEEP is good at:

a. Increases the driving pressure of oxygen b. Decreases shunt by opening alveoli that are collapsed and keep alveoli open at low distending pressure if they are still open c. Decreases surface tension and work of breathing d. Postive alveolar pressure prevents the translation of fluid into the alveoli

Angina Pectoris (Diagnostic)

a. Serum 1. Isoenzymes: negative for cardiac damage 2. Fasting glucose: to identify DM or glucose intolerance as a risk factor b. ECG 1. ST segment depression in unstable angina 2. ST segment elevation in variant angina 3. Ventricular dysrhythmias may be present c. Cardiac cauterization: coronary artery occlusion 75% or greater; may be negative in variant angina but develop occlusion from spasm

Angina Pectoris (objective)

a. Tachycardia b. Hypotension or HTN c. Tachypnea d. Pallor e. Diaphoresis g. S4

Which of the following may occur with angina?

an S4 Angina is associated with myocardial ischemia. Myocardial ischemia causes noncompliance of the ventricular wall and the presence of an S4.

Clinical signs of hypovolemic shock?

flat neck veins, hypotension, tachycardia, and restlessness.

A transient systolic murmur also may be heard, associated with what?

papillary muscle ischemia and dysfunction

During auscultation at the pulmonic area, an extra sound that is heard only during inspiration is most likely which of the following?

split S2