Exam 2

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

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

The patient was admitted with a head injury and an intracranial pressure (ICP) monitoring device was placed. The nurse knows to notify the practitioner if what type of wave start to appear on the monitor? a. A waves b. B wave c. C waves d. D waves

ANS: A A waves are the most clinically significant of the three types. They usually occur in an already elevated baseline intracranial pressure (ICP) (>20 mm Hg) and are characterized by sharp increases in ICP of 30 to 69 mm Hg, which plateau for 2 to 20 minutes and then return to baseline. B waves appear to reflect fluctuations in cerebral blood. C waves are small, rhythmic waves that occur every 4 to 8 minutes at normal levels of ICP. They are related to normal fluctuations in respiration and systemic arterial pressure.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The nurse is caring for a severely head injured comatose patient who is dying. The practitioner asks to be notified when the patient starts to exhibit signs of Cushing reflex. The nurse would call the practitioner when the patient starts to show what signs? a. Bradycardia, systolic hypertension, and widening pulse pressure b. Tachycardia, systolic hypotension, and tachypnea c. Headache, nuchal rigidity, and hyperthermia d. Bradycardia, aphasia, and visual field disturbances

ANS: A The Cushing reflex is a set of three clinical manifestations (bradycardia, systolic hypertension, and widening pulse pressure) related to pressure on the medullary area of the brainstem.

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

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

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

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

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

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

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

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

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

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

5. Which area of the ventricular system is usually cannulated for intracranial pressure monitoring? a. Frontal horn of the lateral ventricle b. Aqueduct of Sylvius c. Foramen of Monro d. Fourth ventricle

ANS: A When cannulation of the ventricular system is required for intracranial pressure monitoring, cerebrospinal fluid (CSF) drainage, or placement of a CSF shunt, the frontal horn of the lateral ventricle on the nondominant side of the brain is most often selected.

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

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

1. Indications for the use of electroencephalography (EEG) include (Select all that apply.) a. cerebral infarct. b. metabolic encephalopathy. c. confirmation of brain death. d. altered consciousness. e. all head injuries.

ANS: A, B, C, D Indications for the use of electroencephalography include suspected seizure activity, cerebral infarct, metabolic encephalopathies, altered consciousness, infectious disease, some head injuries, and confirmation of brain death.

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

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

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

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

What sites can be used for monitoring intracranial pressure (ICP)? (Select all that apply.) a. Intraventricular space b. Epidural space c. Jugular veins d. Subdural space e. Parenchyma

ANS: A, B, D, E The five sites for monitoring intracranial pressure are (1) the intraventricular space, (2) the subarachnoid space, (3) the epidural space, (4) the subdural space, and (5) the parenchyma.

Which statements are correct regarding the assessment of motor function in the neurologically impaired patient? (Select all that apply.) a. The presence of a Babinski reflex is an abnormal finding in an adult. b. Lower extremity muscle tone is assessed by asking the patient to push or pull his or her foot against resistance. c. When using noxious stimuli to elicit a motor response, each limb is tested separately. d. The presence of abnormal extension indicates a less positive outcome for the patient than abnormal flexion. e. The evaluation of deep tendon reflexes is an essential part of the nursing neurologic assessment.

ANS: A, C, D The presence of a Babinski response in an adult is indicative of neurologic dysfunction, pushing or pulling against resistance tests muscle strength not tone, and deep tendon reflexes are not routinely checked by the critical care nurse during assessment.

Which of these substances are examples of small-molecule transmitters? (Select all that apply.) a. Acetylcholine b. Glucose c. Norepinephrine d. Dopamine e. Epinephrine f. GABA receptors

ANS: A, C, D, E Examples of small-molecule transmitters include acetylcholine, dopamine, norepinephrine, epinephrine, serotonin, histamine, γ-aminobutyric acid, glycine, and glutamate.

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

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

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

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

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

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

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

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

Which procedure is the diagnostic study of choice for acute head injury? a. Magnetic resonance imaging b. Computed tomography c. Transcranial Doppler d. Electroencephalography

ANS: B Computed tomography offers rapid, convenient, noninvasive visualization of structures and is the diagnostic study of choice for an acute head injury.

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

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

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

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

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

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

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

ANS: B Nicardipine was the first available intravenous calcium channel blocker and as such could be more easily titrated to control blood pressure. Because this medication has vasodilatory effects on coronary and cerebral vessels, it has proven beneficial in treating hypertension in patients with coronary artery disease or ischemic stroke.

10. When an intra-aortic balloon is in place, it is essential for the nurse to frequently assessa.for a pulse deficit. b.peripheral pulses distal to the catheter insertion site.c .bilateral blood pressures. d.coronary artery perfusion.

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

A patient with a serious head injury has been admitted. The nurse knows that certain neurologic findings can indicate the prognosis for the patient. Which finding denotes the most serious prognosis? a. Decorticate posturing b. Decerebrate posturing c. Absence of Babinski reflex d. Glasgow Coma Scale (GCS) score of 14

ANS: B Outcome studies indicate that abnormal flexion or decorticate posturing has a less serious prognosis than does extension, or decerebrate posturing. Onset of posturing or a change from abnormal flexion to abnormal extension requires immediate physician notification. The Babinski reflex is a pathologic finding; absence of this reflex is a normal neurologic finding in adults. The range of scores for the Glasgow Coma Scale is 3 to 15.

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

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

The nurse is caring for a patient immediately after a craniotomy. When assessing the size and shape of the patient's pupils the nurse notes the patient's left pupil is oval. What does this finding indicate? a. Cortical dysfunction b. Intracranial hypertension c. Hydrocephalus d. Metabolic coma

ANS: B Pupil shape is also noted in the assessment of pupils. Although the pupil is normally round, an irregularly shaped or oval pupil may be noted in patients with eye surgery. Initial stages of cranial nerve III compression from elevated intracranial pressure can also cause the pupil to have an oval shape.

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

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

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

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

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

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

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

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

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

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

The patient's intracranial pressure (ICP) reading has gradually climbed from 15 to 23 mm Hg. The nurse's primary action is to: a. drain off 7 mm of cerebrospinal fluid (CSF) from the catheter. b. notify the physician. c. place the patient in a high Fowler position to decrease the pressure. d. check level of consciousness.

ANS: B Under normal physiologic conditions, mean intracranial pressure (ICP) is maintained below 15 mm Hg. An increase in ICP can decrease blood flow to the brain, causing brain damage. Persistent ICP elevation above 20 mm Hg remains the most significant factor associated with a fatal outcome.

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

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

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

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

The nurse and a new graduate nurse are caring for a comatose patient on continuous electroencephalography (cEEG) monitor. The new graduate says "This monitor is great. How come we don't use it on all the neuro patients?" What are the drawbacks to using this type of monitor? (Select all that apply.) a. Size of machine b. Expensive c. Labor-intensive program d. Requires expertise for interpretation e. Artifacts from ICU environment

ANS: B, C, D, E The drawbacks to the use of continuous electroencephalography (cEEG) are that it is an expensive, labor-intensive program that requires expertise for interpretation, and is subject to artifacts from the intensive care unit environment. More research on cEEG is needed to determine its cost-saving potential and impact on outcome.

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

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

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

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

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

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

The nurse is caring for a patient with an intracranial pressure-monitoring device that provides access to cerebrospinal fluid (CSF) for sampling. What type of device does the patient have? a. Subarachnoid bolt b. Epidural catheter c. Intraventricular catheter d. Fiber-optic catheter

ANS: C An intraventricular catheter allows accurate intracranial pressure (ICP) measurement and provides access to cerebrospinal fluid (CSF) for drainage or sampling. A subarachnoid bolt, epidural catheter, and fiber-optic catheter provide no access for CSF sampling.

Why is assessment of level of conscious (LOC) the most important aspect of the neurologic examination? a. The LOC is the most prognostic indicator of the patient's outcome. b. The LOC is generally limited to the Glasgow Coma Scale making it the quickest part of the assessment. c. In most situations the LOC deteriorates before any other neurologic changes are noted. d. The LOC is the easiest part of the neurologic exam and thus is generally performed first.

ANS: C Assessment of the level of consciousness is the most important aspect of the neurologic examination.

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

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

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

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

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

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

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

ANS: C Nursing interventions focus on early identification of myocardial ischemia, control of chest pain, recognition of complications, maintenance of a calm environment, and patient and family education.

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

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

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

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

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

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

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

ANS: C Unstable angina usually is more intense than stable angina, may awaken the person from sleep, or may necessitate more than nitrates for pain relief. A change in the level or frequency of symptoms requires immediate medical evaluation. Severe angina that persists for more than 5 minutes, worsens in intensity, and is not relieved by one nitroglycerin tablet is a medical emergency. Stable angina is predictable and caused by similar precipitating factors each time; typically, it is exercise induced. Patients become used to the pattern of this type of angina and may describe it as "my usual chest pain." Pain control should be achieved within 5 minutes of rest and by taking sublingual nitroglycerin.

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

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

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

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

The ability to access cerebrospinal fluid (CSF) by a lumbar puncture is attributable to the flow of CSF in which space? a. Subdural b. Subpia c. Epidural d. Subarachnoid

ANS: D Cerebrospinal fluid fills the ventricular system and surrounds the brain and spinal cord in the subarachnoid space.

A patient has been admitted with acute confusion and other focal neurologic signs. The practitioner is going to perform a lumbar puncture. What is an abnormal finding in the cerebrospinal fluid? a. Clear and colorless b. Glucose of 60 mg/dL c. Protein of 20 mg/dL d. 30 red blood cells

ANS: D Cerebrospinal fluid is normally a clear, colorless, odorless solution that contains 50 to 75 mg/dL of glucose, 5 to 25 mg/dL of protein, and no red blood cells.

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

ANS: D Early studies demonstrated coronary artery bypass graft (CABG) surgery was more effective than medical therapy for improving survival in patients with left main or three-vessel coronary artery disease and at relieving anginal symptoms

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

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

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

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

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

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

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

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

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

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

A patient is being prepared for a neurologic work-up. The practitioner is getting ready to perform a lumbar puncture. What is the best position for the nurse to place the patient in for the procedure? a. Prone b. Reverse Trendelenburg c. High Fowler d. Lateral recumbent position with knees and head slightly tucked.

ANS: D Patients undergoing a lumbar puncture are placed either in the lateral recumbent position, with the knees and head tightly tucked, or in the sitting position, leaning over a bedside table or some other support.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A patient is admitted to the critical care unit with a subdural hematoma. The nurse is assessing the patient's Glasgow Coma Scale (GCS) score. When assessing the patient's best motor response, which movement would receive the lowest score? a. Abnormal extension b. Localizing pain c. Withdrawing from pain d. Decorticate posturing

a. Abnormal extension Abnormal extension (decerebrate posturing) receives a score of 2 on the Glasgow Coma Scale (GCS). The only lower score is 1, which is for a flaccid response.

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

a. Aspirin and prasugrel

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

b. Diuretic use

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

b. Heart rate, 88 beats/min; rhythm regular; PR interval, 0.18 second; QRS, 0.06 seconds The parameters for normal sinus rhythm are heart rate, 60 to 100 beats/min; rhythm, regular; PR interval, 0.12 to 0.20 second; and QRS, 0.06 to 0.10 second.

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

b. Tall, peaked T waves

A patient has been admitted with acute confusion and other focal neurologic signs. The practitioner is going to perform a lumbar puncture. What is the most serious complication of lumbar puncture? a. Meningitis b. Dural tear c. Brainstem herniation d. Spinal cord trauma

c. Brainstem herniation two life-threatening risks associated with lumbar puncture include possible brainstem herniation, if intracranial pressure is elevated, and respiratory arrest associated with neurologic deterioration.

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

c. Chest radiography