PCCN Review - Cardiac

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Review questions for the Progressive Care Certification test as given by the AACN.

Calculate the cardiac output for a pt with a HR of 70 and a SV of 65 ml.

70 X 65= 4550
4.6 L/min

Calculate the cardiac output for a pt with a HR of 70 and a SV of 65 ml.

70 X 65= 4550
4.6 L/min

What % of the cardiac cycle is provided by the atrial kick?
• 15%
• 20%
• 30%
• 35%


Atrial kick is a term that represents the amount of the total CO that is supplied via atrial contraction.
If the pt has a condition or dysrhythmia that impairs or eliminates the atrial contraction, the pt may be compromised.

Atrial Kick

Atrial kick is a term that represents the amount of the total CO that is supplied via atrial contraction.

A normal value for an EF would be?
• 65%
• 40%
• 30%
• 25%


The EF should be more than 50%. It represents the amount of blood ejected from the left ventricle compared to the total amount available, expressed as a %. An EF of 35% or less indicates a problem with contractility, outflow or filling.

EXA: If the ventricle contains 90ml of blood and 50mls are ejected, the amount would be expressed as a %, in this case 55%.

A 67 year old male is admitted with chest pain after collapsing at home. He is arguing with his wife that he should not be admitted because he "just over did it" while working in the world. Lee's wife states to you that his chest pain is more frequent, severe and prolonged than before. You should anticipate what diagnosis?
• Exertional angina
• Unstable angina
• Variant angina
• Stable angina


The change in quality, frequency, and duration indicates UNSTABLE ANGINA and may indicate that the pt is at increased risk for an MI. This pt should be closely monitored for EKG changes and rhythm disturbances. Pt/ family teaching should begin on how to identify an MI and basic CPR.

Stroke Volume is comprised of which of the following factors?
• Blood volume, viscosity, impedance
• Cardiac output, HR, compliance
• Contractility, preload, afterload
• Compliance, impedance, HR

Contractility, preload and afterload

A reflex tachycardia caused by the stretch of the right atrial receptors is known as the ____
• Herring-Sines law
• Renin-angiotensin system
• Starling's law
• Bainbridge reflex


It is believed that this reflex exists to speed up the HR if the right side becomes overloaded, thereby helping equalize pressures on both sides

Diastole comprises what & of the cardiac cycle?
• ½
• 2/3
• ¼
• 1/3


Some people that the heart is virtually static during diastole.
During this period, the cardiac vessels and chambers fill—a process that takes up 2/3s of the time necessary to complete the cardiac cycle

What is the MAP (mean arterial pressure) for pt:
BP 120/70
HR 80

MAP=2(DBP) + (SBP)/3
MAP=2(70) + 120/3
Pts should maintain a MAP of at least 60 to ensure adequate perfusion to the brain and kidneys.

What is the MAP (mean arterial pressure) for pt:
BP 120/70
HR 80
MAP=2(DBP) + (SBP)/3

MAP=2(70) + 120/3
Pts should maintain a MAP of at least 60 to ensure adequate perfusion to the brain and kidneys.

Calculate CI (cardiac index)
HR 80
BP 110/70
SV 60
BSA 2.0 m2
Expressed in L/min/m2

CO=80 X 60
CI=2.4 L/min/m2

Calculate CI (cardiac index)
HR 80
BP 110/70
SV 60
BSA 2.0 m2

Expressed in L/min/m2

CO=80 X 60
CI=2.4 L/min/m2

The resistance against which the right ventricle must work to eject its volume is known as
• Resting heart pressure
• Systemic vascular pressure
• Central venous pressure
• Pulmonary vascular resistance

Pulmonary Vascular Resistance

This pressure represents a mean pressure in the systemic vasculature. The higher the resistance, the harder the heart has to work against it.

EXA: Colder temperatures will cause vasoconstriction; the heart then has to pump harder to deliver blood through the narrowed vasculature.

Mr. Ironclaw lives on a nearby Indian Reservation. He is retired and on a fixed income with no insurance. He is being discharged today after an observational stay for Chest Pain. In planning his discharge care, which of the following should be considered FIRST to increase compliance with plan of care once home?
• Arrange for Home Health 1X/week
• Ask doc to consider an OTC antiplatelet medication
• Schedule his follow-up appt with the cardiologist in 3 months
• Suggest a gym membership


Although he may wish to be compliant with plan of care at home, financial limitations may prohibit him from expensive treatments, meds, and support services.

William was diagnosed with unstable angina. He is scheduled for an exercise stress test. He tells you he has a "bad hip" and an old knee injury that makes it difficult for him to walk or stand for more than 20 minutes. You tell him:
• You only need to walk for 10 minutes
• You can ride a bike for 20 minutes instead
• I will call the doc and ask for the Weight-life test instead
• I will call the doc and ask for a stress echocardiography test instead


The exercise stress test requires the pt to walk on a treadmill or stationary bike for 30-60 minutes.
The Stress Echocardiography test uses Dobutamine to stress the cardiac tissues without requiring the pt to walk or ride.
The Weight lift test does not exist.

Approximately what % of coronary artery blockage is needed to cause angina?
• 45%
• 60%
• 75%
• 90%

Anginal pain usually occurs when approximately 75% of the artery's diameter becomes occluded. Pain is usually more pronounced with exertion or emotional distress, when O2 demand by cardiac tissue cannot be met by O2 supply via the occluded arteries. The severity of the pain may be compounded with vasospams that further restrict blood flow through the coronary arteries.

A heart murmur associated with acute valvular regurg would be?
• S3
• S2
• S1
• S4


S1 and S2 are normal heart sounds
S3 is associated with fluid status
S4 is associated with compliance.

Which is the best lead to monitor a RBBB?
• Lead II
Lead I
• Lead V1
• Lead V6

Lead V1

Tall, peaked T waves on an EKG may be indicative of?
• Hypocalcemia
• A non-STEMI
• Hyperkalemia


The PR interval may become prolonged. Also, if the K is greater than 8, a wide-complex tachycardia may occur. Keep in mind that low levels of calcium or sodium may potentiate the cardiac effects, as can a low pH.

Mrs. P suffered a cardiac arrest at home. The family did not perform CPR and paramedics arrived 6 minutes after the arrest. The pt was found in pulseless V-tach. Defib and continuous CPR were provided during transport to the ED. The pt was tx-ed to tele. The doc initiated hypothermic measures and administered vecuronium. This med is for?
• Controlling ventral dysrhythmias
• Prevent shivering
• Sedative
• Pain control


Vecuronium is a paralytic and will prevent shivering. If a pt shivers, her temperature will rise.

Your pt was admitted for malaise, severe dyspnea and had a syncopal episode at work. He states he has a midline burning sensation in his chest that worsens when he is supine. You suspect?
• Pleural effusion
• Pericardial tamponade
• Myocarditis


It can also present as inspiratory pain. The pain when supine is a cardinal sign of myocarditis. Other findings may include respiratory infection and an S3, S4, and pericardial friction rub.

A definitive diagnosis of myocarditis can be made via?
• Endomyocardial biopsy
• Transesophageal ultrasound
• Transmural catheterization
• Chest X-ray


A biopsy is the ONLY definitive way to diagnose myocarditis.

The volume of fluid required to cause a pericardial tamponade is?
• 25-50 ml
• 50-75 ml
• 100-150 ml
• 200-300 ml

50-75 ml of blood

Although 50-75 mls is a small amount, the pressure in the intrapericardial space may equal or exceed atrial and vertricular pressures causing an acute tamponade.

Beck's triad is a combination of symptoms useful in diagnosing cardiac tamponade. They are?
• Pericardial friction rub, hypertension, RV failure
• Increased pulse pressure, increased JVD, tachycardia
• Tachycardia, hypertension, LV failure
• Distended neck veins, muffled heart sounds, hypotension

Distended neck veins
Muffled heart sounds

Tachycardia is an early sign of tamponade. A narrowed pulse pressure occurs, and fluid cannot be ejected from the heart. The muffled heart sounds occur because the fluid in the sac minimized the transmission of sound waves.

Which of the following hemodynamic changes will occur with cardiac tamponade?
• Increased cardiac output
• Stroke volume decrease
• Contractility increases
• Decreased heart rate


Because the heart cannot adequately fill or eject its contents, stroke volume (SV) decreases and causes a decreased cardiac output (CO). Contractility decreases because the muscles cannot stretch and, therefore, cannot contract effectively.

If your pt had a cardiac tamponade, which of the following would you expect to see on a CXR?
• A dilated superior vena cava
• Increased JVD
• Narrowed mediastinum
• Delineation of the pericardium and epicardium


The vena cava is dilated because blood couldn't flow into the right atrium.
JVD would not be visible on a CXR.
The mediastinum would be widened.
Delineation of the pericardium or epicardium would not be visible on a CXR.

Your pt was admitted for severe dyspnea, dysphagia, palpitations and an intractable cough. On auscultation, you hear a loud S1 and a right sided S3 and S4. This pt probably has?
• Mitral insufficiency
• Myocarditis
• Atrial stenosis
• Mitral stenosis


These symptoms could be caused by mitral stenosis, an ischemic left ventricle, or failure of a left ventricle. The S3 and S4 sounds suggest both a fluid problem and a pressure problem.

Quincke's sign is usually seen in which of the following conditions?
• Mitral Stenosis
• Endocarditis
• Aortic insufficiency
• Pericarditis


Quincke's sign is elicited by pressing down on he finger top; a visible pulsation is seen in the nail bed. The sign results from a pulse with a rapid, initial hard pulsation, followed by a sudden collapse as blood flows back through the incompetent valve.

In pts with aortic insufficiency, the popliteal BP is often higher than the brachial BP by at least 40 mm HG. This discrepancy between the measurements is known as?
• DeMusset's Sign
• Hill's Sign
• Holmes' Sign
• Rochelle's Sign


Hills's sign reflects the rapid rise in pulsation.
DeMusset's sign is also found in aortic insufficiency; it consists of the bobbing of the head in time with the forceful pulse.
Holmes' and Rochelle's signs are not diagnostic signs.

In stable angina, which of the following is true?
• A positive treadmill test will indicate CAD
• A thallium test (myocardial scintigraphy) will not diagnose LV dysfunction
• The treadmill test will miss as many as 20% of cases of single-vessel disease
• CK-MB isoenzymes and troponins will not increase


A positive treadmill test may not be positive for CAD.
LV dysfunction may be diagnosed with a thallium test (myocardial scintigraphy).
Treadmill stress tests miss as many as 40% of cases of single-vessel disease.

Actions of beta blockers include?
• Increased myocardial oxygen demand
• Increased heart rate
• Increased diastolic filling time
• Increased afterload


If the inferior wall of the heart is infracted, the leads that will most directly reflect the injury are?
• II, aVF
• I, aVL
• V1 - V2
• V5 - V6

II, a VF - inferior heart

I, aVL - lateral wall
V1 - V2 --septal wall
V5 - V6 - apical area

An anterior wall infarct may be seen in leads?
• V4, R
• V5, V6
• V7, V9
• V2, V4

V2, V4 -anterior wall

V4, R -right ventricular damage
V5, V6 -apical injury
V7, V9 - posterior wall

Pulsus alternans is most often noted with?
• Mitral Stenosis
• Constrictive pericarditis
• Aortic stenosis
• LV failure

LV failure

Pulsus alternans occurs when a weakened myocardium cannot maintain an even pressure with each contraction. The pulses alternate between strong and weak. This phenomenon is also seen in CHF.

Which of the heart valves is most commonly affected by infective endocarditis?
• Aortic
• Pulmonic
• Mitral
• Tricuspid


Aortic valve - is the next most common affected
Pulmonic valve - least likely to be affected
Tricuspid valve - often involved secondarily as a result of IV drug abuse

Alpha-adrenergic effects of norepinephrine include?
• Increased force of myocardial contraction
• Increased SA node firing
• Increase AV conduction time
• Peripheral arteriolar vasoconstriction

Peripheral arteriolar vasoconstriction

Increased force of myocardial contraction
Increased SA node firing
Increase AV conduction time
• These are all affects of beta-adrenergic sympathetic stimulation

Stimulation of the vasomotor center in the medulla occurs when the partial pressure of O2 changes. This sequence is initiated by?
• Baroreceptors
• Chemoreceptors
• The Purkinje system
• The Bainbridge reflex


Minute changes in the partial pressure of O2, pH, and the partial pressure of CO2 result in changes in the heart and respiratory rates. These changes are initiated by the chemoreceptors located in the carotid and aortic bodies.

When attempting to auscultate the aortic area, the location of the stethoscope should be?
• At the 2nd intercostal space, left sternal border
• Over the apical area
• At the 2nd intercostal space, right stenal area
• At the 5th intercostal space, left sternal boarder

At the 2nd intercostal space, right stenal area

At the 2nd intercostal space, left sternal border
• Pulmonic area
Over the apical area
• Mitral valve
At the 5th intercostal space, left sternal boarder
• Tricuspid area

When preparing to teach your 30 YO female pt about goals for weight control, the BMI should be assessed. The BMI should be between?
• 12.6 - 15.0
• 11.2 - 15.8
• 18.0 - 24.9
• 28.6 - 24.7

18.0 - 24.9

BMI= [(wt in #) / (ht in inches)2] X 703
BMI greater than 30 = obesity
BMI of 25-29 = overweight

When preparing to teach your 30 YO female pt about goals for weight control, the BMI should be assessed. The BMI should be between?
• 12.6 - 15.0
• 11.2 - 15.8
• 18.0 - 24.9
• 28.6 - 24.7

BMI= [(wt in #) / (ht in inches)2] X 703

18.0 - 24.9

BMI= [(wt in #) / (ht in inches)2] X 703
BMI greater than 30 = obesity
BMI of 25-29 = overweight

Symptoms of right-sided heart failure include?
• Pulmonary edema
• Elevated pulmonary pressures
• Hepatomegaly
• Orthopnea


Pulmonary edema, elevated pulmonary pressures and orthopnea are all signs of left-sided heart failure.
Often times when the right side of the heart fails it's because the left side has failed. The right ventricle cannot adequately pump blood out, so filling pressures rise and the blood backs up, resulting in HEPATOMEGALY. As a consequence, CVP is elevated.
Additional symptoms may include: SPLENOMEGALY, ASCITES, ABDOMINAL PAIN, S3, S4, AND WEIGHT GAIN.

NSAIDS are contraindicated in the treatment of pts with heart failure because they?
• Decrease myocardial contractibility
• Cause a-fib in pts with heart failure
• Promote fluid retention
• May cause hypocalcemia


And may also contribute to renal insufficiency

Mr. J underwent a CABG 4 days ago and was tx-ed to you yesterday. Today, he c/o dull aching around the sternum. You note increased tenderness to touch along the sternal edge and contracted intercostal muscles. You should?
• Call the doc for orders: EKG, cardiac enzymes, and morphine
• Culture the wound for infection
• Do nothing; his pain is normal
• Administer morphine and diazepam as ordered.


The chest wall pain is most likely from his open-heart surgery. Pain must be addressed. MS and diazepam will treat both pain and muscle spasms.

The pain the pt c/o is not indicative of another MI and EKG changes would not be seen.
There is no indication of infections, so no culture is indicated.
Pain must ALWAYS be addressed.

You are using the PQRST method of pain assessment for your pt c/o CP. The S stands for?
• Sensitivity
• Severity
• Standard
• Symptoms


P - provokes (what makes it hurt?)
Q—quality (sharp, stabbing, dull, ache?)
R—radiation (does it start in one place and move to another?)
S - severity (1-10)
T - time - (duration of pain)

An absolute contraindication for use of a fibrinolytic would be?
• Traumatic CPR
• Cerebrovascular disease
• Subacute bacterial endocarditis
• Oral anticoagulants


Other absolute contraindications are:

The other options are relative contraindications.

Which of the following statements are true about Lidocaine?
• Causes hypotension
• Has a moderate GI intolerance
• Has no impairment of normal contractility
• Can cause nystagmus


Lidocaine may shorten QT intervals.
Side effects usually involve the CNS - slurred speech, drowsiness, confusion, paresthesias, seizures, and convulsions.

The other selections are effects of phenytoin, another class 1B drug.

Which of the medications listed has a high iodine content?
• Flecanide
• Lidocaine
• Mexilitene
• Amiodarone


The high iodine content can actually exert an effect on the thyroid, thereby producing an antiarrhythmic action.

Flecanide - antiarrythmic
Lidocaine - antiarrythmic
Mexilitene - antiarrythmic

The drug of choice to treat AV nodal and atrioventricular re-entrant arrhythmias is?
• Amiodarone
• Clonidine
• Quinidine
• Adenoside


Adenosine is a naturally occurring substance in our bodies and has a very short half-life (only a few seconds). It slows AV nodal conduction or can stop the conduction process altogether, potentially causing a transient AV block (seen as asystole). The pt may experience mild to moderate chest discomfort, slight hypotension, bradycardia, and possibly flushing.

Amiodarone is an antiarrhythmic
Clonidine is an antihypertensive
Quinidine is an antiarrhythmic

Sometimes certain medications prolong the QT interval, potentially causing polymorphic ventricular tachycardia. The drug of choice to treat this rhythm is?
• Magnesium
• Calcium
• Digoxin
• Lidocaine


Magnesium acts on the processes by which calcium is transferred both across the cell membrane and within the cell itself.
If high doses of Magnesium are given, it may slow AV conduction

The QT interval may be prolonged by use of tricyclic antidepressants, erythromycin (ABX), quinidine (antiarrhythmic) or terfenidine (antihistamine).

Calcium-channel blockers act primarily on?
• Reduction of CO (cardiac output)
• Arteries to arterioles
• Lung receptors only
• Venules to veins


Large-lumen vessels in the arteriole system are affected. The advantage of this action is that both systolic and diastolic pressures are reduced and the pt will not have a precipitous drop in BP. The BP may be lowered slightly and cause a reflex baroreceptor response to increase HR to maintain CO (cardiac output).

The fourth heart sound, S4, is?
• Heard as the mitral valve opens
• A low-pitched murmur
• Heard during atrial contraction
• Produced in CHF


When the atria contract and fill the ventricle, there is naturally some resistance to that pressure, as the ventricle is already about 80% full.

If the pt has a problem such as HTN, had an MI, an anginal episode, or aortic stenosis, the S4 sound may become quite pronounced.

An example of a systolic murmur would be?
• Tricuspid stenosis
• Tricuspid insufficiency
• Mitral stenosis
• Pulmonic insufficiency


A heart murmur is the sound made by turbulent blood flow.
A SYSTOLIC murmur would be heard during systole, when the ventricles are contracting. The mitral and tricuspid valves should be closed during this phase of the cardiac cycle. If these valves are incompetent/ insufficient, the blood will flow back through the valve (regurgitation).

Pulmonic and Aortic STENOSIS=
Systolic murmurs
Mitral and Tricuspid INSUFFICIENY=
Systolic murmurs

An example of a pansystolic murmur is?
• Pulmonic insufficiency
• Tricuspid insufficiency
• Atrial stenosis
• Mitral stenosis


PANsystolic means that the murmur is heard throughout systole.
Diastolic murmur
Atrial and Mitral STENOSIS =
Diastolic murmur

Mrs E. was diagnosed with pericarditis on admit to PCU. She is c/o intermittent, sharp, knifelike pain in her chest. Which position would you place her in to help alleviate some of the pain?
• Flat with heels elevated
• Sit up and leaning forward on a stable bedside table
• Prone, Trendelenburg (head down, feet up)
• On her right side


Pericarditis results in inflamed layers of the pericardial sac.

Upright and forward positioning pulls the heart away from the diaphragmatic pleura of the lungs and eases cardiac pain.

Deep respirations, trunk rotation and flat positioning allow the parietal and visceral layers of the pericardial sac greater ability to rub against each other.

Mrs. B was admitted for observation post falling 10 feet into a ravine. She was diagnosed with SLE (systemic lupus erythematosus) 2 yrs ago. She suffered a concussion, 3 fx-ed ribs, a fx-ed radius, and sprained ankle. She is on a Holter monitor and receiving IVF and ABX. Which of the following conditions would be exacerbated by the SLE?
• Hypotension
• Constipation
• Pericarditis
• Polycythemia


SLE - systemic lupus erythematosus is a chronic inflammatory autoimmune disease that affects the vascular and connective tissues within any body system or organ.

As a result of the SLE, inflammation may be increased and the stress of injury would further exacerbate the disease.

S/S to monitor closely for include:
Pericarditis, HTN, diarrhea, thrombocytopenia, anemia, leucopenia, joint and muscle pain, vasculitis, proteinurea, seizures, depression, PNA, pleural effusions, nausea and ulcers.

If the INR (international normalized ratio) is greater than 5.0, the pt is at a significant risk for bleeding. A drug that can cause a significant rise in the INR is?
• Ethacrinic acid
• Amiodarone
• Statins


These cause a SIGNIFICANT rise in INR:
sulfonamides (ABXs)
cimetidine (Tagamet, an H2 antogonist receptor), fluoroquinolones (ABXs)
macrolide antibiotics

Those below all cause a MODERATE rise in INR:
Ethacrinic acid (loop diuretic, antihypertensive) PCN (ABX)
Statins (anticholesterol medications)

A drug that will significantly decrease the INR would be?
• Naficillin
• Vitamin K
• High-dose Vitamin C
• Cyclosporin


Vitamin K is considered the antidote for warfarin, but can actually lower the INR too much and increase warfarin resistance, so careful monitoring is needed.

These cause SIGNIFICANT decrease in INR:
Rifampin (ABX)
Phenobarbital (barbiturate anticonvulsant)
Glutethimide (hypnotic sedative)

Those below cause a MODERATE decrease in INR:
Naficillin (narrow spectrum ABX)
High dose Vitamin C (cancer tx)
Cyclosporin (immunosuppressant)

Your pt has a temporary pacer and has been requiring adjustments to raise the energy output (milliamps). This is probably due to?
• Hyperkalemia
• Necrotic tissue
• Lidocaine toxicity
• An atrioventricular block


Dead meat don't beat. Necrotic tissue cannot conduct an impulse. Ischemic tissue may impair conduction.
If the pt was Hypokalemic, the energy levels (mA) would have to be raised because the low K level depresses the myocardium.

Mr K is a 54 YO dockworker who was admitted with a NSTEMI to the inferior wall. He is c/o dyspnea, weakness, bilateral crackles, and demonstrates orthopnea. He has developed an S3 heart sound. You suspect he has also developed?
• Pulmonary Embolus
• Pulmonary HTN
• A fat embolism
• Cardiogenic shock


The MI has impaired the heart's ability to pump effectively. The CO falls and the body reacts by vasoconstricting peripheral circulation and increasing the HR.
Tachycardia is also the result of catecholamine release, and the myocardial O2 consumption increases.
The left ventricle works harder, but has been compromised by the MI.
Preload increases because fluid cannot be pumped out of the chambers effectively.
S3 is a signal of increased PREload.
Pulmonary congestion occurs because of increased LEFT heart pressures.

Your pt suddenly complains of chest pain. You auscultate a new holosystolic murmur at the lower left sternal border. Your pt has probable experienced a
• Dissecting thoracic aneurysm
• Pulmonary embolus
• Ventricular septal rupture
• Lateral wall MI


A new holosystolic murmur at the lower left sternal border means that turbulent blood flow is occurring there. The turbulence is caused by a hole that is allowing blood to flow through a previously closed area. The SvO2 will increase due to the mixing of blood. This condition must be corrected surgically.

Mrs F was admitted for DVT management 3 days ago. During your initial assessment, you found her sitting on the side of the bed leaning forward. Mrs. F states that this position relieved her newly developed chest pain. She also states her pain is worse on inspiration. You call the doc who orders a CXR and labs. The lab results show that the pt's sed rate and WBCs are elevated. Mrs. F most likely has?
• Pericarditis
• Thoracic aneurysm
• Pulmonary embolus
• Pulmonary edema


The CXR will probably show a pericardial effusion.
The elevated sed rate and WBCs indicate infection.
Learning forward will relieve the chest pain whereas lying supine makes it worse.
If the pain worsens with inspiration, it's because the lungs expand and come in contact with the pericardium.
The pt will also probably have a fever.
It's also important to assess for s/s of tamponade and to make certain that any anticoagulants are d/c'd.

A probable candidate for a CABG (coronary artery bypass graft) might have?
• An EF of 55% and diabetes
• Right main artery disease
• An EF of 35% and CAD (coronary artery disease)
• A previous history of cardiac surgery

An EF of 35% and CAD

You are performing CPR on a pt with an endotracheal tube (ET) in place. The placement of the tube has been confirmed. THe pt should be ventilated every:

6 to 8 seconds
5 Compressions
15 Compressions
3 to 5 seconds

6 to 8 seconds

The new AHA guidelines specify t hat ventilation should occur every 6 to 8 seconds. The compressions should continue at a rate of 100 per minute. The recommended ventilation rate approximates a normal adult rate and allows for cardiac refill. Ventilating too fast raises intrathoracic pressure and interferes with cardiac fill.

If you are using a biphasic defibrillator on an adult, t he energy setting should be:

360 joules
50 to 100 joules
300 joules
200 joules

200 joules

200 joules on a biphasic defibrillator is as effective as 360 joules on a monophasic defibrillator. The purpose of defibrillation is to deliver enough electricity to cause a large enough mass of myocardium to depolarize simultaneously. If that occurs, it is then possible for a normal rhythm to reemerge or become the primary rhythm. It is important to identify the initial cause of the dysrhythmia and treat it, if possible, to prevent recurrence.

Maria has been diagnosed with pericarditis secondary to blunt chest trauma and cardiac contusion after a motor vehicle accident. She asks you how long the pericarditis may last. Your answer will be formulated based on the fact that:

Acute pericarditis will self resolve in 1 week
Acute pericarditis should self resolve in 2-6 weeks
Acute pericarditis will always result in chronic pericarditis
Chronic pericarditis is reoccuring and not associated with any other cardiac symptom

Acute pericarditis should self resolve in 2-6 weeks.

Acute pericarditis is usually self limiting within 2 to 6 weeks after it's initial onset. Treatment includes bedrest, O2 therapy, antivirals, antifungals, or antibacterials. In addition, drainage and management of cardiac tamponade may be necessary. The classic presentation of chronic pericarditis, also known as constrictive pericarditis, demonstrates fibrous pericardial thickening. Treatment may include the extreme measure of pericardiotomy (removal of the pericardium.)

Wellen's syndrome:

Is the same as Prinzmetal's angina
Occurs with the proximal stenosis of the LAD
Is also called cresendo angina
Is variant angina

Occurs with the proximal stenosis of the LAD

Wellen's syndrome is a type of angina that occurs when the LAD is stenosed proximally. The ST segment is not elevated more than 1mm in leads V1-V3, there is a mild T wave inversion in leads V2-V3, and Q waves are not pathologic (greater than 25% of the total length). Because of the location of the stenosis, surgery is emergently needed.

Prinzmetal angina is aka Variant angina -- in this type of angina, the pain occurs at rest and is associated with a vasospasm.

Cresendo angina means that over time, it takes less to initiate the pain and the pain lasts longer.

A vasodilator used in the treatment of anginal pain is:



NTG is a vasodilator for both arterial and venous systems. Sometimes the decreased coronary vessels are stiff and calcified. If the patient has good collateral circulation, O2 and blood can reach the ischemic areas. NTG is now available in a metered-dose oral spray, in addition to pressed tabs, paste, and IV (nitroprusside) formulations.

A pt is at high risk for ventricular septal defect or rupture or even a ventricular aneurysm if an infarct occurs in the:

Left Anterior Descending artery
Left Main Coronary artery
Left Circumflex artery
Right Coronary artery

Left Main Coronary Artery

An infarct in the left main coronary artery is an ominous sign. Sudden death may occur, along with heart blocks and atrial and ventricular dysrhythmias.

If a chronic fluid accumulation occurs, the pericardial sac may hold as much as _____ before the signs of cardiac tamponade will appear.

200 ml
400 ml
1000 ml
2000 ml

2000 ml

In a chronic condition, as much as 2000 ml of fluid may collect in the pericardial sac before symptoms appear. This fluid buildup is usually due to a chronic pleural effusion or uremia.

Acute tamponade may occur with as little as 50 ml of fluid collects in the pericardial sac.

Which of the following statements is true about pericardial effusion?

-Pericardial effusion is a painless, hard to diagnose condition.
-On CXR, a "water bottle" silhouette is noted.
-Diastolic filling is increased.
-The voltage of the QRS complex in increased.

On CXR, a "water bottle" silhouette is noted.

The classic description of the CXR associated with pericardial effusion is the "water bottle" silhouette.
QRS amplitude is decreased, as is diastolic filling.

Increased afterload would be seen with _____.

-Aortic insufficiency


Hypovolemia and Sepsis decrease afterload as does Aortic insufficiency. Aortic stenosis increases afterload, as do peripheral vasoconstriction and hypertension.

Auto-regulatory control of caridac vessels becomes impaired if the coronary perfusion pressure drops below:

35 mm Hg
40 mm Hg
50 mm Hg
60 mm Hg

50 mm Hg

A pressure of at least 50 mm Hg is required to maintain auto-regulatory control.

Renin is secreted by the _____.



Renin, a protease, will be secreted if the sodium concentration falls, sympathetic output increases, or blood pressure decreases. Blood pressure may be lowered by diuretics, hemorrhage, dehydration, or sodium depletion. Something as simple as NG tube drainage can decrease blood pressure, so in any setting, it is critical to maintain accurate I/Os.

If blood pressure is lower by at least 10-11 mm Hg on inspiration than on expiration, this is known as _____.

-Pulsus alternans
-Pulse pressure
-Pulsus paradoxus
-Pulsus parvus

Pulsus paradoxus

Pulsus paradoxus may be present in conjunction with asthma, emphysema, cardiac tamponade, restrictive pericarditis, or hemorrhagic shock.

Pulse pressure is the difference between systolic and diastolic pressures.
Pulsus parvus means a small or weak pulse
Pulsus alternans means the upstroke is more powerful than the downstroke -- that is, the stokes alternate in strength.

Robert suffered an MI but is now in stable condition in the PCU. Seven family members arrive at the unit demanding to see the pt. Your best response would be:

-Notify social services
-Identify the responsible family spokesperson and contact him or her
-Refuse to admit more than one person]
-Call security to remove the visitors.

Identify the responsible family spokesperson and contact him or her.

Visitation policies cary by institution. However, it is best to identify one person as the point of contact. HIPAA regulations require limitations on the release of any medical information be set by the patient if the patient is able to communicate his or her wishes. If the patient is unable to make this decision, the next of kin can act as a contact person.

Robert suffered an MI but is now in stable contition in the PCU. After you have identified his significant other, his estranged wife arrives. Robert tells you that he does not want contact with her. He even writes a note to the effect to be placed on his chart. He also states he wants no information given to his estranged wife. She becomes belligerent when told of Robert's wishes and threatens the staff with a lawsuit. The most appropriate nursing action would be :

-Request an ethics/ multidisciplinary care conference to discuss communication and dissemination of the patient's medical status and to review the visitation policy
-Immediately call the hospial's attorney to speak to the estranged wife
-Give the wife any information she wants, but do not inform Robert that you have done so
-Request that the patient's physician write a non-visitation order for the wife.

Request an ethics/ multidisciplinary care conference to discuss communication and dissemination of the patient's medical status and to review the visitation policy

The best response would be to collaborate and interact with other professionals.

Rebecca, who is a Jehovah's Witness, has just undergone a cardiac surgical procedure. Her Hgb and Hct levels have been falling and are now 6.5 and 24. Her chest tubes have drained 1750 ml in the last 4 hours. The anticipated treatment would be to administer:

-One unit type specific whole blood
-500 ml albumin
-250 ml FFP
-Continuous-circuit auto-transfusion

Continuous-Circuit Auto-transfusion

The religious preference of the patient must be respected. The only acceptable form of transfusion is this case is via auto-transfusion.

The major advantage of using an internal mammary artery for cardiac bypass would be:

-Greater ease of harvesting
-Better postsurgical patency
-A lowered infection rate
-A lowered rate of reperfusion rhythms

Better postsurgical patency

Utilizing the internal mammary artery means grafts do not have to come from the saphenous veins in the legs, minimizing the risk for infection from another site.
In the graft procedure, the internal mammary artery is seperated at only one end and reanastomosed to the affected coronary artery distal to the affected area. The patency of the resulting graft is generally quite good. After 10 years, approximately 90% of the grafts are still patent.

Your patient just underwent a percutaneous intervention for stent placement, after which he was returned to your tele unit. You note a rash over the patient's trunk and arms. This is probably due to _____.

-An allergic reaction to contrast dye
-Petechiae from a fat emolism
-A reaction to the indwelling stent
-A rash secondary to a Candida infection

An allergic reaction to contrast dye.

Iodine dye is used and will cause a rash, itching, swelling and can also lead to laryngospasm and anaphylaxis in some patients. It is imperative to determine whether the patient is allergic to iodine, shellfish, or horses prior to initiating the procedure.

A sign of necrosis on an EKG would include:

-Acute ST elevation
-A Right BBB
-A Left BBB
-A Q wave in lead III

Acute ST elevation.

Along with acute ST elevation, another indicator of necrosis would be an abnormal Q wave. If the Q wave appears within about 6 hours of a transmural MI, it is an ominous sign. If the Q wave is more than 0.04 seconds long, it is a sign of necrosis. In an inferior MI, the Q wave should not exceed 0.03 seconds or it is indicative of necrosis.

Holly recieved 4 mg Morphine IV. She is now unresponsive and her RR and depth are diminished. The antidote for morphine is:



The antagonist for morphine and other opiods is Narcan (naloxone). Generally, the naloxone dose is 0.4 mg IV. This dose can be repeated about every 3 to 4 minutes for a total of 3 times. When you give Narcan, you must always be alert for the patient to relapse once the dose wears off. Administering multiple follow-up doses is not uncommon.

Complications associated with ventricular assist devices (VADs) include:

-Dissection of the aorta


Additional complications that are commonly seen with VADs are infection and bleeding.
Thrombocytopenia, aortic dissection and septicemia are complications of an intra-aortic balloon pump (IAPB).

Indications for use of a VAD include:

-As destination therapy
-Prolonged cardiac arrest
-Extensive organ damage

As destination therapy

Other indications for use of VAD include use as a bridge to transplant, treatment of cardiogenic shock, and inability to wean from cardiopulmonary bypass. Always be aware of the possibility of device failure.

Prolonged cardiac arrest, especially with neuroligical damage is a contraindication for use of a VAD. Extensive organ damage is another contraindication. Dysrhythmias are not indications for use.

The most common infection in patients with VADs is:

-Pericardial effusion


PNA secondary to immobility is the primary reason for infection with VADs. There may also exist a need for some type of ventilatory support. Jst the fact that tubes are placed into the body is a potential source of infection, but this is usually minimized by good hand washing and aseptic technique.

The most common type of VAD is the



The left ventricular assist device is the most commonly used because left heart failure is more common and usually precedes right venticular failure.

The most common major impediment to family education regarding placement of a ventricular assist device is:

-Physician availability


Quite often, the patient develops cardiogenic shock and requires emergent placement of a VAD. If the nurse is able to at least explain the function of the device, it can be a great relief to the family.

The physician has just informed your patient that she needs an LVAD. The patient is crying and says, "I just know I'm going to die. What's the point? It must be my time." The patient is obviously stressed. The priority for th nurse at this time is to:

-Tell the patient that she isn't going to die
-Explore possible suicidal ideation
-Immediately place the pt in a single room
-Notify the hospital's spiritual advisor

Explore possible suicidal ideations.

The patient is approaching crisis and may feel hopeless. The nurse should take the time to fully explore and validate the patient's feelings, then decide on the appropriate course of action.

Your patient was transferred out of the ICU to the PCU. He had a AAA repair 2 days ago. He is somewhat restless, and his vitals are stable. He keeps pointing at the lumbar area of his back and saying that he has discomfort in that area. This may indicate:

-A blister from the surgical ground pad
-Need for repositioning
-Irritation from the dressing
-Retroperitoneal bleeding

Retroperitoneal bleeding

If the patient is bleeding, the blood may settle into the lumbar area. Blood is heavy and will flow into the retroperitoneal space because of gravity. More than an hour may pass and several hundred mL of blood may be lost before vital signs are affected.

The definitive invasive diagnostic procedure to diagnose an aortic dissection is a(n):

-Left lateral recumbent CXR
-Computerized tomography (CT) scan
-Transesophageal ultrasound


The aortogram is the established standard for definitive diagnosis of aortic dissection and is the only invasive procedure listed as an option for this question. This test is sometimes called an aortic angiogram with (radiopaque) contrast dye.

Which of the following statements is true about aortic aneurysms is true?

-The mortality increases when the patient is between 25 and 35 years old.
-Aortic aneurysms are more common in men than women
-There are no warning signs
-Aortic aneurysms are the result of aortic stenosis

Aortic aneurysms are more common in men than women

Men (70%) definitely have more aneurysms than women (30%). Aortic regurgitation is often a cause for an aneurysm, not stenosis.
Advanced age contributes to mortality, with younger patients having a better chance of survival.

An aneurysm that is dissecting upwards (ascending) produces pain:

-In the chest and midscapular area
-In the back of the neck and left shoulder
-From the umbilical area to the shoulder
-In the left shoulder and midsternal area.

In the chest and midscapular area

Quite often the patient will describe a ripping or tearing sensation and severe pain. Hypotension may be present as the dissection progresses. Warning signs include hypertension, a new murmur (aortic insufficiency), weak peripheral pulses, and possible deterioration of LOC.
Aneurysms that dissect downwards (decending) radiate pain to the lower abdomen, lower back and legs.

An aortic aneurysm that extends more than _____ cm will require surgical repair.

-3 cm
-5 cm
-7 cm
-9 cm

5 cm

Any aortic aneurysm that extends over 4 cm will need surgical repair. Other criteria for immediate repair include impending rupture, limb ischemia, uncontrolled pain, cardiac tamponade, and increasing size.

When an arterial aortic dissection occurs, it is usually due to weakness in which area of the artery?

-Tunica intima
-Tunica adventicia
-Tunica media
-Tunica externa

Tunica intima

The inner layer of the vessel becomes separated, and blood enters the area under pressure.

The area most commonly affected by aortic anurysms is:

-The aortic arch
-The abdomen
-The thoracic area
-The lumbar region

The abdomen

The abdomial area is most commonly affected and usually offers good surgical access.
Aneurysms in the aortic arch are sometimes not accessible surgically and may post a high risk of dessection during procedures intended to mitigate them.

You are discussing EKG interpretation with your nursing orientee. She asks you why there is such a difference in the size of the waves. You tell her:

-"The P waves represent repolarization of the atrium and the QRS the depolarization of the ventricles; the size differences is realted to lead placement."
-"The P wave represents repolarization of the atrium and the QRS the repolarization of the ventricles; the size difference is related to the muscle mass involved in the polarization."
-"The P wave represents depolarization of the atrium and the QRS the depolarization of the venticles; the size difference is related to the muscle mass involved in the polarization."
-"The P wave represents the depolarization of the atrium and the QRS the repolarization of the ventricles; the size difference is related to the lead placement."

The P wave represents depolarization of the atrium and the QRS the depolarization of the venticles; the size difference is related to the muscle mass involved in the polarization.
The P wave's amplitude represents the amount or size of the muscle mass involved in the depolarized of the atrium. The QRS wave represents the amount or the size of the muscle mass involved in the depolarization of the ventricles. The greater the muscle mass, the greater the change in amplitude. Non-patient-related factors that may affect these waves' amplitude include gain setting, lead placement, and interference. Patient-related factors may include electrolyte imbalances, hypertrophy, and cardiac injury.

Your patient with obstructive jaundice has no prior history of caridac arrhythmias. He asks why he's on a cardiac monitor. Your best response would be:

-"You may develop sinus bradycardia, which is a slower heart rate. This monitor will alert staff to any dangerous drop in your heart rate."
-"You may develop sinus tachycardia, and the monitor will alert staff to any increase in your heart rate."
-"You will develop artial flutter, and the monitor will alert staff to changes in your heart rate."
-"You may develop ventricular tachycardia and the monitor will alert you to changes in your heart rate."

You may develop sinus bradycardia, which is a slower heart rate. This monitor will alert staff to any dangerous drop in your heart rate.

Obstructive jaundice may lead to cardiac changes, including sinus bradycardia.

Bernard was admitted for PNA. He is two years post heart transplant. When you place EKG monitoring leads, you note sinus tachycardia with PVCs and a 2-mm ST elevation. The patient denies pain. This finding is:

-Indicative of an RBBB
-Indicative of an inferior MI


Patients with heart transplants do not feel cardiac pain because the heart has been denervated.

The primary cause of acquired valvular heart disease is:

-Drug abuse
-Rheumatic fever

Rheumatic fever remains the most common cause of acquired valvular disease. The valves are a perfect place for bacteria to colonize, and blood is the perfect medium for bacterial growth. The causative organism is beta-hemolytic Streptococcus.

A patient who is status post heart transplant may have significant bradycardia. The drug of choice in such cases is:



When the heart is denervated, it has no conduction to the autonomic nervous system, so a reflexive response does not occur. A sympathetic stimulant must be used to provide this response. If no other complications occur, the ventricle will eventually adjust to not receiving autonomic input.

The most common precipitating cause of dissecting aneurysms is:

-Weakness of the vessel wall
-Heart failure


Weakness of vessel walls, heart failure and atheroembolism may contribute to an aneurysm, but HTN remains the primary cause of dissecting aneurysms. Constant pressure on the vessel walls will weaken the vessel over time.

Your patient is 36 hours status post right femoral bypass graft. The patient is compaining of pain with even slight movement of the limb. You suspect:

-An arterial obstruction
-A venous obstuction
-A leg cramp from prolonged bedrest

An arterial obstruction

Pain is a cardinal sign of arterial obstruction. The nurse should check for pallor, other signs of an arterial blockage, sensation, and quality of pulses. If the obstruction is venous, the limb may exhibit cyanosis.

You are discussing pericardial effusions with a nursing student. He asks you if fluid in the pericardial sac is normal. Your best answer is:

-"No; if there is any fluid in the pericardial sac, it always leads to pericarditis."
-"No; any fluid in the pericardial sac leads to cardiac tamponade."
-"Yes; there is a small amount of blood in the pericardial sac."
-"Yes; there is a small amount of fluid in the pericardial sac."

Yes; there is a small amount of fluid in the pericardial sac.

The pericardial sac usually contains 20-25 ml pericardial fluid. This fluid is secreted and reabsorbed, acting as a lubricant between the parietal and visceral pericardial layers.

Your patient recieved streptokinase about 30 minutes ago for a lateral wall STEMI. You would expect which of the following events to occur?

-Lowered CPK isoenzymes
-Reperfusion rhythms
-Transient increased chest pain
-Mild CHF

Reperfusion rhythms

Reperfusion rhythms such as v-tach, sinus brady, accelerated idioventricular rhythm, and underlying sinus rhythms with ventricular ectopy may occur.
The patient should experience less chest pain.
The CPK isoenzymes may temporarily become elevated as blood flows freely through newly opened arteries.
CHF is not a result of this therapy.

A quadriplegic patient has undergone a CABG and has had no complications. You are about to teach his wife how to change the chest dressings and the graft site dressings on the legs. Principles of teaching include:

-Teaching all the information at once
-Teaching the information as fast as possible
-Explaining the rationale for the procedure, and then demonstrating it
-Speaking slowly so that the patient can hear.

Explaining the rationale for the procedure, and then demonstrating it

Family members are probably quite used to providing care for this patient. Do not ignore the patient. There is no point in speaking slowly unless the caregiver or the patient has difficulty understanding your instructions. Teaching quickly is counterproductive and may be considered rude and unprofessional. Allow time fora return demonstration of skills and allow for questions.

Your patient had a cardiac arrest. You are doing CPR near his implanted ICD generator. If the ICD defibrillates, you would feel:

-A powerful shock
-Mild tingling
-Mild shock

Mild tingling

You should not fear this device to the point of not performing CPR, and CPR should not be delayed in any event. If the ICD fires, anyone touching the patient at that moment may feel the tingling sensation.

Newer ICDs use the most effecient shock waveforms for defibrillation and cardioversion. The most efficient waveform would be:

-Square wave technology
-Fixed Curve


Biphasic defibrillation works by sending electricity from cathode to anode, and the reversing the current. It takes less energy to cause mass depolarization of the myocardium. Cardioversion is much more successful as well. Both defibrillation and cardioversion take less energy to convert patients. Be certain to follow the latest AHA guidelines when using these devices.

Your patient requires emergent programming of her ICD. How many joules above the defibrillation threshold should the ICD to set?

-10 joules
-20 joules
-30 joules
-40 joules

10 joules

The ICD should be set 10 joules above the defibrillation threshold on at least two successive attempts. The threshold varies from patient to patient and depends on the patient's current catecholamine levels. The standard is to set the ICD 10 joules above the defibrillation threshold. Some physicians routinely set the ICD to 10 joules below the maximum output. This practice saves time, but does not really fine-tune the ICD to the patient.

When you receive report on your patient, you are told his ICD was reset. you notice a large magnet on the table outside his room. What is the purpose of the magnet?

-It inhibits all output from the ICD
-It inhibits the shocking portion only of the ICD
-It inhibits the pacemaker funtion of the ICD
-It allows timing of the ICD to be set.

It inhibits the shocking portion only of the ICD

The magnet is used to inhibit the shocking (tachy) feature of the ICD. It can shut down a malfunctioning ICD. Patient teaching includes letting the patient know the dangers of being in proximity to large magnets. Most ICDs have a warning tone built in so that if the patient comes too near a magnet, the tone is emitted. The type of tone produced varies with manufacturer.

Tachyarrhythmias that are refractive to conventional therapies may have to be treated with radio-frequency ablation. This treatment is usually successful on reentry tachyarrhythmias. The radio-frequency destroys myocardial tissue via:

-An overriding signal to ablate the pacemaker


These waves actually heat the tissue around the active sites and prevent reentry loop. Once the temperature reaches 50'C, cell damage and death occurs. The containing heat creats a lesion approximately 2-5 cm in diameter. This "burned" area causes necrosis and will not conduct electricity.

Your patient has A-Fib and needs to be cardioverted. The patient was medicated for pain and anxiety with morphine and Versed. Which additional medication will help the process of cardioversion from A-Fib to a normal sinus rhythm?



Ibutilide is a relatively new Class III/IV medication. It must be used at the time of the cardioversion and will be ineffective if used prior to cardioversion.

Symtoms of chronic pericarditis most often mimic which other disease process?

-Chronic right-sided heart failure
-Pulmonary HTN

Right sided heart failure

Chronic pericarditis presents as chronic right-sided heart failure caused by increased systemic venous pressures, fluid retention, ascites, and hepatomegaly.
Many of the symptoms relate to restrictive cardiac tamponade accompanied by decreasing forward blood flow and altered cardiac constriction.

Helen developed infective pericarditis after renal failure and sepsis. Morning labs should show a(n):

-Increased WBC, decreased ESR, normal CK-MB
-Normal WBC, decreased ESR, elevated CK-MB
-Increased WBC, increased ESR, elevated CK-MB
-Increased WBC, normal ESR, elevated CK-MB

Increased WBC, increased ESR, elevated CK-MB

Renal failure and sepsis may lead to pericarditis, so AM labs should show an increased WBC, increased ESR, cardiac tissue involvement, and an elevated CK-MB level. Additional lab test would focus on detecting uremia. Assessment would also include checking for ST-segment elevations, arrthythmias, and pleural effusions on echocardiography.

Which of the following organisms is most often the cause of myocarditis?

-E. Coli


The Coxsackievirus is the most common cause of myocarditis, although any bacteral, viral, or fungal pathogen may be the inital infectious agent.

During insertion of a CVP catheter, your patient has a short run of V-Tach and shows unifocal PVCs. Your immediate response should be to:

-Administer lidocaine 1 mg/kg
-Hand an amiodarone gtt
-Notifiy the physician who is inserting the catheter
-Immediately have the physician completely withdraw the catheter

Notifiy the physician who is inserting the catheter

If the catheter is in the right ventricle and touches the myocardium, PVCs can result. Occasionally, the physician will insert the catheter a bit too far, causing PVCs. In this case, the catheter simply has to be withdrawn to a better position in the right atrium. This is a rare occurance. If the patient's catheter was left in the right ventricle, the V-tach might continue and the patient might suffer cardiac arrest.

What % of acute MIs may be considered "silent?"



Silent infarcts account for approximately 20% of all MIs. Silent infarcts are often seen in patients who present atypically, such as the elderly and persons with diabetes.

During shift report, you are told that your patient has a 90% occlusion to the circumflex artery. Which type of MI is this patient at greatest risk for developing?

-Lateral wall infarct
-Anterior wall infarct
-Posterior wall infarct
-Septal wall infarct

Lateral wall infarct

The circumflex coronary artery feeds the left atrium and left ventricle. Infarctions as a result of occlusion of this artery result in lateral or left-sided heart damage. The left anterior descending artery and circumflex artery both branch off from the left coronary artery.

Laura suffered an MI as a result of 100% occlusion of the LAD and circumflex arteries. Although cardiac catheheterization returned some blood flow to the left side of her heart, you note a new murmur at the fifth intercostal space, midclavicular line. You suspect:

-Tricuspid valve stenosis
-Mitral Valve regurgitation
Pulmonic stenosis
-Aortic regurgitation

Mitral Valve regurgitation

New onset or acute mitral regurgitation is often a result of MI of the LAD and circumflex arteries. These arteries feed the papillary muscles, which in turn support mitral valve function. Prolonged ischemia causes the papillary and/ or chordae tendinae of the mitral valve to rupture and prevent full closure of the mitral valve during systole. As the blood flows back into the left atrium, the murmur can be auscultated.

Gina was admitted to the PCU with cough, fever, chills, anorexia, malaise, and HA. She has a pericardial friction rub. She also has a history of rheumatic fever. While examining Gina, you note fine, dark lines in her nail beds and some flat lesions on her palms. These flat lesions are known as:

-Janeway lesions
-Roth spots
-Osler's nodes
-Pella's sign

Janeway lesions

Gina has endocarditis. It is thought that microcascular cloths form in the heart and pass through the microcirculation and impede circulation, sometimes causing necrosis (i.e. Janeway lesions, Osler's nodes, and Roth spots).
Janeway lesions are flat and painless erthematous areas typically found on the palms and soles of the feet.
Osler's nodes are small, painful nodules found on the fingers and toes.
Roth spots are rounded, white spots seen when examining the retina.
Pella's sign is not a medical term.

Under the Fontaine classification for peripheral vascular disease, intermittent claudication occurs at:

-Stage I
-Stage II
-Stage III
-Stage IV

Stage II

Stage I disease (pathological arterial changes) produces no symptoms.
Stage II is representative of a 75% occlusion and the patient will exhibit intermittent claudication.
Stage III represents 90-95% occlusion and the patient will have pain at rest.
Stage IV is a 99-100% occulsion that will result in necrosis if not treated.

Which of the following nursing actions would be important in the care of a patient with occlusive disease of the terminal aorta and a nonhealing wound on the left foot?

-Elevate the legs
-Place the patient in Fowler's position
-Maintain normothermia
-Fluid restriction

Maintain normothermia

Patients with peripheral vascular disease are often hypothermic because of poor blood circulation. The nurse should provide proper alignment without impeding circulation and monitor the patient's peripheral pulses for presence and quality. The color and temperature of the extremity should be monitored and results charted.

In a patient with cardiogenic shock, an undesirable outcome would produce:

-Increased cardiac output
-Increased systemic vascular resistance
-Decreased ventricular preload
-Decreased pulmonary artery pressures

Increased systemic vascular resistance

A primary goal in cardiogenic shock is to improve the pumping action of the heart (improve myocardial contractility), reduce the workload of the heart, reduced O2 demand and improve cardiac output. If possible, systemic vascular resistance should be decreased and the left ventricule augmented with an inotrope. Nitoprusside will reduce preload and afterload. The cardiac workload and the myocardial O2 demand should decrease.

Marvin has heard the staff talking about his mitral valve regurgitation; they also mentioned that it could be mitral valve stenosis. He asks you how you can tell the difference just by listening to his heart. Your best answer is:

-"Mitral stenosis produces a high-pitched murmur and mitral valve regurgitation produces a low-pitched murmur."
-"Mitral stenosis produces a murmur during systole and mitral valve regurg produces a murmur during diastole."
-"Mitral stenosis murmurs do not radiate their sound, whereas mitral valve regurg murmurs will radiate towards the left arm. "
-"There is no difference between the presentation of mitral valve stenosis and the presentation of mitral valve regurg."

Mitral stenosis murmurs do not radiate their sound, whereas mitral valve regurg murmurs will radiate towards the left arm.

Mitral valve stenosis presents with a low-pitched murmur that can be heard during diastole and that does not radiate. Mitral valve regurgitation presents with a high-pitched murmur that is hearding during systole that may radiate to the left arm. If severe, both conditions present with symptoms of pulmonary edema, low cardiac output, and heart failure.

If your patient's temporary pacemaker is not sensing, your first action should be to:

-Place patient on their right side
-Increase the mA output
-Check the sensitivity control for proper setting
-Immediately turn off the pacemaker and notify the physician

Check the sensitivity control for proper setting

The first step is to check the sensitivity control. Even though most of these pacemakers have a cover, the dial may have been moved and indicate that a fixed rate is set. If the pacer continues to fire, it may cause R-on-T phenomenon and cause ventricular tachycardia or fibrillaation. If the patient has an adequate rhythm, you can turn off the paver and notify the physician. If the patient has a non-sustaining rhythm, try positioning the patient on the left side to see if the wire will come in contact with the myocardium. You can also try turning up the mA level. Either way, the physician must be notified and vital signs carefully monitored until the physician can reposition the electrodes.

A diastolic murmur will occur as a result of regurgitant blood flow over which of the following valves?

-Mitral and aortic
-Mitral and tricuspid
-Pulmonic and aortic
-Tricuspid and pulmonic

Pulmonic and aortic

During ventricular diastole, both the aortic and pulmonic valves close. If a valve is incompetent, the blood will flow backwards through the valve, creating turbulent blood flow-- that is, a murmur.

Blood flow that moves forward through the stenotic valves can also dause a diastolic murmur. The valves involved are the:

-Mitral and aortic
-Mitral and tricuspid
-Pulmonic and aortic
-Tricuspid and pulmonic

Mitral and tricuspid

During diastole, the tricuspid and mitral valves close just prior to systole. If the valve is stenotic, it will not close completely. When the atria contract, a murmur is heard as blood goes through this narrow opening.

Sid is a 30 year old male who lost control of his motorcycle while riding in the rain. At the time of the accident, he was wearing a helmet and protective gear. Sid suffered a fractured left femur, a fractured rib, a cervical sprain, and road rash on his face and neck. He is admitted with a BP of 84/44, HR 100, RR 26 and shallow, T 98.4'F. His 12 lead EKG shows ST elevation in the anterior leads. His CXR shows a normal cardiac silhouette and no inflitrates. His H/H is 9.0/32. MB is 18%. Sid is restless and compains of pain in the chest and left leg. Which condition would you anticipate?

-Systolic dysfuntion
-Hypovolemic shock
-Pulmonary hypertension
-Pulmonary edema

Systolic dysfuntion

The injuries to the patient's chest may have caused a pulmonary artery laceration or a cardiac contusion (the latter condition is more likely). His BP is low and the EKG shows ST-segment elevation in the anterior leads. If the myocardium is contused, it will react the same way as if an MI had occurred. The ST elevation may be the result of a physiologic insult to a coronary artery, and an area of the myocardium may be ischemic. If so, the pumping function of the myocardium will be compromised and may need additional support with inotropes. The patient may undergo angiography and/ or surgery. Volume replacment may be necessary. This patient is probably in the first stage of cardiogenic shock.

Four days ago, Gert, who is 70 years old, was admitted to your unit status post laparotomy for an unknown abdominal mass. During surgery, Gert had minimal blood loss and an uneventful course. The patient's history includes smoking since she was 15 (unknown number of ppd), DM, a permanent pacemaker, an anterior MI, and a right-sided stroke 20 years ago with no deficits.
Three days ago, Gert had a hypotensive episode; her BP dropped to 82/48, HR 70. The doctor ordered dobutamine and the BP increased until the MAP was 72.
Today, Gert remains on the dobutamine gtt at 2 mcg/kg/min. Her BP is 108/60, MAP 76, HR 70. Attempts at weaning have failed-- her BP drops precipitously if the dobutamine dosage is lowered.
What do you think is the cause Gert's inital hypotensive episode?

-Hypovolemic shock
-Previous MI
-Rapid rewarming postoperatively
-Cell mediated response

Cell mediated response

Approximately 24 hours after a surgical procedure, the release of inflammatory cell mediators can lead to casodilation. Gert has a permanent pacer, but apparently her heart rate cannot compensate for the drop in BP. The caridac output did not increase as a result of the reduced systemic resistance. Her pacer did not allow the HR to climb above 70. The dobutamine acted on the pump and increased the heart's contractility. Gert also has a history of a previous MI.

Four days ago, Gert, who is 70 years old, was admitted to your unit status post laparotomy for an unknown abdominal mass. During surgery, Gert had minimal blood loss and an uneventful course. The patient's history includes smoking since she was 15 (unknown number of ppd), DM, a permanent pacemaker, an anterior MI, and a right-sided stroke 20 years ago with no deficits.
Three days ago, Gert had a hypotensive episode; her BP dropped to 82/48, HR 70. The doctor ordered dobutamine and the BP increased until the MAP was 72.
Today, Gert remains on the dobutamine gtt at 2 mcg/kg/min. Her BP is 108/60, MAP 76, HR 70. Attempts at weaning have failed-- her BP drops precipitously if the dobutamine dosage is lowered.
Which additional action could be taken to improve Gert's cardiac output and help wean her from dobutamine?

-Initiate a fluid challenge
-Start dopamine
-Place a pulmonary artery catheter
-Turn up the rate on the pacer

Turn up the rate on the pacer

Turning up the rate on the pacer should allow for weaning off dobutamine. This patient is also in the beginning stages of cardiogenic shock, but she can easily be helped by simply changing the rate on the pacer.

What does AICD stand for?

-Automated internal cardiac defibrillator
-Autocardiac internal converting defibrillator
-Automated implantable cardioverter/defibrillator
-Automatic implanted coronary defibrillator

Automated implantable cardioverter/defibrillator

AICDs may be implanted in patients with recurrent ventricular tachycardia. They can also be programmed to act as pacemakers.

Matthew has has an AICD for 6 months. He has been admitted to your PCU for syncope. You notice his pulse is very irregular, and he complains of getting "zapped" often. On his monitor, the rhythm is sinus bradycardia with numerous pacemaker spikes. What could be wrong?

-Matthew's ACID has a faulty lead
-Matthew has had an MI
-The battery in the AICD is losing power
-Matthew has experienced a generator failure of the AICD

Matthew's ACID has a faulty lead

He has probably dislodged a lead, or the lead may have been damaged on insertion. Either way, Matthew needs either a new AICD or new leads.

Which physical finding is significant for carotid stenosis:

-Heberden's nodules
-Systolic murmur Grade IV/VI
-Carotid bruit
-Broussard's nodules

Carotid bruit

Carotid bruit is the significant physical finding associated with carotid stenosis.
Heberden's nodules and Broussard's nodules are seen with arthritis.
The systolic murmur is an indication of a valve problem.

Barry has Wolf-Parkinson-White syndrome. He is experiencing increasing bouts of tachycardia. It has been decided to utilize overdrive pacing. How do you explain this type of pacemaker to a new orientee?

-The pacer is set to a constant rate of 70 bpm and is synchronized
-The pacer or AICD is set on demand mode and is asynchronous
-The pacer or AICD is set on demand mode and is synchronous
-The pacer or AICD is set on inhibit mode and is synchronous

The pacer or AICD is set on demand mode and is asynchronous

This patient needs a pacer or AICD that can deliver a more powerful impulse.
The asynchronous mode will override Barry's internal pacer.

Which pacemaker/AICD program code would you expect for a patient with complete heart block:



A dual lead pacer/AICD is necessary to maintain the atrial kick. Single chanber pacing can lead to pacemaker syndrome. The letters on pacer modes are:

Chamber paced
V = Ventricle
A = Atrium
D = Dual chamber

Chamber sensed
V = Ventricle
A = Atrium
D = Dual chamber

Mode of response
I = Inhibit
T = Triggered
D = Dual (T & I)

Programmability, Rate modulation
P = Simple programmable
M = Multi-programmable
R = Rate modulation

Anti-arrhythmia Function
P = Pacing
S = Shock
Dual = Dual (P & S)

Gene had a DDD pacer inserted 3 years ago. He has been admitted for pacemaker syndrome. Which of the symptoms do you expect to see:

-Fatigue, agitation, dyspnea
-Fatigue, dizziness, confusion
-Fatigue, agitation, forgetfulness
-Fatigue, dizziness, syncope

Fatigue, agitation, forgetfulness

Pacemaker syndrome is caused by a loss of atrial kick or regurgitation against a closed AV valve. Gene's atrial lead may be damaged or may have failed.

Georgia, a 49 year old woman with an acute myocardial infarction, suddenly develops a complete heart block. Her blood pressure drops, her HR is 27 and her color ashen. What should you do?

-Apply an external pacemaker and notify the doctor
-Wait for the doctor to return your call and give 4 mg atropine IV
-Apply a transvenous pacemaker, medicate the patient and notify the doctor
-Call a Code Blue and prepare to start CPR

Apply an external pacemaker and notify the doctor

The most important action is to improve the cardiovascular status of this patient. A patient with a transcutaneous pacemaker must be sedated for comfort. The doctor must be notified for a possible transvenous or permanent pacemaker insertion. It would be acceptable to give the patient atropine for this condition, but not at the dose listed (4 mg)

Your acute MI patient waited 16 hours before coming to the hospital. He has a RBBB and a left anterior fascicular block. What is the significance of his condition?

-He has extensive myocardial damage
-He needs a pacemaker as soon as possible
-He needs to be transferred to a facility that can perform heart transplants
-This problem will resolve itself over the next few weeks

He needs a pacemaker as soon as possible

Because your patient has lost two of the three main fascicles that innervate the heart, he is at great risk for sudden death. He needs a pacer as soon as possible.

Thomas has had an anterolateral MI. Where so you expect to see changes on the 12-lead EKG?

-V1, V2, I, AVL
-V2, V3, V4, I, AVL
-V2, V3, V4, II, III, AVF
-V1, V2, II, III, AVF

V2, V3, V4, I, AVL

Changes in V2, V3, V4, I and AVL indicate an anterolateral MI. The MI could also be detected in V5 and V6 which are also lateral leads.

What do abnormal Q waves signify on a 12-lead EKG?

-Nothing - They are of no significance
-Repolarization of the myocardium
-Complete- thickness infarction of the myocardium
-Partial- thickness death of myocardium

Complete- thickness infarction of the myocardium

When tissue dies as a result of MI, it becomes electrically dead, causing the opposing energy to become the dominant feature.
Partial- thickness myocardial death would be classified as a non-Q wave MI.

Mary has had an inferior wall MI. Where do you expect to see the changes in her 12-lead EKG?

-V1, V2


Your patient has had an anteroseptal MI. Where do you expect to see the changes on the 12-lead EKG?

-V1, V2, V3, V4
-V2, V3, V4, V5, V6
-V1, V2, II, III, AVF
-V1, V2, I, AVL

V1, V2, V3, V4

Which parameter is measured by the vertical lines on the EKG paper?



The vertical lines on the EKG graph paper represent time. When conduction defects occur, the tracings are wider because it takes more time to travel the same distance.

Which parameter is measured by the horizontal lines on the EKG paper?



Voltage is measured by the horizontal lines on the EKG graph paper. If a ventricle is enlarged, a larger voltage will be apparent on the 12-lead EKG

V1 and V2 show which type of bundle branch block?

-Dual bundle
-V1 and V2 do not show BBBs


V1 and V2 show RBBBs

What are the most valuable pieces of information evaluated with a 12-lead EKG?

-Rate, arrhythmias, infarction
-Rate, rhythm, axis, hypertrophy, infarction
-Rate, BBB, hypertrophy
-Rate, rhythm, arrhythmias

Rate, rhythm, axis, hypertrophy, infarction

Which of the following conditions are associated with ST/T wave abnormalities?

-Ventricular hypertrophy, pericarditis, COPD
-COPD, axis deviation
-Atrial hypertrophy, axis deviation
-Pericarditis, axis deviation

Ventricular hypertrophy, pericarditis, COPD

Which 12-lead EKG changes would you expect to see in a patient with COPD?

-Low voltage P waves, tachycardia
-Tall P waves, left ventricular hypertrophy
-Tall, peaked P waves, right ventricular hypertrophy, low-voltage QRS
-Low-voltage QRS, left atrial hypertrophy

Tall, peaked P waves, right ventricular hypertrophy, low-voltage QRS

COPD causes changes in the 12-lead EKG due to the workload for the right side of the heart. Changes commonly seen in patients with COPD include tall, peaked P waves, right axis deviation, right ventricular hypertrophy and low-voltage QRS.

What are some common reasons for pacemaker insertion?

-Tachycardia, Wenckebach, bradycardia
-Symptomatic bradycardia, overdrive pacing, acute MI with sinus dysfunction
-Complete heart block, Wenckeback, tachycardia
-CCC, Wenckebach, tachycardia

Symptomatic bradycardia, overdrive pacing, acute MI with sinus dysfunction

There are multiple reasons for pacemaker insertion -- for example symptomatic bradycardia, bradycardia with escape beats, overdrive pacing, bradycardia/ arrest, acute MI with sinus dysfunction, 2nd heart block type 2 (Mobitz type 2), complete heart block (3rd degree heart block), and development of a new bundle branch block.

Quinidine and hypomagnesemia can both lead to which condition?

-Torsades de Pointes
-Ventricular tachycardia
-Ventricular fibrillation
-Atrial tachycardia

Torsades de Pointes

Quinindine and hypomagnesemia can lead to Torsades de Pointes -- a recurrent ventricular tachycardia that turns on its axis every 6 to 8 beats, giving the EKG a twisting or "turning on point" look. Hypomagnesemia can occur when the patient recieves TPN (total parental nutrition).

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