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PCCN Review - Cardiac

Review questions for the Progressive Care Certification test as given by the AACN.
STUDY
PLAY
Calculate the cardiac output for a pt with a HR of 70 and a SV of 65 ml.
HR X SV=CO
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.
HR X SV=CO
HR X SV=CO
70 X 65= 4550
4.6 L/min
What % of the cardiac cycle is provided by the atrial kick?
• 15%
• 20%
• 30%
• 35%
20%

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%
65%

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
UNSTABLE 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
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
2/3

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
MAP=260/3
MAP=86.6
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
MAP=260/3
MAP=86.6
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
CI=CO/BSA
CO=HR X SV
CO=80 X 60
CI=4800/2.0
CI=2400
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
CI=CO/BSA
CI=CO/BSA
CO=HR X SV
CO=80 X 60
CI=4800/2.0
CI=2400
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
ASK DOC TO CONSIDER AN OTC ANTIPLATELET MEDICATION

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
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%
75%
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
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
• A LBBB
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
PREVENT SHIVERING

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
• GERD
• Myocarditis
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
ENDOMYOCARDIAL BIOPSY

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
Hypotension

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
STROKE VOLUME DECREASE

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
A DILATED SUPERIOR VENA CAVA

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
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
AORTIC INSUFFICIENCY

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
HILL'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
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
INCREASED DIASTOLIC FILLING TIME
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
MITRAL

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
CHEMORECEPTORS

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
HEPATOMEGALY

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
PROMOTE FLUID RETENTION

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.
ADMINISTER MORPHINE AND DIAZEPAM AS ORDERD.

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
SEVERITY

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
TRAUMATIC CPR

Other absolute contraindications are:
HYPERTENSTION
BLEEDING DISORDERS

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 HAS NO IMPAIRMENT OF NORMAL CONTRACILITY

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
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

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

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
ARTERIES TO ARTERIOLES

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
HEARD DURING ATRIAL CONTRACTION
AKA ATRIAL GALLOP

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
TRICUSPID 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
TRICUSPID INSUFFICIENCY

PANsystolic means that the murmur is heard throughout systole.
Pulomonic INSUFFICIENCY=
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
SIT UP AND LEANING FORWARD ON A STABLE BEDSIDE TABLE

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
PERICARDITIS

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
• PCN
• Amiodarone
• Statins
AMIODARONE

These cause a SIGNIFICANT rise in INR:
ASA
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

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
NECROTIC TISSUE

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
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
VENTRICULAR SEPTAL RUPTURE

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
PERICARDITIS

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:

Morphine
Ticlid
Aspirin
NTG
Nitroglycerine

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 _____.

-Polycythemia
-Aortic insufficiency
-Hypovolemia
-Sepsis
Polycythemia

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 _____.

-Pancreas
-Lungs
-Liver
-Kidneys
Kidneys

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:

-Regitine
-Bicarbonate
-Naloxone
-Atropine
Naloxone

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:

-Thromboembolism
-Thrombocytopenia
-Dissection of the aorta
-Septicemia
Thromboembolism

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:

-Dysrhythmias
-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:

-Septicemia
-Pericarditis
-Pneumonia
-Pericardial effusion
Pneumonia

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

-RVAD
-VAD
-BIVAD
-LVAD
LVAD

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:

-Language
-Technology
-Time
-Physician availability
Time

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
-Aortogram
Aortogram

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:

-Impossible
-Normal
-Indicative of an RBBB
-Indicative of an inferior MI
Normal

Patients with heart transplants do not feel cardiac pain because the heart has been denervated.
The primary cause of acquired valvular heart disease is:

-Heredity
-Smoking
-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:

-Atropine
-Isuproterenol
-Apresoline
-Adenosine
Isuproterenol

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
-HTN
-Atheroembolism
HTN

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 DVT
-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
-Nothing
-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
-Monophasic
-Fixed Curve
-Biphasic
Biphasic

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:

-Radiation
-Heat
-Cold
-An overriding signal to ablate the pacemaker
Heat

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?

-Digitalis
-Amiodarone
-Pronestyl
-Ibutilide
Ibutilide

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
-PNA
-Cardiomyopathy
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?

-Coxsackievirus
-E. Coli
-Streptococcus
-Staphylococcus
Coxsackievirus

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?"

-5%
-10%
-20%
-30%
20%

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:

-VVI
-DDD
-VVT
-DDI
DDD

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-tachycardia/
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?

-II, III, AVF
-I, II, AVL
-I, III, AVF
-V1, V2
II, III, AVF
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?

-Velocity
-Time
-Voltage
-Intensity
Time

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?

-Velocity
-Time
-Voltage
-Intensity
Voltage

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?

-Right
-Left
-Dual bundle
-V1 and V2 do not show BBBs
Right

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).
Which condition is required for a diagnosis of HAP (hospital acquired pneumonia)?

-Recent common cold prior to admission
-Cigarette smoking
-Acute myocardial infarction
-Hospitalization for more than 2 days
Hospitalization for more than 2 days

Hospitalization for more than 2 days is required for a diagnosis of hospital acquired PNA. If PNA occurs prior to 2 days' stay in the hospital, the infection is considered to be a community-acquired PNA. HAP is especially dangerous in a cardiac patient, but can be prevented most of the time via handwashing and aseptic technique.
What is the most common causative organism in HAP (hospital acquired PNA)?

-MRSA (methicillin resistanct Staphylococcus aureus)
-Pseudomonas aeruginosa
-Streptococcus pneumoniae
-Acinobactor species
Pseudomonas aeruginosa

Pseudomonas aeruginosa is the organism most commonly impilcated in HAP.
MRSA is is the second most common cause of HAP.
Cardiac patients are usually already quite compromised and susceptible to these organisms.
What are some risk factors for developing HAP (hospital acquired PNA)?

-Altered level of consciousness, urinary catheter, sedation
-COPD, ill hospital staff, beta blockers
-H2 blockers, age, history of smoking
-H2 blockers, postpartum patient, age
H2 blockers, age, history of smoking

Factors associated with higher risk of HAP include altered level of consciousness, placement of NG tube, the elderly, COPD, postoperative patients, use of H2 blockers, antacids, periodontal work, and acute illness or injury.
Millie is a 78 year old patient admitted postoperatively 2 days ago after undergoing a colon resection for cancer. She has an NG tube through which she is receiving routine doses of antacids. Her morning labs are: WBCs 15.6, neutrophils 9100, CXR is inconclusive. What is Millie's problem?

-Pulmonary embolism
-HAP (hospital acquired PNA)
-Congestive heart failure
-Atelectasis
HAP (hospital acquired PNA)

Millie's age, time in the hospital, NGT, use of antacids are all risk factors for HAP. THe fact that her CXR is inconclusive is not unusal with elderly patients. Elderly patients often have other underlying diseases that make it difficult to identify PNA.
How does HAP (hospital acquired PNA) differ from VAP (ventilator acquired PNA)?

-There is no difference
-Different sausative organisms
-The VAP patient is intubated
-Therapies differ
The VAP patient is intubated

The major difference between HAP and VAP is that the patient who develops VAP is intubated. Both types of PNA are caused by the same organism, Pseudomonas aeuruginosa.
What does SVO2 measure?

-Oxygen saturation of blood in the brachial vein
-Oxygen saturation of the blood returning to the lungs
-Oxygen saturation of blood in the coronary sinus
-Oxygen saturation in the capillary bed
Oxygen saturation of the blood returning to the lungs

Oxygen saturation of venous blood returning to the lungs for oxygenation. Normal SVO2 is in the range of 60-80% range. This % decreases as lung funtion worsens, meaning the blood leaving the left ventricle has less oxygen to deliver in the first place.
Mannie is a 15 year old victim of a gunshot wound to his left chest and has a pneumon-hemothorax. He has been stable all day with minimal chest drainage. Over the last 4 hours, his O2 saturation has been decreasing. The doctor orders mixed venous gases, and the results show SVO2 of 64%. What does this information tell you?

-The amount of shunting that is occuring
-CO2 levels
-HCO3 levels
-PO2 levels
The amount of shunting that is occuring

The SVO2 shows shunting. There is a normal 5% physiologic shung due to blood loss in the bronchial , pleural and Thebesian veins. When there is an infection, trauma or ARDS, blood is shunted at a higher rate which is seen as a lower SVO2 level.
Mannie is a 15 year old victim of a gunshot wound to his left chest and has a pneumon-hemothorax. He has been stable all day with minimal chest drainage. Over the last 4 hours, his O2 saturation has been decreasing. The doctor orders mixed venous gases, and the results show SVO2 of 64%. One hour later, Mannie's SVO2 is 22%. What does this indicate about his condition?

-It is a normal reading
-His shunt is improved
-His shunt is worsening
-His shunt is stable
His shunt is worsening

A CXR should also be done to assess his pneumon-hemothorax for possible increase in size. His chest tube drainage sustem should be examined for the possibility of blocks blocking drainage. The patient will probably be transferred to ICU and placed on a ventilator.
Promethazine is contraindicated with fluroquinolone antibiotics for what reason?

-This combination leads to increased sedation
-This combination leads to QT prolongation and arrhythmias
-Promethazine is inactivated by fluoroquinolones
The antibiotic is inactivated by promethazine
This combination leads to QT prolongation and arrhythmias

Concomitant use of promethazine and fluoroquinolones is contraindicated because their combination can produce prolongation of the QT interval and increase the patient's risk of arrhythmias.
What is the infusion rate for Lasix (furosemide)?

-It can be given as at IVP at any dose
-4 mg/min
-1 mg/min
-It should always be given as a piggyback
-4 mg/min

The infusion rate should not exceed 4 mg/min. A rate faster than 4 mg per minute may result in tinnitis or hearing loss.
Why is Lasix (furosemide) given slowly?

-Rapid infusion can lead to nausea
-Rapid infusion can lead to rash
-Rapid infusion can lead to hyperkalemia
-Rapid infusion can lead to hearing loss
Rapid infusion can lead to hearing loss

A rate faster than 4 mg per minute may result in tinnitis or hearing loss.
Your patient has undergone an angiogram today with stent placement. He is to start Plavix, and you are teaching him about this mediation. The patient takes numerous herbal remedies daily. Which ones should be avoided while he is on Plavix?

-Dong quai, gingko biloba, saw palmetto
-Aloe extract, bilberry
-Calendula, clove
-Fenugreek, licorice
Dong quai, gingko biloba, saw palmetto

Dong quai, gingko biloba and ginseng can all increase bleeding times.
Saw palmetto decreases the effectiveness of Plavix.
What history should you know before starting Reo Pro (abciximab)?

-Chest pain
-Any bleeding history
-Previous MI
-Family history
Any bleeding history

Reo Pro, like any other anti-platelet, requires the patient to be carefully questioned regarding any bleeding history.
Wargarin is indicated for which of the following conditions?

-DVT, CHF, A-fib
-DVT, A-fib, heart valve replacement
-Pulmonary embolism, DVT, COPD
-Pulmonary embolism, A-fib, CHF
DVT, A-fib, heart valve replacement

DVT, A-fib, heart valve replacements and MI are conditions that REQUIRE the use of warfarin. Patients with DVT, A-fib, and heart valve replacements will take warfarin on a chronic basis. By comparison, MI patients may be weaned off warfarin in 3 to 4 months.
You are teaching Anne about her Coumadin (warfarin) therapy. Part of your teaching must include foods to avoid while on this medication. Which of the following should be avoided?

-Broccoli, soy bean oil, spinach
-Olive oil, peanut butter, kale
-Avocado, broccoli, peas
-Broccoli, green beans, spinach
Broccoli, soy bean oil, spinach

Many foods must be avoided when the patient is taking warfarin. Specifically, patients must avoid food high in Vitamin K: broccoli, Brussels sprouts, watercress, soybeans, canola, salad oils, spinach, turnip greens, endive, scallions, parsley, red leaf lettuce.
All of these foods decrease the effectiveness of warfarin.
Integrilin (eptifbatide) is indicated for which condition?

-DVT
-Pulmonary embolism
-ACS (acute coronary syndrome)
-Occlusive cerebrovascular accident
ACS (acute coronary syndrome)

Integrilin (eptifbatide) is used primarily for patients with acute coronary syndrome to inhibit platelet aggrigation.
You overhear your patient discussing his aortic stenosis with his family. He states, "It can't be that bad, because the murmur isn't that loud." Your best response is:

-Do not say anything, it would be considered eavesdropping
-Interrupt and say that nothing has yet been confirmed
-Ask the patient if his doctor told him that or if he learned it by searching on the internet
-Use the opportunity to teach the patient by asking if you can clarify his understanding of his disease process
Use the opportunity to teach the patient by asking if you can clarify his understanding of his disease process

If the conversation is not hushed and you overhear the statement as part of your regular duties, it would be appropriate to clarify or correct misinformation if it would not involve diagnosing the patient's disease process. In this case, the patient provides you an opportunity to teach him about his cardiac murmur. Aortic stenosis will cause a murmur, but the harshness or degree of auscultation is not directly correlated with the degree of severity or risk to the patient. Based on his statement, he may not understand what a diagnosis of aortic stenosis entails. By asking about his comprehension, you will be able to determine what his degree of understanding is, which knowledge you may correct or clarify, and to what degree his doctor may need to discuss his prognosis or plan of care.
The pain associated with aortic stenosis is caused by:

-Angina
-Left ventricular hypertrophy
-Decreased left coronary artery flow
-Increased aortic pressures
Decreased left coronary artery flow

Aortic stenosis is directly caused by decreased blood flow to the coronary arteries during systole due to the stenotic valve. Prolonged resistance to blood flow via the stenotic aortic valve results in left ventricular hypertrophy and left sided heart failure. The pronosis is poor unless the aortic valve is replaced.
Mr B was admitted to the PCU to rule out MI two days ago. He has a history of GERD and stomach ulcers. He is due to be discharged today on digoxin and oral antacids. You review his morning labs prior to beginning your physical assessment. Labs are:
WBC 1100/mm3 Sodium 140 mEq/L
RBCs 5.2 mil/mm3 Potassium 4.5 mEq/L
PLT 350000/mm3 Chloride 104 mEq/L
Hgb 13 g/bL Total Calcium 13.5 mg/dL
Hct 48 mL/dL Magnesium 1.87 mg/dL

You would probably expect to see which of the following signs and symptoms during your assessment of Mr. B.?

-Hypotension, prolonged QT interval, junctional tachycardia
-Bradycardia, confusion, hypertension, decreased grasp strength
-Second degree Type 2 heart block, shortened QT intervals, hypotension
Bradycardia, confusion, hypertension, decreased grasp strength

Mr B would exhibit signs and symptoms of hypercalcemia, confirmed by his lab value of 13.5 mg/dL. Signs and symptoms would include smooth muscle relaxation, lethargy, confusion, shortened QT intervals, bradycardia, heart blocks, bundle branch blocks, and hypertension.
Symptoms can be furthered compounded by the effects of digitalis and, possibly, digitalis toxicity.
You are caring for a 7 day opstoperative CABG patient. He remains severly hypocalcemic despite calcium supplementation. Which of the following complications is this patient at greatest risk for developing?

-Bleeding
-Muscle tetany
-Flattened T waves
-Deep vein thrombosis
Bleeding

Due to the decreased availibility of calcium essential to the coagulations phase (used with intinsic, extrensic and common pathways), the patient will not have formed permanent clots. The platelet plugs formed over damaged vessels initially after surgery may be dislodged by blood flow, leading to recurrent bleeding at postoperative days 7 to 10.
You are preparing to flush Mr N's heparin locked PICC line with 1 ml of heparin. As you examine the vial, you note that its concentration is 10,000 units/ml. If adminiistered at this dosage, which clotting factors would heparin impair?

-I, V, VIII
-VIII
-II
-II, VII, IX,X,XI
II

Heparin impairs Factor II in the clotting cascade.
The vial provided by pharmacy is more than 100 times the normal dose for a heparin lock flush (the normal hose is 10 units/ml or 100 units/ml). It is imperative that the order be compared to the medication received prior to administration to prevent serious medication errors. A heparin overdose may result in cardiac arrhythmias, seizures, coma, agitation, fever, thermal fluctuations, blood pressure instability, and severe bleeding.
Factors I, V, and VIII are impaired in DIC and fibrinolysis.
Factor VIII complications are related to autoimmune disorders.
Impaired Factors II, VII, X, and XI are seen with vitamin K deficiencies and Coumadin (warfarin) administration.
Carl was intially admitted to the PCU with a diagnosis of CHF. After further study, it was determined that he has restrictive cardiomyopathy. A common cause of restrictive cardiomyopathy is?

-Unknown etiology
-Glycogen storage disease
-History of diabetes
-Viral infection
Glycogen storage disease

Amyloidosis is another cause of restrictive cardiomyopathy. The myocardium, especially the left ventricle, becomes rigid from fibrosis, which results in inadequate left ventricular filling and increased atrial dilation. Left ventricular diastolic dysfunction occurs, but systolic function remains normal in this type of cafrdiomyopathy. Fluid backs up into the lungs and the patients looks as if he has CHF. There is no cure for restrictive cardiomyopathy; instead symptoms are treated as they occur.
The type of cardiomyopathy that is characterized by replacement of normal cells by fatty tissue is known as:

-Hypertrophic
-Dilated
-Arrhythmogenic
-Restrictive
Arrhythmogenic

This is a relatively new classification for cardiomyopathy. In this condition, the normal myocardial cells are replaced by fatty tissue and fibrous tissue. THe right ventricle is primarily affected. Conduction cannot occur normally, so the patient will have multiple ventricular arrhythmias and right ventricular failure. Young people with arrhythmogenic cardiomyopathy are at risk for sudden death. The cause of this condition is unknown, but some research has shown a possible link to an autosomal dominant gene.
Which of the following hemodynamic effects would be seen in a patient with hypertrophic cardiomyopathy:

-Decreased CO, decreased EF
-Normal CO, increased EF
-Increased CO, increased EF
-Decreased CO, increased EF
Normal CO, increased EF

In hypertrophic cardiomyopathy, the myocardium thickens, but it is not symmetrical. Specifically, there is more thickening of the ventricular septum than of the venticle. If you were to look at a heart with this condition, it could appear normal externally. When the septum is thicker, it creates a hyperdynamic state by increasing contractility, so the EF is increased. In rare conditions where the septum is asymmetrically thickened, then the left ventricular outflow will be impaired, so the CO will be decreased.
Dilated cardiomyopathy is characterized by dilation of the ventricles and impaired systolic function. Common causes are valvular heart disease and ischemic heart disease. Other causes are idopathic. The most common cause of idiopathic dilated cardiomyopathy is:

-Alcohol
-Familial
-Genetic
-Autoimmune
Alcohol

The exact causes of this condition are unknown, but a large number of alcoholics develop dilated cardiomyopathy. Three possible reasons for this link have been identified:
The alcohol itself, or the metabolites, may have a toxic effect
Alcohol sometimes contains additives, such as cobalt
The cause may be nutritional in origin, such as a thiamine deficiency

New research shows that a viral link between chronic alcoholism and dilated cardiomyopathy may exist.
Interestingly, this type of cardiomyopathy may potentially reverse itself if the drinking is stopped. Other types of cardiomyopathy are not reversible.
Peripartum cardiomyopathy is a form of:

-Restrictive cardiomyopathy
-Hypertropic cardiomyopathy
-Viral cardiomyopathy
-Dilated cardiomyopathy
Dilated cardiomyopathy

Peripartum cardiomyopathy develops during the first 3 to 4 months after completion of pregnancy. Sometimes the cause is myocarditis.
Your patient was admitted for ascites, orthopnea, paroxysmal nocturnal dyspnea, and excessive fatifue. On physical assessment, you note S3 and S4 gaoolops, basilar crackles, and the EKG shows sinus tachycardia. These symptoms are usually indicative of which type of cardiomyopathy.

-Dilated
-Restrictive
-Alcohol induced
-Hypertrophic
Dilated

Dilated cardiomyopathy causes systolic dysfunction. As a result, you will hear S3 and S4 gallops and the EKG may show A-fib, ventricular dysrththmias or sinus tachycardia most of the time. The patient may have a systolic murmur of the AV valves. In addition, the patient will probably have peripheral edema or ascites, hepatomegaly, and pale, cool extremities. Changes in mentation are possible as well. Hypertrophic and restrictive cardiomyopathies are diastolic dysfunctions.
The most common new-onset dysrhythmias seen is a patient with pulmonary edema is:

-Supraventricular tachycardia
-RBBB
-Ventricular tachycardia
-Atrial fibrillation
Atrial fibrillation

A Fib is the result of the constant stretching and disruption of normal pathyways in the atrium due to inreased preload produced by the pulmonary congestion.
Your patient will be having an LVAD placed this evening and will subsequently be cared for in the PCU. Family members are quite anxious to learn more about the device and to participate in the patient's care. An important point when teaching caregivers is to make certain that they understand which changes in the patient's condition should be reported immediately to the staff. A complication that should be reported immediately would be:

-Irritation or redness at the incision site
-A temperature of 99.6'F
-Any change in the mentation of the patient
-A rise in blood pressure of more than 10 mm Hg.
Any change in the mentation of the patient

The nurse would monitor the patient's vital signs. This family is so eager to help the patient, and they would probably have someone at the bedside many hours during the day. Any change in mentation is very significant, and the family can help monitor the patient when the nurse is away from the room. The family will be ready to embrace learning and assume more tasks as time passes if they are positively reinforced for their efforts.
Stan is a 40 year old construction worker who was seen in the ED after falling into a trench. Stan sustained a left fractured tibia and fibula and a fractured left scapula. Stan required a spenectomy and was just admitted to your care. The nursing supervisor tried to get a bed in the ICU, but none was available. Your initial assessment results are:

EKG: ST at 126 with isolated PVC
BP 84/50
Skin pale, cool, clammy
RR 26, breath sounds clear, slightly diminished RLL
O2 2 L/min via NC
Mentation: Responds to questions slowly, oriented to self, time
CVP 4

Which of the following conditions do you believe this patient is developing?

-Cardiogenic shock
-Hypovolemic shock
-Septic shock
-Left ventricular failure
Hypovolemic shock

Both the BP and CVP are low. The RR is low, and the patient's mentation is diminished. These values indicate hypovolemic shock.
You are preparing to give Mrs D her 0900 dose of Coumadin (warfarin) as part of her atrial fibrillation management. You are reviewing her AM labs prior to administration of the medication. Which lab result would cause alarm?

-PTT 72 seconds
-PLT 180000/mm3
-APTT 38 seconds
-PT 28 seconds
PT 28 seconds

Coumadin (warfarin) blocks vitamin K coagulation factors II, VII, IX, X, and XI of the extrensic pathway. Normal PT is in the range of 11.2 to 13.2 seconds. A PT of 28 seconds indicates severe risk of bleeding and the Coumadin dose should be held and the doctor notified immediately. Many labs and doctors will use the INR value for purposes of Coumadin titration, as it is more reliable and standardized. The PT value must still be obtained to determine the INR calculation. The INR target is 2 to 3.5. INR values >4.5 indicate that the patient is at increased risk for bleeding, and a value >6 indicates the need for vitamin K administration.
Which of the following medications would you anticipate using to improve the pumping action of the heart when the patient is developing cardiogenic shock?

-Dobutamine
-Epinephrine
-Diltiazem
-Isoproterenol
Dobutamine

Dobutamine is an inotrope and will improve the pumping action of the heart. This alpha-, beta1-, and beta2-agonist will increase contractility and cardiac output, with little or no concomitant increase in myocardial oxygen demand. Dobutamine has a very mild vasodilatory effect, through high doses can cause ischemia.
Yesterday, Warren was shoveling snow when he became SOB and felt diffuse chest discomfort. WHen he went inside for lunch, the pain disappeared. Warren later resumed shoveling snow and felt more fatigued than ever. Today, he was admitted to your PCU with orthopnea and profound dyspnea. He is constantly saying, "I'm 56 years old and have been outside all my life. I'm not sick enough to be in here." His girlfriend reports that over the past 3 wks, Warren has been more tired than usual, even when performing small tasks around the house.

EKG: Borderline ST at 100 with rare PACs
Manual cuff BP 142/74
Skin warm, pale
Capillary refill 4 seconds, 2+ pitting edema, pretibial
RR 20, breath sounds: crackles in posterior lobes
O2 2 L/min via NC
ABGs were drawn, but results are unavailable
Mentation: Alert, oriented X4

Warren has probably developed:

-Mild pericarditis
-Pulmonary edema, noncardiac
-Chylothorax
-Left ventricular failure
Left ventricular failure

Warren has increased exercise intolerance, edema, and dyspnea, all of which are signs of left ventricular failure. The crackles are probably the result of fluid buildup in the lungs. Because the left heart cannot pump effectively, the fluid backs up.
Nancy is 64 years old and has a history of COPD. Today, she was admitted with an inferior wall MI. About 30 minutes ago, she complained of increasing SOB. When Nancy changed her position, her dyspnea abated. She is again complaining of dyspnea, and you perform a 12 lead EKG because your unit monitor allows monitoring of only leads II and MCL1. The EKG shows lead V1-V4 ST-segment depression. Other physical and lab findings are:

EKG: Sinus arrhythmia at 93
Manual cuff BP 102/60
Skin pale, cool, clammy; sacral edema, pedal and pretibial edema
RR 22, breath sounds: bilateral crackles
O2 2 L/min via NC
ABGs: pH 7.38, pCO2 48, paO2 66, HCO3 34
Mentation: Alert, oriented X4

What is the interpretation of the ABGs?

-Uncompensated metabolic acidosis
-Compensated respiratory acidosis
-Uncompensated metabolic alkalosis
-Compensated respiratory alkalosis
Compensated respiratory acidosis

The pH is normal (compensated), the CO2 level is high (respiratory acidosis), and the HCO3 level is normal.
Nancy is 64 years old and has a history of COPD. Today, she was admitted with an inferior wall MI. About 30 minutes ago, she complained of increasing SOB. When Nancy changed her position, her dyspnea abated. She is again complaining of dyspnea, and you perform a 12 lead EKG because your unit monitor allows monitoring of only leads II and MCL1. The EKG shows lead V1-V4 ST-segment depression. Other physical and lab findings are:

EKG: Sinus arrhythmia at 93
Manual cuff BP 102/60
Skin pale, cool, clammy; sacral edema, pedal and pretibial edema
RR 22, breath sounds: bilateral crackles
O2 2 L/min via NC
ABGs: pH 7.38, pCO2 48, paO2 66, HCO3 34
Mentation: Alert, oriented X4

Nancy is probably developing:

-Pulmonary effusion
-Left ventricular failure
-Pericarditis
-Congestive heart failure
Congestive heart failure

Nancy's intolerance for activities and crackles indicate pulmonary congestion. Edema indicates 3rd spacing. All of these symptoms are cardinal signs of CHF.
Approximately what % of coronary artery blockage is needed to cause angina?

-45%
-60%
-75%
-90%
75%

Anginal pain usually occurs when approximately 75% of the artery becomes occulded. Pain is more pronounced with exertional or emotional distress when oxygen demand by cardiac tissues cannot be met by the oxygen supply via the ocluded artery. The severity of the pain may be compounded by vasospasms that further restrict blood flow through the coronary arteries.
Which of the following lead changes will identify a lateral MI?

-II, III, aVF
-V1-V4
-V2-V6
-I, aVL, V5, V6
I, aVL, V5, V6

A lateral MI is identified by changes in leads I, aVL, V5, and V6
Garrett was admitted to the PCU about 6 hours ago with an inferior MI. He has been medicated for pain and is resting comportably at this time. His wife is visiting when she approaches you and says Garrett is dizzy and cannot catch his breath. His EKG now shows a sinus bradycardia with multifocal PVCs at 4 per minute. Other findings include:

EKG: Sinus bradycardia at 52 with rare multifocal PVCs
Manual cuff BP 82/46, previous BP 110/76 (30 minutes ago)
Skin pale, cool, clammy
RR 28
O2 2L/min via NC
Mentation: Anxious, oriented X4

Garrett's current arrhythmia will probably be:

-Permanent, asymptomatic
-Transient, possibly symptomatic
-Permanent, symptomatic
-Transient, asymptomatic
Transient, possibly symptomatic

Because the RCA perfuses the SA node in slightly more than half of the population, and supplies the proximal bundle of His and the AV node in more than 90% of people, conduction defects may occur, but will probably be transient.
Joanne had a VVI pacemaker inserted. What does the first V in the acronym stand for?

-Paced, ventricular
-Paced, inhibited
-Ventricular inhibited
-Ventricular
Paced, ventricular
Joanne had a VVI pacemaker inserted. What does the second V in the acronym stand for?

-Ventricular paced
-Ventricular inhibited
-Ventricular sensed
-Ventricular programmed
Ventricular sensed
Maria is 60 years old. She was alert and active last evening, but was found this morning sitting in her kitchen, hardly able to move. At first, it was thought she had suffered a stroke. Maria was admitted because her EKG showed large R waves in leads V1 and V2. Physical parameters include the following:

EKG: SR at 92, no ectopies
Manual cuff BP 94/62
Skin pale, cool, clammy
RR 18, breath sounds clear, slightly diminished LLL
O2 2L/min via NC
Moderate jugular venous distention, no bruits
CVP 18
Mentation: lethargic

An expected diagnosis for Maria would be:

-Aortic insufficiency
-LV hypertrophy
-RV infarction
-Pericarditis
RV infarction

Of the options presented here, the problem is in the right venticle. The CVP is high and there is some jugular distention. These findings indicate a problem with the right ventricle-- it cannot pump effectively. The lethargy may be unrelated and needs to be evaluated because it is a significant change for this patient.
Pete was working on his roof yesterday when he slipped and fell, impaling his leg on a piece of rebar. The rebar was removed and he is now being cared for in the PCU. Today, you note the following parameters and symptoms:

EKG: ST at 120 without ectopy
Manual cuff BP 90/64
Skin warm, dry
Capillary refill 2 seconds
RR 22, breath sounds: clear
O2 3 L/min via NC
Temp 100.8'F
Mentation: alert, oriented X4

Pete is probably developing:

-A pericardial tamponade
-Left heart failure
-Distributive shock
-Septic shock
Septic shock

Pete is in the hyperdynamic, "warm," phase of septic shock. The endotoxins are causing an increase in metabolism and act as vasodilators. his temperature is increased because of the increased metabolism and infection. Hypotension occurs because of vasodilation, and the HR increases to compensate. Urine output should be quite high. Pete needs immediate treatment with large quantities of fluids, vasopressors, antibiotics, and anti-endotoxins.
Mona was flying cross country and ate the snack provided by the airline. After about 5 minutes, she began to wheeze and her respirations became labored. A doctor onboard administered epinephrine, and the symptoms abated. The doctor did not explain the reason for the reaction to Mona.
Two days later, Mona was sharing some of her snack mix with her nephew when she began to wheeze again. She became severely tachypneic and was transported to the ER. She required treatment with spinephrine and steroids. She was stabilized and sent to the PCU. Mona is 8 months pregnant. She is currently exhibiting the following signs and symptoms:

EKG ST at 128 without ectopy
Manual cuff pressure 88/58
Skin, cool, pale
Capillary refill 4 seconds
RR 30, breath sounds: LLL crackles
Temp 99.4'F (oral)
Mentation: Awake, restless

Mona is probably developing:

-Anaphylactic shock
-Cardiogenic shock
-Hypovolemic shock
-Distributive shock
Distributive shock

Mona was admitted for anaphylactic shock. She is 8 months pregnany and the baby is probably pressing on her aorta and vena cava. A simple change of position might fix the problem.
In anaphylactic shock, the BP would be low in the initial stages because of vasodilation. Mona probably has a mild form of distributative shock, and her symptoms will probably resolve quickly once this problem is elimated.
Your patient is a 45 year old iron-worker. He was admitted for mardiomyopathy. His inital ejection fraction was 21%, and he has been confused most of the time since his admission yesterday. On admission, his EKG showed ST depression in leads V1-V4. He has been more dyspneic and is getting restless. Current vital signs and parameters are:

EKG: ST at 116
Manual cuff BP 102/70
Skin pale, cool
Temp 99'F
Bilateral pretibial and pedal edema
Sacral edema also present
RR 30, breath sounds clear, slightly diminished RLL
O2 4L/min via mask
Mentation: Oriented to self, confused at times

From which condition does this patient appear to be suffering at this time?

-An anterior MI
-Inferior wall MI
-Biventricular failure
-Right ventricular failure
Biventricular failure

The heart cannot pump the fluid out and the lungs are congested (dyspnea). Edema is a sign of pump failure. The patient will probably develop ascites and hepatomegaly.
Daniel was involved in a gang fight last week, during which he was stabbed several times in the anterior chest and twice in the abdomen. He has undergone 2 surgeries and is now post splenectomy, small bowel repair, and repair of a small laceration to the left subclavian vein. Daniel has recieved multiple units of blood and blood products. He was extubated this morning, but is now complaining of increased SOB. He is easily fatigued and his pulse oximeter reading is 0.94, down from 0.97. His am CXR shows "bilateral widespread infiltrates." Other labs and parameters are:

EKG: ST at 114, isolated PACs
Manual cuff BP 114/76
Skin warm
Temp 101'F
RR 30, breath sounds clear, slightly diminished RLL
O2 4L/min via mask
ABGs: pH 7.32, PaCO2 29, paO2 70, HCO3 19
Mentation: oriented X4 most of the time, two episodes of confusion, easily reoriented

Which condition do you believe Daniel is developing?

-ARDS
-PNA
-Pulmonary emboli
-Sepsis
Sepsis

Daniel has all the classic signs of sepsis. He has a low grade fever, increased RR, and subtle changes in mentation.
Your patient has been precribed paroxetine (Paxil) 50 mg PO/day. Your patient and family teaching should include side effects such as:

-Agitation, headaches, insomina
-Anaphylaxis, rash, seizure activity
-Abdominal cramps, nausea, diarrhea
-Dizziness, drowsiness, blurred vision
Agitation, headaches, insomina

Agitation, headaches, and insomina are all common side effects to paroxetine (Paxil). Additional side effects to monitor for include exacerbation of manic symptoms, seizures, tremors, nervousness, confusion, vertigo, risk of suicide, hallucinations, hypertonia, dry mouth, constipation, rectal hemorrhage and anemia.
Your patient is placed on an EKG monitor. The rhythm is a sinus rhythm, rate of 78 with isolated PVCs and a depressed ST segment. The ST segment depression might be indicative of:

-An MI in progressive infarction
-Ischemia
-Prolonged ventricular depolarization
-Hyperkalemia
Ischemia

Depression of the ST segment is indivative of myocaridal ischemia: Electrical conduction through the heart is altered as cardiac tissue dies. Dead or necrotic myocardial tissue is unable to conduct electricity, do the electrical impulse must go around the tissue and is seen as a depression on the cardiac monitor.
The type of myocardial infarction that involves the entire thickness of myocardium in a region is called:

-Subendocardial
-Anterioseptal
-Transmural
-Inferior wall
Transmural

Transmural describes the full thickness of the myocardial wall.
Subendocardial indicates that the infarction has not effected the full thickness of the myocardium.
The anterioseptal and inferior walls are potential locations of the MI.
In myocarditis, which medicatin is typically used to trat venticular failure by improving contractility and reducing ventricular rate?

-Inderal
-Imuran
-Amiodarone
-Digoxin
Digoxin

Digoxin is often used to treat ventricular failure because it improves myocardial contractility and reduces the ventricular rate. Use this drug with caustion when patients have myocarditis because digoxin's cardiac side effects are more likely to occur.
Your patient has undergone a mitral valve repair with reconstruction of the valve leaflets and the annulus. This procedure is called a(n):

-Valvuloplasty
-Annuloplasty
-Mitral commissurotomy
-Mital valve replacement
Annuloplasty

In annuloplasty, the mitral valve is repaired through reconstruction of the valve leaflets and the annulus. This technique may also be used to repair the tricuspid valve. A prosthetic ring may or may not be used.
What size is the average heart?
Approximately 5" (12.5 cm) long and 3.5" (9cm) wide.

It is approximately the size of the patient's closed fist.
How much does the average heart weigh?
Typically, the heart weighs 9 to 12 ounces (255 to 340g).

The weight of the heart depends on he person's size, age, sex, and athletic conditioning.
Name the 3 layers of the heart's wall.
Epicardium, Myocardium, Endocardium
Epicardium
The outer layer of the heart muscle is made up of squamous epithelial cells overlying connective tissue.
Myocardium
The middle layer of the heart muscle makes up the largest portion of the heart's wall. This layer of muscle tissue contracts with each heartbeat.
Endocardium
The heart's innermost layer contains epithelial tissue with small blood vessels and bundles of smooth muscle.
Pericardium
A layer of connective tissue which surrounds the heart and acts as a tough, protective sac. It consists of fibrous pericardium and serous pericardium.
Fibrous Pericardium
Fibrous pericardium is composed of tough, white fibrous tissue that loosely fits around the heart to protect it. It also attaches to the great vessels, diaphragm, and sternum.
Serous Pericardium
Serous pericardium is thin and smooth and consists of 2 layers; the parietal layer and the visceral layer.
Parietal layer: lines the inside of the fibrous pericardium
Visceral layer: adheres to the surface of the heart
Pericardial Space
The space between the visceral and parietal layer. It contains 20 to 30 ml of thin, clear pericardial fluid that lubricates the two surfaces and cushions the heart.
Pericardial effusion
Excess pericardial fluid that compromises the heart's ability to pump blood.
Atrioventricular Valves
Tricuspid--located between the RIGHT atrium and RIGHT ventricle. Has 3 cusps.
Mitral -- located between the LEFT atrium and the LEFT ventricle. Has 2 cusps.
Semi-lunar Valves
Aortic-- located where the LEFT ventricle meets the aorta. It allows blood to flow from the LEFT ventricle to the aorta and prevents backflow. Has 3 cusps.
Pulmonic--located where the pulmonary artery meets the RIGHT ventricle. It permits blood flow from the RIGHT ventricle to the pulmonary artery and prevents backflow. Has 3 cusps
Tricuspid Valve
Located between the RIGHT atrium and RIGHT ventricle. Has 3 cusps. Atrioventricular valve.
Mitral Valve
Located between the LEFT atrium and the LEFT ventricle. Has 2 cusps. Atrioventricular valve.
Aortic Valve
Located where the LEFT ventricle meets the aorta. It allows blood to flow from the LEFT ventricle to the aorta and prevents backflow. Has 3 cusps. Semi-lunar Valve.
Pulmonic Valve
Located where the pulmonary artery meets the RIGHT ventricle. It permits blood flow from the RIGHT ventricle to the pulmonary artery and prevents backflow. Has 3 cusps. Semi-lunar Valve.
Chordae Tendineae
Papillary muscles in the heart wall that anchor the heart valve cusps. These cords work together to prevent the cusps from bulging backward into the atria during ventricular contraction. If damage to these cords occur, blood can flow backward into a chamber, resulting in a heart murmur.
Pulmonary Circulation
Deoxygenated blood from the body returns to the heart through the inferior and superior vena cava and empties into the RIGHT atrium. From there, the blood flows through the Tricuspid valve into the RIGHT atrium. The RIGHT ventricle pumps blood through the Pulmonic valve into the pulmonary arteries and then into the lungs. Oxygenated blood travels from the lungs through the pulmonary veins and empties into the LEFT atrium.
Systemic Circulation
When pressure rises to a critical point in the LEFT atrium, the Mitral Valve opens and blood flows into the LEFT ventricle. The LEFT ventricle then contracts and pumps blood through the Aortic valve into the aorta, and then throughout the rest of the body. Blood returns to the RIGHT atrium through the veins and thus completing the cycle.
Coronary Ostium
The coronary ostium is an opening in the aorta that feeds blood to the conornary arteries and is located near the Aortic Valve.
During systole, when the LEFT ventricle is pumping blood through the aorta and the Aortic Valve is OPEN, the coronary ostium is partially covered.
During diastole, when the LEFT ventricle is filling with blood, the Aortic Valve is CLOSED, the coronary ostium is open which allows for blood to fill the coronary arteries.
Right Coronary Artery
Originates off of the ascending aorta from the area known as the sinuses of valsalva. The RCA supplies blood to the right atrium, right ventricle, and part of the inferior and posterior surfaces of the left ventricle.
The RCA also supplies blood to the bundle of His and the AV node.
In about 50% of the population, the RCA also supplies blood to the SA node.
Left Coronary Artery
Originates off of the ascending aorta from the area known as the sinuses of valsalva. It runs along the surface of the left atrium where it splits into 2 major branches:

Left Anterior Descending -- the LAD runs down the surface of the left ventricle toward the apex and supplies blood to the anterior wall of the left ventricle, the interventricular septum, the right bundle branch, and the left anterior fasciculus of the left bundle branch

Left Circumflex-- Supplies blood to the lateral walls of the LEFT ventricle, the LEFT atrium and in 50% of the population, to the SA node. It also supplies blood to the LEFT posterior fasciculus of the left bundle branch. This artery circles the LEFT ventricle and provides blood to the ventricle's posterior portion.
Left Anterior Descending Artery
The LAD runs down the surface of the left ventricle toward the apex and supplies blood to the anterior wall of the left ventricle, the interventricular septum, the right bundle branch, and the left anterior fasciculus of the left bundle branch.
Branches of the LAD include the Septal Perforators and the Diagonal arteries which help supply blood to both ventricles.
Left Circumflex Artery
Supplies blood to the lateral walls of the LEFT ventricle, the LEFT atrium and in 50% of the population, to the SA node. It also supplies blood to the LEFT posterior fasciculus of the left bundle branch. This artery circles the LEFT ventricle and provides blood to the ventricle's posterior portion.
Coronary Sinus
Cardiac veins collect deoxygenated blood from the capillaries of the myocardium. These veins join to form an enlarged vessel called the Coronary Sinus. The Coronary Sinus returns the blood to the RIGHT atrium where it continues through circulation.
Diastole
The ventricles relax, the atria contract.

Blood is forced through the OPEN Tricuspid and Mitral valves.

The Aortic and Pulmonic valves are CLOSED
Systole
The atria relax and fill with blood.

The Mitral and Tricuspid valves are CLOSED.

Ventricular pressure rises, which forces OPEN the Aortic and Pulmonic valves.

Then the ventricles contract and blood flows through the circulatory system.
Cardiac Cycle
Isovolumetric ventricular contraction
Ventricular ejection
Isovolumetric relaxation
Ventricular filling
Atrial systole/ atrial kick
Isovolumetric Ventricular Contraction
In response to ventricular depolarization, tension in the ventricles increases. The rise in pressure within the ventricles leads to closure of the Mitral and Tricuspid valves. The Pulmonic and Aortic valves stay closed during the entire phase.
Ventricular Ejection
When ventricular pressure exceeds aortic and pulmonic arterial pressure (80 mm Hg), the Aortic and Pulmonic valves open and the ventricles eject 70% of the blood.
Isovolumetric Relaxation
When the ventriclar pressure falls below pressure in the aorta and pulmonary artery, the Aortic and Pulmonic valves close. ALL valves are CLOSED during this phase. Atrial diastole occurs as blood fills the atria.
Ventricular Filling
Atrial pressure exceeds ventricular pressure, which causes the Mitral and Tricuspid valves to OPEN. Blood then flows passively into the ventricles. About 70% of ventricular filling takes place during thie phase.
Atrial systole/ atrial kick
Known as the atrial kick as it coincides with late ventricular diastole, supplies the ventricles with the remaining 30% of the blood for each heartbeat.
Atrial fibrillation can cause a loss of atrial kick and a subsequent drop in cardiac output.
Tachycardia allows for less filling time by shortening diastole. Less filling time means less blood will be ejected during ventricular systole and less will be circulated.
Preload
Preload is the stretching of muscle fibers in the ventricles and is determined by the pressure and amount of blood remaining in the left ventricle at the end of diastole.
Preload is the passive stretching of muscle fibers in the ventricles. This stretching results from blood volume in the ventricles at end-diastole. According to Starling's Law, the more the heart muscles stretch during diastole, the more forcefully they contract during diastole. Think of preload as the balloon stretching as air is blown into it. The more air, the greater the stretch.
Afterload
Afterload is the amount of pressure the left ventricle must work against to pump blood into the circulation. The greater this resistance, the more the heart works to pump out blood.
Afterload refers to the pressure that the ventriclar muscles must generate to overcome the higher pressure in the aorta to get the blood out of the heart. RESISTANCE is teh know on the end of the balloon, which the balloon has to work against to get the air out.
Contractility
Contractility is the ability of muscle cells to contract after depolarization. This ability depends on how much the muscle fibers are stretched at the end of diastole. Overstretching or understretching these fibers alters contractility and the amount of blood pumped out of the ventricles.
Contractility refers to the inherent ability of the myocardium to contract normally. Contractility is influenced by preload. The greater the stretch the more forceful the contraction -- or the more air in the balloon, the greater the stretch, and the farther the balloon will fly when air is allowed to expel.
Sympathetic (adrenergic) Nervous System in the heart
The SYMPATHETIC (ADRENERGIC) nervous system is basically the heart's accelerator. Two sets of chemicals, epinephrine and norepinephrine, are highly influenced by this system. These chemicals increase heart rate, automaticity, AV node conduction, and contractility.
Parasympathetic (cholinergic) Nervous System in the heart
The PARASYMPATHETIC (CHOLINERGIC) nervous system serves as the heart's brakes. One of this system's nerves, the VAGUS nerve, carries impulses that slow heart rates and conduction of impluses through the AV node and ventricles. Stimulating this system releases the chemical ACETYLCHOLINE, which slows the heart rate. The bagus nerve is stimulated by baroreceptors in the aorta and the internal carotid arteries.