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CCRN Cardiac Questions and Answers: A Comprehensive Guide for Critical Care Nurses, Exams of Nursing

A series of multiple-choice questions and answers related to cardiac care, specifically focusing on the ccrn (critical care registered nurse) certification exam. It covers various aspects of cardiac physiology, pathophysiology, and management, including topics like myocardial infarction, heart failure, and hemodynamic monitoring. The questions are designed to test the knowledge and understanding of critical care nurses preparing for the ccrn exam.

Typology: Exams

2024/2025

Available from 12/20/2024

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A 59 year old male is admitted with ST elevation in V2, V3, V4. IV thrombolytics therapy was started in the ED. Indications of successful reperfusion would include all of the following except: a) Pain cessation b) Absence of troponin elevation c) Reversal of ST segment elevation with return to baseline

d) Short runs of ventricular tachycardia answer ✓✓ Answer B

The patient is having an anterior wall MI. Even with reperfusion achieved in a timely manner, the cardiac biomarkers (troponin) will be elevated. When the artery opens choices A, C, and D will occur A patient is admitted with chest pain and ST elevation in II, III, aVF. Fe is receiving dobutamine at 10 mcg/kg/min and nitroglycerin at 20 mcg/min. His BP is 90/60, sinus tachycardia at 110 minute. A pulmonary artery catheter is inserted and the following are obtained: RAP= 16 PAOP= 5 PAP= 26/ Cardiac Index: 1.9 L/min The patient has JVD in a semi-fowlers position; Tall, peaked P-waves are seen in lead II. Which of the following therapies is indicated for this patient? a) Increase the Dobutamine infusion to 20 mcg/kg/minute, and infuse 50 mL b) Begin milrinone infusion at 0.5 mcg/kg/minute after a loading dose of 50 mcg/kg c) Discontinue the nitroglycerin and infuse 500 mL NS

d) Discontinue dobutamine, and start a dopamine infusion at 10 mcg/kg/minute answer ✓✓

Answer C The patient is having an acute inferior MI. The elevated RAP, JVD, and tall peaked P-waves are clinical indications of RV failure, most likely secondary to RV infarct. Preload reduction (nitroglycerin) will further decrease LV filling and CO. Therefore, it should be discontinued, and fluid boluses will help to increase the LV preload. Dobutamine has a mild dilating effect and

may further decrease the BP. Therefore, an increase in dose would not be advisable. Starting milrinone would provide no benefits at this time. Dopamine 20 mcg/kg/min, not at 10 mcg/kg/min A patient was 48-hours post aortic valve replacement. Which of following would be a major goal for this patient? a) Diuretic therapy b) Stabilize blood pressure c) Prophylactic antibiotics

d) Prevent thrombus answer ✓✓ Answer: D

Clot formation on the valve is a major complication of valvular replacement, especially a mechanical valve. Therefore, anticoagulation will be needed. Fluid overload, labile BP, and infection are all possible complications. However, they are not as likely as thrombus formation and resultant stroke (if related to aortic valve) A patient with a history of heart failure and MI presents following an episode of syncope. The assessment 2 hours later demonstrates: BP 134/64 (supine); 110/70 (sitting) HR 115 with weak and thready pulse (supine) 130 (sitting) RR 32 and shallow Urine output 30 mL over the past 2 hours Breath sounds are clear The patient most likely requires a) Vasodilators b) loop diuretics c) IV fluids

d) Vasopressors answer ✓✓ Answer C

The decrease in bp and increase in heart rate with position change (orthastatic hypotension), clear lungs, and low urine output is a sign of hypovolemia. Vasodilators or diuretics will

exacerbate this problem. Vasopressors will only further elevate the SVR, increasing the work of the heart All of the following support the diagnosis of cardiac tamponade EXCEPT: a) Widening pulse pressure b) equalization of right and left heart pressures c) Pulsus paradoxus

d) enlarged heart on chest x-ray (CXR) answer ✓✓ Answer A

The pulse pressure narrows with cardiac tamponade. The other 3 choices are seen with cardiac tamponade Cardiogenic shock secondary to left ventricular failure will generally result in: a) Decreased afterload b) narrow pulse pressure c) decreased preload

d) Widening pulse pressure answer ✓✓ Answer: B

The systolic pressure decreases due to a drop in cardiac output; however, the diastolic pressure either stays the same or increases due to a compensatory increase of the systemic vascular resistance. The remaining choices are not found in cardiogenic shock. Desirable BP ranges vary depending on the neurological problem and need to be clarified with the physician. Which of the following BP ranges is correct? a) Treat BP for an acute ischemic stroke patient, not a candidate for thrombolytic therapy, if greater than 200-220 mmHg systolic or 100 mmHg diastolic b) Keep systolic BP greater than 180 mmHg for an acute ischemic stroke paient who is a candidate for thrombolytic therapy c) Keep systolic BP for a patient wit acute subarachnoid hemorrhage, preop 160-180 mmHg d) Keep systolic BP less than 120 mmHg to prevent vasospasms after a subarachnoid

hemorrhage answer ✓✓ Answer A

Abrupt lowering of the BO to normal in the presence of an acute schemic stroke may decrease perfusion to the area of injury and result in greater brain injury. Elevated BP is contraindicated

for the patient who is a candidate for thrombolytic therapy. The patietn with acute SAH requires treatment of elevated BP pre-op in order to prevent further bleeding. The BP needs to be somewhate elevated after repair of acute SAH rather than <120 mmHG systolic as normal to low BP is thought to contribute to cerebral vasospasms. Despite emergent PCI and dobutamine infusion, the patietn with acute anterior wall MI remained hypotensive. An intra-aortic balloon (IAB) is inserted via left femoral artery. The immediate effect of IABP therapy is: a) decreased preload and myocardial oxygen consumption b) decreased preload and afterload c) decreased afterload and improved coronary artery perfusion

d) decreased afterload and increased myocardial contractility answer ✓✓ Answer C

When the intra-aortic balloon closes right before systole begins, the LV afterload is decreased. When the balloon inflates during diastole, coronary artery perfusion is increased. Preload may eventually decrease as coronary artery perfusion increases and afterloa has decreased. However, this is an indirect effect of IAB therapy. The balloon does not directly increase myocardial contractility ECG changes associated with ST-elevation myocardial infarction (STEMI) affecting the lateral wall would includ changes in which of the following leads? a) II, III, aVF b) V1, V2, V c) V2, V3, V

d) V5, V6, I, aV1 answer ✓✓ Answer: D

V5, V6 represents the lower lateral wall of the left ventricle and I, aVL represents the high lateral wall of the left ventricle, supplied by the left circumflex artery in most of the population Nitrate therapy is indicated for the treatment of unstable angina and acute heart failure because it: a) decreases preload and increases myocardial 02 demand b) increases preload and increases myocardial 02 demand c) increases preload and decreases myocardial 02 demand

d) decreases preload and decreases myocardial 02 demand answer ✓✓ Answer: D

Nitrate cause venodilation, which results in a decrease in venous return to the heart (left ventricular preload reduction). The decrease in preload decreases the work of the left ventricle and myocardial oxygen demand On arrival to the ICU from the cardiac catheterization lab where the patient had a diagnostic right heart catheterization and a percutaneous coronary intervention, the cardiologist informed the nrse that the patient had an elevated left ventricular filling pressure and a low CO. Which of the following therapies would be beneficial for this patient? a) Left ventricular afterload reduction b) Heart rate reduction c) Left ventricular preload elevation

d) Negative inotropic therapy answer ✓✓ Answer A

An elevated LV filling pressure (PAOP) and a decrease in cardiac output would benefit from decreased SVR ( LV afterload). A vasodilating drug such as an ACE inhibitor (or mechanically with intra-aortic balloon therapy) would provide this effect. HR reducation might benefit diastolic filling but not necessarily help an elevated LV filling pressure. Elevation of the LV preload or negative inotropic therapy would make the problem worse. One hemodynamic benefit of intra-aortic balloon therapy is: a) Balloon inflation prevents right to left shunt b) Balloon deflation increases coronary artery perfusion c) Balloon inflation optimizes aortic valve performance

d) Balloon deflation decreases left ventricular afterload answer ✓✓ Answer: D

Balloon deflation in the descending aortic arch right before systole creates a drop in afterload. When the balloon inflates during diastole, blood is displaced into the coronary arteries, increasing coronary artery perfusion. Preload and afterload are affected by carious interventions. Which of the following statements is accurate? a) Afterload is increased by nitroglycerin b) Afterload is decreased by enalaprilat (Vasotec)

c) Preload is increased by furosemide (Lasix)

d) Preload is decreased with fluid administration answer ✓✓ Answer B

Enalaprilat (Vasotec) is an angiotensin-converting enzyme inhibitor drug that prevents the conversion of angiotensin I to angiotensin II (a potent vasoconstrictor) and thereby causes vasodilation and a decrease in SVR. The other 3 choice are incorrect because afterload is decreased by nitroglycerin (high dose NTG) Preload is decreased by furosemide and is increased with fluids Priority treatment for aortic dissection requires which of the following? a) fluids and vasopressors b) intra-aortic balloon therapy and transfusion c) aggressive management of hypertension and emergent surgery

d) emergent aortic valve replacement and pain control answer ✓✓ Answer: C

Emergent surgery is essential for survival, and blood pressure control is essential preoperatively. Pain control and transfusion may be indicated, but the remaining therapies are not beneficial. Pulmonary hypertension may result in which of the following? a) Left heart failure b) Right heart failure c) Increased lung compliance

d) Arterial hypertension answer ✓✓ Answer: B

The right ventricular wall normally is thinner than the left because the RV generally ejects into a low pressure pulmonary system with a mean pulmonary pressure of approximately 20 mmHg. An increase in pulmonary pressure may result in failure of the RV. Short episodes of non-sustained torsade de pointes ventricular tachycardia are seen on the cardiac monitor. The nurse should anticipate orders for which of the following infusions for this patient? a) amiodarone b) magnesium c) digoxin

d) potassium answer ✓✓ Answer: B

Torsade de pointes VT is due to prolonged QT interval, and magnesium is indicated for this problem. Amiodarone may worsen the problem by further prolonging the QT interval. The remaining choices are not effective treatments for torsade de pointes. The 75-year-old patient develops frequent 6 to 10 second episodes of asystole, interspersed with normal sinus rhythm that is associated with hypotension. The priority intervention is: a) Trans-cutaneous pacing b) Fluid bolus c) Trans-venous pacing

d) Vasopressors answer ✓✓ Answer: A

The rhythm described is sinus arrest. Because the patient is having serious signs and symptoms, the immediate treatment is transcutaneous pacing. Transvenous pacing may be done once the patient is stabilized. The remaining two choices are not indicated for sinus arrest. The ECG demonstrates ST elevation in leads II, III and aVF. The nurse needs to monitor the patient closely for which of the following? a) Tachycardia, lung crackles b) Sinus bradycardia, acute systolic murmur in the fifth intercostal space, midclavicular c) Second-degree heart block Type 2, hypotension

d) Hypoxemia, acute systolic murmur, 5th intercostal space left sternal border answer ✓✓

Answer: B Complications likely to occur after an acute inferior wall MI include bradycardia secondary to ischemia to the SA and/or AV node, and papillary muscle rupture or dysfunction due to the anatomical distance between the right coronary artery and the papillary muscle. The remaining choices are not common complications of inferior MI. The nurse assessing a patient with acute coronary syndrome needs to know that: a) there are always acute ECG changes, chest pain, and positive troponin b) The standard of care for a NSTEMI is emergent reperfusion within 90 minutes c) The most common cause is plaque rupture and most common complication is arrhythmias

d) it includes stable angina, unstable angina, NSTEMI, and STEMI answer ✓✓ Answer C

Chest pain may not always be present. Emergent reperfusion is not indicated for a NSTEMI. Stable angina is not considered ACS since it is not usually due to plaque rupture The nurse caring for the patient after coronary artery bypass graft (CABG) surgery should: a) Anticipate possible drop in BP during rewarming b) Strip chest tubes hourly to maintain patency c) Maintain Blood sugar 150-200 mg/dL with insulin infusion

d) Maintain serum potassium 3-4 mEq/dL to prevent arrhythmias answer ✓✓ Answer A

As the patient's temperature rises, vasoconstriction that was present at lower temperature decreases with a possible drop in BP. Chest tubes should not be stripped. A blood sugar of 150- 200 is too high for a post-op CABG surgery patient. Serum potassium needs to be close to 4. mEq/dL and 3.0-4.0 is too low The nurse is caring for a patient with acute inferior wall MI, post-coronary artery stent deployment. For optimal care of the patient, the nurse should: a) administer an analgesic for acute back pain b) Apply pressure dressing to groin c) Continuously monitor the patient in lead II

d) Maintain the patient in a supine position answer ✓✓ Answer: C

It is best practice to continuously monitor the patient status post PCI with stent, in the lead that was most abnormal during the acute occlusion. Lead II would most likely meet this criterion for the patient with an inferior wall MI. The remaining interventions are NOT indicated for the patient post PCI. The patient complains of chest pain with deep inspiration, worse when lying supine. There is a frction rub on auscultation and sinus tachycardia. Which of the following would you expect to find on the stat 12-lead EKG? a) ST depression in V1-V b) ST elevation in II, III, aVF, and V2-V c) ST depression rV2, rV

d) ST elevation in II, III, aVF answer ✓✓ Answer: B

The patient has pericarditis, and the expected EKG change is global ST elevation. Choice (a) is seen in anteriror wall ishcemia or NSTEMI. Choice (c) is associated with RV ischemia/infarct. Choice (d) is seen with acute inferior wall STEMI The patient complains of chest tightness, SOB, and difficulty breathing shortly after the IV antibiotics is initiated. Hives have appeared across the face and chest. Vital signs include BP 84/34, HR 130 min, sinus tachycardia, RR 28 with wheezing, Sp02 94% on room air. Which of the following interventions are most appropriate for the patient? a) Stat ECG, aspirin, oxygen, pressor b) Albuterol, steroids, 02, fluids c) Fluids, 02, CT of the chest, 02, heparin

d) Epinephrine IM, steroids IV, Antihistamine, fluids answer ✓✓ Answer D

The clinical signs and symptoms indicate an allergic reaction and anaphylatic shock. The epinephrine, steroids, and antihistamine will couteract the effects of the massice histamine release. Fluids will address the hypotension and relative hypovolemia caused by massive dilation. The remaining responses include options not indicated or helpful for anaphylaxis. The patient develops PSVT, and synchronized cardioversion is being considered. Which of the following would be a contraindication to the cardioversion? a) Digoxin level of 4.0 mg/dL b) Potassium level of 5.1 mgEq/L c) Magnesium level of 2.6 mg/dL

d) Creatinine level of 3.1 mg/dL answer ✓✓ Answer A

If synchronized cardioversion is attempted in the presence of digoxin toxicity, ventricular tachycardia or fibrillation may result. The remaining 3 options would not be contraindicated to synchronized cardioversion The patient had an episode of chest pain at rest with ST elevation on the ECG. The chest pain was relieved, and teh ST segments normalized after administration of nitroglycerin sublingual. The patient most likely had: a) Stable angina

b) ST-elevation MI c) Prinzmetal's or variant angina

d) Wellen's syndrome answer ✓✓ Answer C

ST segment elevation that normalizes and chest pain is relieved after administration of nitroglycerin are indicative of Prinzmetal's angina. Stable angina occurs with activity; it is predictable. STEMI does not respond to NTG with normalization of ST segments and complete pain relief. Wellen's syndrome does not present with ST elevation but rather a biphasic T-wave specific to lead V1 and V The patient has acute right ventricular infarct and RV failure. Which of the following is an indication that this patient's condition has improved? a) The PAOP has decreased b) The RA pressure has decreased c) The RV pressure has increased

d) The PA diastolic has decreased answer ✓✓ Answer: B

The RA pressures are elevated in RV failure secondary to RV infarct, and a decrease is evidence that treatment is effective. The PAOP is a left heart pressure. It is often already low in the setting of RV infarct/failure since the preload to the left heart drops. A further decrease is not warranted. An increase in RV pressure is a sign of worsening RV failure. The PAD is already low with RV infarct, and a further decrease is not desirable. The patient has cardiogenic shock and cardiogenic pulmonary edema. Which of the following therapies would be most effective for this patient? a) Ventricular assist device to increase coronary artery perfusion b) Beta blocker to increase cardiac contractility c) Alpha-adrenergic drug to increase coronary artery perfusion

d) angiotensin-converting enzyme inhibitors to decrease afterload answer ✓✓ Answer A:

Mechanical devices such as a VAD or IABO will increase coronary artery perfusion, a positive hemodynamic effect in the seting a cardiogenic. Alph-adrenergic drugs such as phenylephrine or norepinephrine constrict arteries decrease erfusion and increase the work of the heart. Beta blockers decrease myocardial contractility. Afterload reduction will decrease the work of the heart; this affect alone will decrease blood pressure and coronary perfusion.

The patient has global ST elevation and pain with deep inspiration. Which of the following interventions should the nurse anticipate? a) Morphine b) Beta-adrenergic blocker c) Nitrate

d) Non-steroidal anti-inflammatory agent answer ✓✓ Answer: D

The clinical signs are those of pericarditis, and NSAIDs may be beneficial by decreasing inflammation. The remaining choices have not been found to be of benefit for the treatment of pericarditis. The patient is describing an episode of chest pain. Which of the following would mos likely indicate coronary artery disease as the etiology? a) The pain is associated with nausea, extreme fatigue, and radiates to the right arm b) The pain is burning, started after eating, and was relieved by an antacid c) The pain is squeezing, going to the back, and associated with shortness of breath

d) The pain is sharp, worse with deep inspiration, and relieved by turning to the side answer

✓✓ Answer C

  • Choice A is incorrect because pain due to CAD does not radiate to the right arm. Choice B is incorrect becuase it describes the pain of indigestion or acid reflux. Choice D is not correct becuase it describes the pain typical of pericarditis The patient is receiving amiodarone. Which of the following assessments are important? a) PR interval, renal function, blood pressure b) QRS interval liver function, lung sounds c) QT interval, thyroid function, HR

d) ST segment, pulmonary function, urine ouput answer ✓✓ Answer C

Amiodarone may prolong the QT interval, and a 200 mg tablet is estimated to contain about 75 mg of organic iodide. This may result in amiodaron-induced thyrotoxicosis (AIT) or amiodarone-induced hypothyroidism (AIH) both of which can develop in apparently normal thyroid glands or in glands with preexisting abnormalities. Amiodarone does not affect PR interval or renal function. It does not affect the QRS interval, liver function, or lung sounds. It also does not affect the ST segment or urine output. Amiodarone might decrease BP if a large

dose (300 mg) is given in a rapid IV to a patient with a pulse and could affect pulmonary function (fibrosis) when used orally for long periods of time. The patient is receiving positive inotropes, vasodilators, and diuretics. The patient most likely has which of the following problems? a) right ventricular failure b) left ventricular systolic heart failure c) papillary muscle rupture

d) Hypertrophic cardiomyopathy answer ✓✓ Answer: B

Positive inotropes increase contractility; vasodilators decrease afterload, and diuretics decrease preload. Since the patient with systolic heart failure has decreased contractility and increased afterload and preload, these agents will be useful for the treatment of this problem. The patient is status post motor vehicle accident with a large chest bruise. The nurse knows the patient needs to be assessed for which of the following? a) Positive troponin and aortic valve damage b) Pain with inspiration and pericardial friction rub c) Retroperitoneal bleed and global ST elevation

d) Atrial fibrillation and mitral valve damage answer ✓✓ Answer: A

The chest bruise implies the patient's chest struck the steering wheel. This in turn may have caused aortic valve trauma (the valve lying most anterior in the chest), or caused myocardial trauma damage. The patient of an orientee experiences cardiac arrest and requires resuscitation. The preceptor who is orienting the new nurse to the unit arrives to see that the orientee has placed the patient in reverse Trendelenberg position. What would be the preceptor's best response at this time? a) Immediately begin chest compressions b) Explain to the orientee the problem with the current position and instruct on the correct position c) Place the patient in a supine position

d) Ask the orientee why she put the patient in this position answer ✓✓ Answer: C

The preceptor needs to do what is best for the patient in this emergency situation. Beginning chest compressions with the head of the bed elevated, choice (A), would not be the best intervention for the patient; using the situation to coach the orientee, choice (B), would not be appropriate timing; discussion of the orientee's rationale, choice (D), would best be done at a later time as well. The patient presented to the ED with a history of palpitations and dyspnea, persisting on and off for one week. The heart monitor shows atrial fibrillation with rapid ventricular response, blood pressure 112/70. Treatment will most likely include: a) calcium channel blocker and anticoagulation b) cardioversion and beta blocker c) digoxin and aspirin

d) amiodarone and oxygen answer ✓✓ Answer: A

The patient history seems to be one of intermittent atrial fibrillation over the past week. Controlling rate (calcium channel blockers) and addressing potential left atrial clot formation (anticoagulation) are priority treatments. Cardioversion, choice (B), is reserved for the unstable patient; digoxin, choice (C), may be used for rate control, although onset is slow and aspirin is not an anticoagulant; amiodarone, choice (D), may result in conversion to sinus rhythm, but this should not be attempted until the patient is anticoagulated. The patient presents with blood pressure 232/129 and acute chest pain. Which of the following would be the agent of choice to use for this patient? a) Nicardipine (cardene) b) Labetalol ( Normadyne) c) Nitroprusside (Nipride)

d) Diltiazem (cardizem) answer ✓✓ Answer B

The patient has hypertensive crisis as evidence by high blood pressure and signs of end-organ damage (chest pain). The labetalol will helo lower BP plus provide some anti-ischemic effect, which the patietn most likely needs in the presence of chest pain. Although nicardipine is an antihypertensive and can prevent chest pain, it is not recommended for hypertensive crisis and active chest pain. Nitroprusside is indicated for hypertensive crisis but is not recommended for cardiac ischemia. Diltiazem may be used for hypertension but not for hypertensive crisis.

The patient was admitted 2 days ago with ST elevation in II, III, and aVF. Two days later, the patient developed hypotension, tachypnea, hypoxemia, and a new loud holosystolic murmur at the apex. The definitive treatment for the patient will be: a) Percutaneous coronary intervention b) Intra-aortic balloon pump therapy c) surgery

d) intubation and mechanical ventilation answer ✓✓ Answer C

The patient had an acute inferior wall MI. The sudden change in condition is most likely due to acute mitral valve regurgiation secondary to papillary muscle dysfunction. With hypotension, the MV regurgitation is massive and is most likely a surgical emergency. A PCI is not indicated as there is not recurrence of ST elevation. Although IABO therpay and mechanical ventilation might help, they are not definitive treatments for this life-threatening problem. The patient was admitted with acute inferior wall STEMI; the physician advises the nurse to monitor the patient for signs of right ventricular (RV) infarction. Which of the following are signs of RV infarction? a) S2 heart sounds, lung crackles b) Hypotension, flat neck veins c) Hypertension, systolic murmur

d) Distended neck veins, clear lungs answer ✓✓ Answer: D

If the RV contractility decreases, pressure proximal to the right ventricle (which is the right atrium) increases, resulting in distended neck veins. As the right heart fails, left heart preload decreases, lung sounds clear. The patient was admitted with an acute anterior wall MI and suddenly develops a loud holosystolic murmur, loudest at the left sternal border, 5th intercostal space, tachypnea, and bibasilar crackles. Which of the following would provide the most definitive diagnosis of this problem? a) Decreased Cardiac output b) Increased oxygen saturation in the pulmonary artery and the right ventricle c) Central venous pressure less the pulmonary artery diastolic pressure

d) Decreased arterial saturation answer ✓✓ Answer B

The clinical picure is one of ventricular septal defect (based on location of the murmur and the patient's chief presenting problem.) The 02 saturation on the right side of the heart would be expected to be g=higher than normal f arterial blood from the left ventricle is shunting into the right ventricle The patient with a temporary transvenous pacemaker develops pacemaker malfunction. The orientee is instructed to reposition the patient to try to correct the problem. The cardiac monitor most likely demonstrates: a) Periods of asystole without pacemaker activity b) Runs of ventricular tachycardia c) Pacemaker spikes without a QRS

d) Pacemaker spikes on the T-wave of the patient's own beats answer ✓✓ Answer: C

Failure to capture (spikes present without QRS) may be corrected by repositioning the patient to the side. The remaining problems would not be helped by repositioning the patient. The patient with acute ST-elevation myocardial infarction received fibrinolytic therapy. Which of the following is a sign of successful coronary artery reperfusion? a) Increased blood pressure b) Return of ST segment to baseline c) resolution of S4 heart sound

d) improved oxygenation answer ✓✓ Answer: B

Since ST segment elevation is a result of myocardial infarction (MI) secondary to a lack of perfusion, then return of the ST segment to baseline is a sign of return of perfusion. The remaining choices are not a direct result of MI. The patient with aortic regurgitation will have which of the following on auscultation? a) Diastolic murmur, loudest at the 5th intercostal space, midclavicular b) Systolic murmur, loudest at the apex of the heart c) Diastolic murmur, loudest at the second intercostal space, right sternal border

d) Systolic murmur, loudest at the base of the heart answer ✓✓ Answer: C

Aortic insufficiency (regurgitation) is backflow of blood during the time the aortic valve should be closed. When is the aortic valve closed? During diastole — therefore it is a diastolic murmur. The aortic area of auscultation is at the base of the heart, second intercostal space, right sternal border. The patient with diastolic heart failure develops supraventricular tachycardia, heart rate 220/min. The most dangerous hemodynamic effect is a decrease in: a) Myocardial contractility b) Coronary artery perfusion c) ejection fraction

d) Arterial oxygenation answer ✓✓ Answer: B

Diastolic heart failure results in a problem with left ventricular FILLING secondary to ventricular thickening, and contractility and ejection are maintained in diastolic failure. The rapid heart rate will decrease filling time, worsen left ventricular filling and because coronary artery perfusion occurs during diastole, this arrhythmia may be life-threatening. The patient with ST elevation in II, III, aVF is most likely to develop a ______ heart block, whereas the patient with ST elevation in V1, V2, and V3 is most likely to develop a ______ heart block. a) Second-degree heart block Type 2, sinus exit block b) Second-degree heart block Type 2, third degree heart block c) Third-degree heart block, second degree heart block Type 2

d) Second-degree heart block Type 2, sinus arrest answer ✓✓ Answer: C

ST elevation of II, III, aVF is generally secondary to right coronary artery occlusion (inferior wall MI), and in most of the population the RCA supplies the AV node, which would result in complete heart block. ST elevation in V1 through V3 is indicative of left anterior descending artery occlusion, which supplies the main bundle of HIS in most of the population, and which would result in a second-degree heart block Type II. The patient with which of the following signs most likely requires an emergent pericardiocentesis? a) Hypotension, distended neck veins, and pulsus paradoxus b) Hypertension, flat neck veins, pulsus alternans

c) Acute systolic murmur, enlarged ventricular septum, hyperventilation

d) elevated left heart pressures, S3 heart sounds, lung crackles answer ✓✓ Answer: A

Cardiac tamponade requires emergent pericardiocentesis. Fluid in the pericardial space prevents venous return up into the right atrium, leading to hypotension and distended neck veins. Inspiration decreases venous return to an even greater extent, which results in pulsus paradoxus. Unlike the patient with systolic dysfunction, the patient with diastolic heart failure may benefit from: a) Digoxin b) Calcium-channel blocker c) ACE Inhibitor

d) Dobutamine answer ✓✓ Answer B

Calcium channel blockers help to decrease pressure/stiffness and help LV filling in the presence of diastolic heart failure. Calcium-channel blockers are not helpful for systolic dysfunction. Digoxin and dobutamine are positive inotropic drugs. They will increase LV wall tension and may exacerbate symptoms. ACE inhibitors are not harmful to the patient with diastolic heart failure, but they are not a first-line agent for diastolic failure. Ventricular septal defect is most likely to have which of the following clinical findings? a) diastolic murmur at the apex of the heart b) systolic murmur at the fifth intercostal space, midclavicular c) Diastolic murmur at the base of the heart

d) Systolic murmur at the fifth intercostal space, left sternal border answer ✓✓ Answer: D

The murmur caused by a ventricular septal defect occurs during left ventricular ejection (systole) and is best heard at the left sternal border, fifth intercostal space. When there is a drop in cardiac output, which of the following is a normal compensatory response? a) Increased oxygen extraction b) Deceased oxygen consumption c) Decreased heart rate

d) Increased oxygen delivery answer ✓✓ Answer A

Oxygen utilization is about 300 mL/min, where as oxygen delivery is 1,000 mL/min. If the CO decreases, myocardial extraction will increase. The heart rate will alos increase. A drop in oxygen consumption and a decrease in heart rate do not occur with a drop in CO. If the CO drops, oxygen delivery will decrease, not increase. Which clinical sign might patients with both systolic and diastolic heart failure have in common? a) Peripheral edema b) Enlarged heart size on chest radiograph c) Lung crackles

d) Ejection fraction less than 40% answer ✓✓ Answer: C

Both a problem with ejection (systolic failure) and a problem with filling (diastolic failure) will increase left heart pressure and cause cardiogenic pulmonary edema (lung crackles). The remaining three choices are associated with systolic heart failure rather than diastolic heart failure. Which of the following clinical findings is indicative of hypertensive crisis? a) BP 222/ b) BP 218/128 and mental status change c) BP 220/130 and anxiety

d) BP 230/124 and fatigue answer ✓✓ Answer: B

End organ damage is present with hypertensive crisis. Mental status change is a sign of end organ (brain) involvement. (Stroke is a major concern in the setting of hypertensive crisis.) Headache, anxiety and fatigue are not evidence of organ involvement. Which of the following clinical signs is most specific for cardiogenic pulmonary edema? a) S3 heart sound b) Lung crackles c) Respiratory rate 32

d) Hypoxemia answer ✓✓ Answer: A

An S3 heart sound is due to increase in left ventricular pressure, which is the cause of cardiogenic pulmonary edema. The other signs may be present in non-cardiogenic pulmonary edema (ARDS). Which of the following findings would be expected on chest auscultation of the patient with systolic heart failure? a) S4 at the apex of the heart b) A systolic murmur at the apex of the heart c) A diastolic murmur at the left sternal border

d) S3 at the apex of the heart answer ✓✓ Answer D

An S3 heart sound at the apex is thought to be due to high pressure within the LV presents in heart failure. S4 is usually due to hypertension or acute MI. A systolic murmur at the apex is usually due to mitral valve regurgitation. A diastolic murmur at the left sternal border is usually due to tricuspid valve disease Which of the following is a clinical sign of right heart failure? a) peripheral edema b) hypoxemia c) mitral regurgitation

d) Flat neck veins answer ✓✓ Answer: A

Peripheral edema is the result of prolonged high right-sided heart pressures with a resultant displacement of fluid from capillaries into the interstitial space. Hypoxemia and mitral regurgitation are due to left heart problems, and right heart failure results in distended neck veins, not flat neck veins. Which of the following is associated with mitral regurgitation? a) Systolic murmur, sinus bradycardia b) Diastolic murmur, heart failure c) Systolic murmur, inferior wall myocardial infarction

d) Diastolic murmur, complete heart block answer ✓✓ Answer: C

Inferior wall MI may result in ischemia and dysfunction (regurgitation) of the mitral valve. The mitral valve is closed during systole (left ventricular ejection). A murmur is produced when the mitral valve is not fully closed during systole Which of the following is indicated to maintain patency of a coronary artery stent? a) Nitrates b) Metoproplol (Lopressor) c) Aspirin

d) clopidogrel (Plavix) answer ✓✓ Answer: D

The patient requires anti-platelet therapy post-procedure (and for some patients up to one year) to prevent thrombus formation at the site of a stent. While the patient may require the remaining three choices, they are prescribed for other reasons. Which of the following may be a result of pulmonary hypertension? a) Pulmonic stenosis b) Left ventricular failure c) Tricuspid regurgitation

d) Increased lung compliance answer ✓✓ Answer C

The pulmonary pressure get increasingly high with pulmonary hypertension, which causes right ventricular strain and dilation, which in turn may result in an inability of the tricuspid valve to close fully. Pulmonary hypertension does not cause pulmonic stenosis, left ventricular failure, or increased lung compliance. Right ventricular failure and decreased lung compliance are more likely. Which of the following patients is most likely to experience a heart block? a) Cardiac transplant b) CABG c) Mitral valve repair

d) Ventricular septal defect repair answer ✓✓ The answer: C

The aortic, tricuspid, and mitral valves are anatomically located near conduction pathways. Therefore, the patient who has undergone mitral valve repair may develop heart block post procedure, which is thought to be due to a local effect on conduction pathways Which of the following therapies will decrease preload and decrease myocardial oxygen demand? a) Nitrate b) Cardiac glycoside c) Positive inotrope

d) diuretic answer ✓✓ Answer: A

Due to venodilation and some arterial dilation (at high doses), nitrates decrease preload and thereby decrease myocardial oxygen demand. Clinical effects may include a decrease in blood pressure and relief of chest pain. While getting a 71-year old male patient's history, the patient tells the nurse that he has mitral stenosis. The nurse would anticipate which of the following findings? a) Systolic murmur, sinus bradycardia b) Systolic murmur, atrial fibrillation c) Diastolic murmur, atrial fibrillation

d) Diastolic murmur, sinus bradycardia answer ✓✓ Answer C

Murmurs of stenosis occur when the valve is open, and the mitral valve is open during the filling phase of the heart cycle. Chronic resistance produced by stenosis of the mitral valve will result in an enlarged left atrium, which in turn may lead to atrial fibrillation, not sinus bradycardia. During systole, the mitral valve is closed. Therefore, mitral regurgitation would cause a systolic murmur.