CCRN Practice Questions and Rationales: Critical Care Nursing, Exams of Nursing

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CCRN Practice Questions, Answers and

Rationales.

A 52-year-old accountant is admitted to the critical care unit with frank gastrointestinal bleeding for more than 18 hours. He has had a blood loss of more than 1000 mL. Which of the following sets of vital signs would be consistent with the patient's blood loss? A. Blood pressure (BP) 100/84 mm Hg, heart rate 124 beats/min B. BP 86/40 mm Hg, heart rate 92 beats/min C. BP 124/66 mm Hg, heart rate 124 beats/min D. BP 112/60 mm Hg, heart rate 92 beats/min - Correct answer A! With a loss of 750 to 1500 mL of blood, an increase in heart rate greater than 100 beats/min and a narrowing of the pulse pressure is expected. These changes are due to sympathetic nervous system innervation. Option a shows a narrow pulse pressure and tachycardia. Which is the most critical concern during the acute phase of care for a patient with an intestinal obstruction? A. Aspiration B. Hyperkalemia C. Hypovolemia D.

Metabolic alkalosis - Correct answer C - hypovolemia In intestinal obstruction, hypovolemia is the result of vomiting and sequestration of fluids in the lumen of the intestine. Intravascular volume decreases which can cause hypovolemic shock. Aspiration is a potential risk if the patient is vomiting. Hypokalemia and metabolic acidosis occur as a result of trapping of fluid within the lumen of the intestine. A patient is brought to the hospital after inadvertent consumption of shellfish. He says he knew he was allergic to shellfish but did not know that the casserole that he was eating had shellfish in it. His face is edematous and his tongue is swollen. His voice is hoarse and he has inspiratory stridor. His medical history includes a myocardial infarction last year, and he has been taking metoprolol (Lopressor) since that time. Symptoms of anaphylaxis would have occurred how long after exposure to the antigen? A. 5 to 20 minutes B. 20 to 60 minutes C. 48 hours D. 3 days - Correct answer A Symptoms of anaphylaxis occur within 5 to 20 minutes. These immediate hypersensitivity reactions are life threatening. Later reactions, including cytotoxic hypersensitivity, cause urticaria but rarely are life threatening. Which of the following would not occur during a stressful situation? A. Hypersalivation B. Hyperventilation

C.

Increased muscle tension D. Palpitations - Correct answer A Oral and gastrointestinal secretions are reduced with sympathetic nervous system stimulation. A patient arrives with multisystem trauma after falling out of a second-floor window. She is lethargic and has peripheral cyanosis. Her vital signs are blood pressure 80/60 mm Hg, heart rate 145 beats/min, and respiratory rate 40 breaths/min. Which class of hemorrhagic shock is she in? A. I B. II C. III D. IV - Correct answer D. IV She is hypotensive with a narrowed pulse pressure, significantly tachycardic and tachypneic, and cyanotic. This clinical presentation is consistent with Class IV hemorrhagic shock and a loss of more than 40% of blood volume, or greater than 2000 mL. A patient arrives in the emergency department at 10:30 am with severe chest pain. He has ST segment elevation in leads V3 to V6. He has been given morphine for pain and is being evaluated for fibrinolytic therapy. The family arrives in the waiting room. Which of the following would be the best action? A.

Ask the unit secretary to tell the family that the patient has had a cardiac arrest and that the nursing staff will talk to the family as soon as possible. B. Ask the unit secretary to take family members to a private area and tell them that the physician will be there to talk to them soon. C. Take the family to a private area yourself and briefly explain what has happened. D. Take family members to a private area yourself and tell them that the physician will be there to talk to them soon. - Correct answer C Family members need privacy as they begin to deal with this crisis. They should be briefly told what has happened as soon as possible, and then the physician can talk to them as soon as he or she is available. A nurse is asked to lead a project team to develop a new protocol for suctioning endotracheal tubes. The nurse conducts a literature search for clinical practice guidelines that have been developed already and revises the protocol for the hospital according to the recommendations of the clinical practice guidelines and the findings from research that has been conducted since the development of the clinical practice guidelines. A clinical practice guideline is an example of: A. discovery of knowledge. B. summary of evidence. C. translation of evidence. D. implementation of evidence. - Correct answer C

Using the ACE Star Model, original research is an example of discovery of knowledge. Systematic review of the research related to a specific clinical question is an example of summary of the evidence. A clinical practice guideline is an example of translation of evidence. A pilot test would be an example of implementation of evidence. Which of the following is the underlying cause of multiple organ dysfunction syndrome (MODS) in the majority of cases? A. Anergy B. Sepsis C. Multisystem trauma D. Major surgery - Correct answer B Sepsis is the underlying cause of MODS in about 90% of cases A 23-year-old woman is beginning her second hemodialysis treatment for acute kidney injury. Suddenly she complains of headache and nausea. She is agitated and confused, and you notice twitching in her right hand. Which of the following is causing these findings? A. Uremia B. Dialysis disequilibrium syndrome C. Intracerebral hemorrhage D. Fluid overload - Correct answer B

Dialysis disequilibrium syndrome occurs when urea is removed from the blood at a rate faster than it is removed from the brain tissue. The greater amount of urea in the brain causes a fluid shift resulting in cerebral edema. A 45-year-old man is admitted with acute epigastric pain that radiates to his back. He says that he has been vomiting continuously for 12 hours and that the pain has been worsening. His social history includes the information that he drinks about two six-packs of beer each night. He has dry, cracked lips and poor skin turgor. His abdomen is distended and tender. He is restless and agitated. Vital signs are blood pressure of 90/60 mm Hg, heart rate of 135 beats/min, and respiratory rate of 28 breaths/min. Acute pancreatitis is suspected. Which of the following diagnostic study results are consistent with a diagnosis of acute pancreatitis? A. Elevated serum amylase, elevated serum lipase, decreased serum albumin B. Decreased serum amylase, decreased serum lipase, elevated serum calcium C. Elevated serum bilirubin, decreased serum albumin, elevated serum calcium D. Elevated serum amylase, elevated serum lipase, - Correct answer A Acute pancreatitis causes elevations in serum amylase, serum lipase, and possibly bilirubin, whereas calcium and albumin are decreased. A 67-year-old man is in the critical care unit after repair of an abdominal aortic aneurysm. His nasogastric tube has been removed, and he is eating a soft diet. He is now 4 days postoperative and is complaining of excruciating abdominal pain. After a meal he urgently asks for the bedpan and has a large, dark reddish stool. The most likely cause of these recent events is:

A.

stress ulcer. B. mesenteric infarction. C. hemorrhoids. D. bowel perforation. - Correct answer B Mesenteric ischemia and infarction are not uncommon after abdominal aortic aneurysm repair. They may be due to embolization or cross-clamping of the aorta above the mesenteric arteries. The primary clinical indications of mesenteric ischemia are abdominal pain and bloody diarrhea (i.e., currant-jelly diarrhea). Stress ulcer most likely would be located in the stomach or duodenum, and the stool would appear black. Hemorrhoids cause stool to be streaked with blood and/or toilet paper to be bloody. Bowel perforation causes the signs/symptoms of an acute abdomen: abdominal distention; rigid, boardlike abdomen; decreased bowel sounds; and rebound tenderness. A 16-year-old girl with a history of type 1 diabetes mellitus (DM) is admitted to the critical care unit. Her friend states that she has had a cold for the last few days. She is now lethargic. Diabetic ketoacidosis causes dehydration by: A. ketones causing diarrhea. B. ketones causing Kussmaul's respirations. C. glucose causing a diffusion diuresis. D. glucose causing an osmotic diuresis. - Correct answer D

Remember that osmolality and osmotic pull are increased by the addition of solutes such as sodium or glucose. The high serum glucose in diabetic ketoacidosis causes an increase in osmotic pull in the renal tubules and an osmotic diuresis. Pigment-related acute tubular necrosis (ATN) occurs primarily in patients with which of the following A. Abdominal trauma B. Knife wounds C. Crush injuries D. Thoracic trauma - Correct answer C Crush injuries cause muscle destruction and rhabdomyolysis, which liberates myoglobin into the blood. This heavy pigment potentially causes tubular occlusion and ATN. Myoglobinuria also may occur in electrical burns, status epilepticus, muscle ischemia, and statins. A 22-year-old man is admitted with spontaneous pneumothorax. He is extremely dyspneic and anxious. He also is complaining of tingling around his mouth and his fingertips and feeling light-headed. Blood pressure is 120/82 mm Hg, heart rate is 110 beats/min, respiratory rate is 36 breaths/min and deep, and temperature is 37° C (98.6° F). Which of the following would not be an appropriate method to treat this patient's anxiety and dyspnea and decrease his respiratory rate? A. Administer analgesics and anxiolytics. B. Reassure him in a calm, confident manner. C.

Tell him to relax. D. Elevate the head of the bed 45 degrees. - Correct answer C Though this is often heard, telling the patient to relax does not help him relax. Elevating the head of the bed, treating his pain, and reassuring him are appropriate. Clinical findings in neurogenic shock are related to which of the following? A. Loss of sympathetic nervous system innervation B. Parasympathetic nervous system stimulation C. Injury to the hypothalamus D. Focal injury to cerebral hemispheres - Correct answer A Think of neurogenic shock as no alpha and no beta caused loss of sympathetic nervous system innervation. Lack of alpha causes loss of vascular tone and a decrease in systemic vascular resistance. Lack of beta causes decrease in heart rate, contractility, and conductivity. A patient received Humulin NPH insulin at 7 am. He was nauseated and vomiting at lunchtime and did not eat. If this patient develops manifestations of hypoglycemia, treatment would include: A. 25 mL of 50% dextrose in water (D50W). B. glucagon intramuscularly. C. 4 oz of apple juice.

D.

100 mL of 5% dextrose in water (D5W). - Correct answer A The treatment for mild hypoglycemia is 10 to 15 g of carbohydrates. This normally is administered as 4 oz of orange juice if the patient can drink (unless the patient has renal failure when lower potassium, lower water options are better). This patient has not been able to take anything by mouth all day. Glucagon is a hormone that mobilizes glucose from glucose stores but takes longer than directly giving glucose. D5W has 5 g of dextrose per 100 mL, which would provide only 20 calories. D50W has 50 g of dextrose per 100 mL. A volume of 25 mL of D50W would provide 12.5 g of carbohydrate and 50 calories. An African-American patient with hypertension would not be likely to be receiving which of the following drugs? A. Labetalol (Normodyne) B. Valsartan (Diovan) C. Captopril (Capoten) D. Diltiazem (Cardizem) - Correct answer C African-Americans do not respond well to angiotensin-converting enzyme inhibitors (e.g., captopril [Capoten]), but they do respond well to an angiotensin II blocker (valsartan [Diovan]). Of the beta-blockers, labetalol works best. Of the calcium channel blockers, diltiazem works best. Variation in response to drugs because of a patient's age, gender, size, body composition, and ethnicity is called drug polymorphism. A 45-year-old man is admitted with acute epigastric pain that radiates to his back. He says that he has been vomiting continuously for 12 hours and that the pain has been worsening. His social history includes the information that he drinks about two six-packs of beer each night. He has dry, cracked

lips and poor skin turgor. His abdomen is distended and tender. He is restless and agitated. Vital signs are blood pressure of 90/60 mm Hg, heart rate of 135 beats/min, and respiratory rate of 28 breaths/min. Which of the following is the priority of care for this patient? A. Replacement of fluids and electrolytes B. Administration of antibiotics C. Exploratory laparotomy D. Insertion of nasogastric tube - Correct answer A In reviewing this patient's assessment, it is evident that he is hypovolemic (cracked lips, poor skin turgor, hypotension, tachycardia, restlessness). Administration of intravenous fluids prevents hypovolemic shock. The loss of fluids and electrolytes (i.e., sodium, potassium, and calcium) is severe and life threatening. Which of the following is the preferred screening study for patients with abdominal trauma? A. Computed tomography B. Diagnostic peritoneal lavage (DPL) C. Focused abdominal sonography for trauma (FAST) D. Physical assessment of the abdomen - Correct answer C FAST can accurately predict the need for laparotomy in trauma patients and has very good sensitivity and excellent specificity.

What are the most commonly prescribed anxiolytics used in the critical care setting? A. Benzodiazepines B. Opioids C. Barbiturates D. Phenothiazines - Correct answer A Benzodiazepines cause sedation and some degree of amnesia. They are less likely than the other agents listed to cause significant side effects. Which of the following descriptions about intracranial pressure (ICP) monitoring systems is incorrect? A. Intermittent flush devices are not used. B. Heparin is not added to the solution used to prime the tubing. C. Only preservative-free saline is used to prime the tubing. D. The transducer is leveled to the phlebostatic axis. - Correct answer D Intermittent flush devices ensure a continuous flush of ~5 mL/hr. This is undesirable in monitoring intracranial pressure because even small volumes may cause significant increases in intracranial pressure in some patients. Heparin is not added because it may cause intracranial hemorrhage, and cerebrospinal fluid does not clot. Only preservative-free

saline is used to prime the tubing due to the potential of meningeal irritation from preservatives. The transducer is leveled to the foramen of Monro rather than the phlebostatic axis. Externally the tragus of the ear is used as the reference point. If a nurse were to leave her unit and the hospital after deciding that staffing was inadequate, which ethical principle would be violated? A. Fidelity B. Beneficence C. Justice D. Veracity - Correct answer A Fidelity refers to an individual's faithfulness or loyalty to agreements and responsibilities that the individual has accepted. If you have agreed to work a shift and you do not arrive to work or you leave work before the end of your shift, you have violated the ethical principle of fidelity. Which of the following arterial blood gas findings supports the diagnosis of pulmonary embolism? A. Low pH B. Hypercapnia C. Hypoxemia D. Elevated base excess - Correct answer C

A pulmonary embolism causes hypoxemia because there is a perfusion, and therefore diffusion, problem. Remember that diffusion problems affect PaO2 but not PaCO2 because carbon dioxide is 20 times more diffusible that oxygen, so eliminate option b. Patients with a pulmonary embolism hyperventilate and, therefore, arterial blood gases show a respiratory alkalosis, so eliminate option a. An elevated base excess would indicate a metabolic alkalosis, so eliminate option d. A patient has had an inferior myocardial infarction. He now has a new holosystolic murmur at apex, acute severe dyspnea, decreased cardiac index, and a normal cardiac silhouette on x-ray film. Which of the following complications most likely is occurring in this patient? A. Acute mitral regurgitation B. Rupture of left ventricular free wall C. Ventricular septal rupture D. Acute aortic stenosis - Correct answer A With an inferior myocardial infarction, the risk of the papillary muscles being affected is greater than in other types of myocardial infarction. The papillary muscles of the left ventricle maintain normal mitral valve function. If damaged, acute mitral regurgitation occurs and is manifested by a new holosystolic murmur at the apex, acute pulmonary edema, and decreased cardiac output/index. A patient has a history of mania and is on anticonvulsant medication. How do these drugs help with this disorder? A. Cause slight sedation B. Prevent seizures

C.

Reduce neuropathic pain D. Regulate mood - Correct answer D Anticonvulsants are used to improve mood stability in patients with mania or bipolar disorder. Which of the following drugs stabilizes epithelial mast cells, thereby reducing the release of histamine? A. Triamcinolone (Azmacort) B. Ipratropium bromide (Atrovent) C. Cromolyn sodium (Intal) D. Metaproterenol (Alupent) - Correct answer C Cromolyn is given by inhalation and prevents the degranulation of the mast cells with release of histamine. Cromolyn is a prophylactic agent. It has no effect in an acute asthmatic attack. Which of the following types of drugs can cause hypotension, hyperkalemia, angioedema, proteinuria, and cough? A. Beta-blockers B. Loop diuretics C. Calcium channel blockers

D.

Angiotensin-converting enzyme (ACE) inhibitors - Correct answer D These are adverse effects of ACE inhibitors, such as captopril (Capoten) and enalapril (Vasotec). A new nurse manager of the surgical intensive care unit would like to have more input from the entire multidisciplinary team in the care of the patients. She would like to incorporate multidisciplinary rounds and family conferences as part of the daily unit activities and also would like to initiate weekly conferences to discuss all of the patients' current issues and progress. The plan is that the nurse manager would initially facilitate these conferences, but then the charge nurses would take over. Which of the following would be the best way to educate every staff member about the new processes to be implemented on the unit? A. Give each day-shift charge nurse a list of nurses to educate about the new process, focusing on the day-shift employees because that is when the conferences will be held. B. Hold a series of mandatory in-service workshops educating the staff about the new procedures. C. Provide the - Correct answer D Because the goal of the new processes is to facilitate a more multidisciplinary approach overall, it is important to focus on employees on all shifts, not just day shift. Mandatory in-service meetings and email notifications are insufficient methods of educating about changes in unit philosophy. While auscultating the patient's heart, an S3 is noted. What does this heart sound indicate? A.

Atrial contraction and propulsion of blood into a noncompliant ventricle B. Inflammation of the pericardium C. Opening of a defective semilunar valve D. Rapid ventricular filling into an already distended ventricle - Correct answer D An S3 is an indication of heart failure. S3 occurs early in diastole (the rapid filling phase) when the ventricle is already distended. Option a describes the cause of an S4. Option b describes the cause of a pericardial friction rub. Option c describes the cause of an opening snap. A patient with acute kidney injury has the following arterial blood gas results: pH 7. Paco2 35 mm Hg HCO3 18 mEq/L This acid/base imbalance is the result of the inability of the kidney to: A. excrete acid by-products of metabolism. B. excrete carbon dioxide. C. excrete bicarbonate ions. D. excrete calcium ions. - Correct answer A The patient has a metabolic acidosis because the kidneys are unable to excrete the acid by-products of cellular metabolism.

Which of the following is the wave on the electrocardiogram seen in Wolff- Parkinson-White syndrome that widens the QRS complex? A. P wave B. Agonal wave C. Delta wave D. Gamma wave - Correct answer C The slurring at the beginning of the QRS complex that represents the preexcitation is a delta wave. Which of the following would not be associated with a false-positive result for an acute myocardial infarction using the total creatine kinase (CK)? A. Hypothyroidism B. Hemorrhagic stroke C. Cardioversion D. Ulcerative colitis - Correct answer D CK may be elevated by chronic alcoholism, cardioversion, strokes, hypothyroidism, intramuscular injections, skeletal muscle injury, and trauma.

Which of the following would cause an increase in the amplitude of the v wave with a normal amplitude a wave on the pulmonary artery occlusive pressure (PAOP) waveform? A. Mitral stenosis B. Mitral regurgitation C. Cardiac tamponade D. Left ventricular failure - Correct answer B Mitral stenosis causes large a waves on the PAOP waveform. Cardiac tamponade and left ventricular failure cause high pressures and large a and v waves. Mitral regurgitation causes large v waves, so choose option b. The other pathologic condition that causes large v waves is ventricular septal rupture. patient has just returned to the critical care unit from the operating room. He has a VDD pacemaker. Which of the following is an accurate description of this type of pacemaker? A. The atrium and ventricle are paced and sensed, atrial pacing can be inhibited by an intrinsic atrial impulse, and ventricular pacing can be triggered by an intrinsic atrial impulse or inhibited by an intrinsic ventricular impulse. B. The ventricle is paced in response to a sensed intrinsic atrial impulse. C. The atrium and ventricle are paced, but only ventricular pacing can be inhibited by a sensed intrinsic ventricular impulse.

D.

The ventricle is paced in response to a sensed intrinsic atrial impulse or inhibited by a sensed intrinsic ventricular impulse. - Correct answer D The first letter indicates which chamber is being paced, the second letter indicates which chamber is being sensed, and the third letter indicates the mode of response to the sensed event. Option a describes a DDD pacemaker, option b describes a VAT pacemaker, option c describes a DVI pacemaker, and option d describes a VDD pacemaker. A 65-year-old man was admitted 2 hours ago after coronary artery bypass grafting. He has had the following vital sign changes: Admission 2 Hours Later Blood pressure (mm Hg) 110/80 96/ Heart rate (per minute) 85 100 Right atrial pressure (RAP; mm Hg) 6 2 Pulmonary artery pressure (PAP; mm Hg) 24/12 18/ Pulmonary artery occlusive pressure (PAOP; mm Hg) 10 5 Cardiac output (L/min) 6 4 Cardiac index (L/min/m2) 3.5 2. Systemic vascular resistance index (SVRI; dynes/sec/cm−5) 1920 2590 What is the most likely cause of these changes? A. Stunned myocardium B. Blood loss C. Cardiac tamponade D. Intraoperative myocardial infarction - Correct answer B Note that all of the volume indicators (RAP, PAP, PAOP) have decreased. The increase in SVRI is compensatory and is caused by sympathetic

nervous system stimulation. Stunned myocardium and intraoperative myocardial infarction more likely would cause an increase in PAOP because of heart failure. Cardiac tamponade would cause an increase in RAP, PAP, and PAOP. This is classic hypovolemic shock in the compensatory stage. What are the typical steps in corrective discipline, in order? A. Counseling, written warning, suspension, termination B. Verbal warning, written warning, counseling, suspension, termination C. Counseling, verbal warning, written warning, suspension, termination D. Verbal warning, written warning, suspension, termination - Correct answer C Counseling is informal and first. Verbal warning is followed by written warning, if necessary. Suspension for a specified number of days occurs if the problem persists. Termination is, of course, the final step. Which of the following is the most common reason that organs of medically suitable potential donors are not recovered for donation? A. Staff not approaching the family B. Family refusal C. Recipient not available D.

Inability to contact the organ transplant coordinator - Correct answer B Family refusal accounts for approximately 35% of loss of potential donation. Which of the following diagnostic tests would be most definitive in identifying aortic rupture? A. Electrocardiogram B. Echocardiogram C. Thoracic aortogram D. Transesophageal echocardiogram - Correct answer C A thoracic aortogram would show leakage of dye with aortic rupture Which of the following statements is true regarding a patient who comes to the emergency department with chest pain and has a negative myoglobin level 3 hours after the onset of chest pain? A. Myocardial infarction (MI) cannot be ruled out. B. MI can be ruled out. C. The myoglobin level test should be repeated in 4 hours. D. A troponin level is necessary to rule out MI. - Correct answer B

Myoglobin elevates early in MI (within 3 hours) and has a very high sensitivity, so a negative myoglobin 3 hours after the onset of chest pain rules out MI. If a patient is breathing room air and his PaCO2 level is elevated, must his PaO2 be reduced? A. Yes, because of Fick's law of diffusion B. Yes, because of Dalton's law of partial pressures C. No, because of the driving pressure of oxygen D. No, because PaCO2 is a reflection of ventilation, not oxygenation - Correct answer B If the patient is breathing room air and the PaCO2 is elevated, the PaO2 must be reduced because of Dalton's law, which basically says that all the partial pressures cannot add up to more than atmospheric pressure. So if we have only 760 mm Hg maximum, and PaCO2 takes more than its fair share, there is less "room" for oxygen, and the PaO2 will be decreased. Fick's law of diffusion says that the rate of transfer of a gas through a sheet of tissue is proportional to the tissue area, so it is not pertinent to this situation. The driving pressure is the concentration of the gas times the pressure of the gas, so the driving pressure of oxygen is not affected by PaCO2. PaCO2 is a reflection of ventilation, but impaired ventilation and an increase in PaCO2 can limit how high the PaO2 can be because of Dalton's law. However, if the patient is breathing supplemental oxygen, he can have an elevated PaCO2 and a normal PaO2. This is why pulse oximetry does not tell you that your patient is ventilating adequately. He can have a normal pulse oximetry but be significantly hypercapnic if he is breathing supplemental oxygen because the driving pressure of oxygen is increased by increasing the concentration of oxygen. On a pulmonary artery waveform, the dicrotic notch represents closure of which valve?

A.

Aortic valve B. Pulmonic valve C. Tricuspid valve D. Mitral valve - Correct answer B In a pulmonary artery waveform the three components of the waveform are systole, dicrotic notch, and diastole. Systole is the pressure generated by the right ventricle so that the pulmonic valve will be pushed open, the dicrotic notch is caused by the closure of the pulmonic valve, and diastole is the pressure in the pulmonary artery during ventricular diastole. The diastolic pressure is a reflection of the vascular tone in the pulmonary vascular bed. If the vessels are constricted or if there is back pressure from the left side of the heart, the diastolic pressure will be high. Which of the following is associated with chest pain, confusion, and petechiae? A. Dissecting aneurysm B. Fat embolism C. Pneumothorax D. Myocardial infarction - Correct answer B Chest pain, confusion, and petechiae are suggestive of a fat embolism, especially within the first 48 to 72 hours after a long-bone fracture.

Which of the following may occur with angina? A. Transient diastolic murmur B. S4 C. Paradoxical split of S2 D. Midsystolic click - Correct answer B Angina is associated with myocardial ischemia. Myocardial ischemia causes noncompliance of the ventricular wall and the presence of an S4. A transient systolic murmur also may be heard, associated with papillary muscle ischemia and dysfunction. A midsystolic click is associated with mitral valve prolapse. Paradoxical split of S2 is associated with left bundle branch block, right ventricular premature ventricular contraction, transvenous endocardial pacemaker, or valvular problem. Associate an S4 with noncompliance caused by ischemia, infarction, or hypertrophy. Choose option b. A 46-year-old woman is admitted to the critical care unit with acute respiratory failure as a result of pneumonia. Vital Signs Blood pressure 140/88 mm Hg Heart rate 108 beats/min Respiratory rate 26 breaths/min Temperature 39.8° C (103.8° F) Arterial Blood Gases pH 7.29 PaCO2 54 mm Hg