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CEN Cardiovascular
Emergencies – actual
solution
Preload refers to: a. The volume of blood entering the left side of the heart b. The volume of blood entering the right side of the heart c. The pressure in the venous system that the heart must overcome to pump the blood d. The pressure in the arterial system that the heart must overcome to pump the blood - ANS-b. Preload is the volume of blood that enters the right side of the heart. This volume stretches the fibers in the heart prior to contraction. Preload is commonly measured as atrial pressure. When suctioning during a cardiac arrest, suctioning should be limited to which of the following? a. Less than 5 seconds
b. Less than 10 seconds c. Less than 20 seconds d. Less than 30 seconds - ANS-B. According to the 2010 BLS and ACLS guidelines, suctioning for longer than 10 seconds may result in pulling too much oxygen out of the airways resulting in hypoxemia. You are caring for a 65 year old who collapsed outside of the hospital and was brought in to the emergency department. During CPR, quantitative waveform capnography shows a PETCO2 level < 10 mm HG. Which of the following is the correct response to this finding? a. Do nothing; this is normal. b. Increase the amount of oxygen being delivered. c. Attempt to improve the quality of CPR. d. Decrease the amount of oxygen being delivered. - ANS- C. Quantitative waveform capnography provides a good indication of the quality of CPR. Levels < 10 mm HG indicate either a problem with the quality of CPR or with the placement of the ETT. EtCO2 levels of ≤10 mmHg predicted death in adult patients with cardiac arrest. Measurement of EtCO2 varies directly with the cardiac output produced by chest compression. Goal is 35- 45mmg HG or 5-6% CO2. You are caring for an 85 year old and are having trouble establishing an intravenous line. The ED physician asks for an intraosseous needle to establish an IO line for
oxygen is needed, what is the correct sequence for these frontline drugs? a. Oxygen, Aspirin, Nitroglycerin, Morphine b. Aspirin, Oxygen, Nitroglycerin, Morphine c. Nitroglycerin, Oxygen, Aspirin, Morphine d. Aspirin, Oxygen, Morphine, Nitroglycerin - ANS-A. Oxygen should be the first drug given for the patient with ACS. Aspirin is the front line drug for dissolving clots associated with ACS. Nitroglycerine is typically readily available and should be administered third. Finally, for continued pain, morphine may be necessary. During the initial assessment phase, the following steps should be accomplished for any patient at significant risk for ACS: •Airway, breathing, and circulation assessed •Preliminary history and examination obtained •12-lead ECG interpreted •Resuscitation equipment brought to the bedside •Cardiac monitor attached to patient •Oxygen given •IV access and blood work obtained •Aspirin 162 to 325 mg given •Nitrates and morphine given (unless contraindicated) A 75-year-old patient has the rhythm on the right. He is short of breath, lethargic and has a systolic blood
pressure of 80 mm Hg. What is the most appropriate first step in treatment for this patient? a. Obtain an EKG to determine the rhythm. b. Give Adenosine 6 mg IV rapid push. c. Perform immediate synchronized cardioversion. d. Give Amiodarone 150 mg over 10 minutes. - ANS-C. The rhythm is tachycardia and can be further classified as unstable due to the fact that the patient is short of breath and lethargic with a low blood pressure. A patient with unstable tachycardia should be immediately cardioverted in a synchronized mode. A 76-year-old man is brought in by EMS with distended neck veins, tracheal deviation and asymmetrical chest expansion. What should immediately be suspected? a. Pulmonary embolus b. Tension pneumothorax c. Second degree heart block d. Asthma - ANS-B. Tension pneumothorax occurs when a lung is fully or partially deflated. Lung deflation will change the pressures in the chest causing the trachea to deviate and the chest to expand only on the unaffected side. When performing carotid massage, all of the following are true EXCEPT:
a. Pericarditis b. Dissecting aortic aneurysm c. Angina d. Acute myocardial infarction - ANS-B. Dissecting aortic aneurysms are characterized by the sudden onset of tearing pain that may radiate into the back or abdomen. As the aneurysm dissects, peripheral pulses may disappear. In extreme cases, it may be possible to see a pulsating mass in the lower chest/upper abdomen. A dissecting aortic aneurysm is a life-threatening emergency that must be quickly recognized. Part of the diagnosis of acute myocardial injury is measurement of cardiac biomarkers. The best cardiac biomarker for cardiac injury is: a. Myoglobin since it is cardiac muscle specific and an early indicator of damage b. Troponin since it is cardiac muscle specific and an early indicator of damage c. CK-MB since it is cardiac muscle specific and an early indicator of damage d. None of the above - ANS-B. Troponin and CK-MB are both cardiac specific biomarkers. However, although CK- MB was once the standard measure of cardiac damage, Troponin I and T both elevate earlier leading to a definitive diagnosis in a timelier manner.
A 65-year-old ED patient has been diagnosed with an acute myocardial infarction. The nurse assesses the patient for possible fibrinolytic therapy. Which of the following is an absolute contraindication for fibrinolytic therapy? a. Severe hypertension b. Current use of an anticoagulant c. Active peptic ulcer d. Prior intracranial hemorrhage - ANS-D. A prior intracranial hemorrhage is an absolute contraindication to use of fibrinolytics due to the high risk of recurrent bleeding. The other options are all relative contraindications that should be documented and evaluated by the treating physician. The physician and patient will make the risk/benefit decision. Other contraindications for fibrinolytic therapy include: previous intracranial hemorrhage (ICH), ischemic stroke within three months, suspected aortic dissection, active bleeding or bleeding diathesis, or significant closed-head or facial trauma within three months. Common physiological findings with CHF include all of the following EXCEPT: a. Decreased stroke volume b. Decreased Cardiac output c. Increased venous congestion d. Decreased peripheral systemic pressure - ANS-D. In heart failure, it is typical to see venous congestion,
auscultation of a pericardial friction rub when the inflamed pericardial surface loses its lubricating fluid. You are caring for a 20-year old patient with pericarditis. What is the likely cause of pericarditis in a young patient? a. Heart failure b. Acute MI c. Hypertension d. Infectious processes - ANS-D. In younger patients, pericarditis is typically caused by an infection commonly caused by Coxsackie virus, streptococcus, staphylococcus, or Haemophilus influenzae. In older adults, the most common cause is AMI. The type of aneurysm that dilates only a portion of the artery is a ___________ aneurysm. a. fusiform b. saccular c. dissecting d. None of the above - ANS-B. In fusiform aneurysms, a segment of the artery is dilated around the entire circumference of the artery. A saccular aneurysm dilates only a portion of the artery. A dissecting aneurysm results in a tear in the artery.
Your patient has been diagnosed with a dissecting aortic aneurysm. His oxygen saturation is 95%, pulse rate is 90, and systolic blood pressure is 160 mm Hg. What is the most critical intervention for this patient? a. Prepare to give medication to lower blood pressure. b. Give morphine to control pain. c. Give bolus of fluids at 20 cc fluid/kg body weight. d. Increase oxygen to get oxygen saturation > 98%. - ANS-A. For patients with dissecting aneurysms, it is important to keep the systolic blood pressure between 100 and 120 mm Hg. Nitroprusside or a Beta Blocker are drugs commonly used to control systolic blood pressure. A 28-year old patient presents to the ED with fever, heart rate of 94, pleuritic type chest pain and an abnormal chest x-ray. As a nurse does the physical assessment, he notices old and fresh "tracks" on the patient's arms. What is the likely diagnosis? a. Acute MI b. Heart failure c. Endocarditis d. Pericarditis - ANS-C. There is a growing population of infectious endocarditis in IV drug abusers. These infections are typically caused by enterococci or Staph aureus. While most patients with endocarditis require surgical treatment, those with IV drug abuse endocarditis may respond to antibiotics.
d. Stage II hypertension - ANS-C. Normotensive is a systolic pressure less than 120. Prehypertension is a systolic pressure of 120-139. Stage I hypertension is a systolic pressure of 140-159. Stage II hypertension is a systolic pressure greater than 160. A 68-year old African American female with a history of hypertension presents to the emergency department with a systolic blood pressure of 240 mm Hg. She has a headache, photophobia, nausea and vomiting. The goal of treatment should be to: a. Maintain the systolic blood pressure at the current level. b. Decrease the systolic blood pressure to about 120 mm Hg over 1 to 2 hours. c. Decrease the systolic blood pressure to about 140 mm Hg over 1 to 2 hours. d. Decrease the systolic blood pressure to about 160 mm Hg over 1 to 2 hours. - ANS-D. The goal should be to decrease the systolic pressure to about 160 mm Hg. Lowering the pressure more than that over a short period of time may compromise cerebral blood flow. A 29-year old man is brought to the emergency department after an automobile crash. As the unrestrained driver, he has bruising over his sternum, shortness of breath, pain and anxiety. The cardiac monitor shows a sinus tachycardia. Chest x-ray reveals a
non-displaced fracture of the sternum. Treatment for this patient will include all of the following EXCEPT: a. Immediate surgery to correct the fractured sternum. b. Medication for pain relief. c. An ECG to evaluate potential cardiac injury. d. Supplemental oxygen. - ANS-A. Unless the fractured sternum is displaced and causing problems, surgical intervention is usually not required. Frequent assessments and continuous monitoring should be implemented. A 45-year old man comes to the emergency department with a complaint of chest pain after being kicked in the chest by his horse the previous night. He is diagnosed with blunt cardiac injury. The most critical intervention for this patient is to: a. Perform an echocardiogram b. Ensure continuous cardiac monitoring. c. Treat the pain with nitroglycerine. d. Collect serial cardiac enzymes. - ANS-B. Continuous cardiac monitoring is essential. An echocardiogram may help develop the extent of the cardiac injury but may be delayed. Nitroglycerine will not relieve the pain associated with a cardiac injury. Cardiac isoenzyme evaluation is not predictive of injury from blunt cardiac injury.
A 25-year-old male is brought by EMS to the emergency department. He has been shot in the chest. When he arrives, he is alert and talking. His blood pressure begins to fall and the chest tube that has been inserted drains 1600 cc of bright red blood. The cardiac monitor shows tachycardia with palpable pulses. Suddenly, the patient goes into witnessed cardiac arrest. What should the nurse do? a. Prepare the patient for a transesophageal echocardiogram. b. Perform synchronized cardioversion. c. Continue to monitor. d. Prepare the patient for a thoracotomy. - ANS-D. A patient with penetrating chest trauma who begins to drain large amounts of blood from a chest tube and then experiences cardiac arrest should be prepared for an emergency thoracotomy. It is likely that this patient has experienced a penetrating injury to his heart. While another staff member calls the operating room, you should call the ED physician and prepare for a thoracotomy to temporarily plug the hole while a surgical suite is prepared. Cardiac tamponade can be clinically assessed by the presence of: a. Hypotension, muffled heart tones, distended neck veins
b. Hypertension, muffled heart tones, distended neck veins c. Hypotension, muffled heart tones, flat neck veins d. Hypertension, muffled heart tones, flat neck veins - ANS-A. Called Beck's triad, the classic signs of cardiac tamponade include hypotension, muffled heart tones, and distended neck veins caused by compression of the heart. Secondary symptoms may include air hunger, agitation and decreased level of consciousness. The current recommendation for magnesium sulfate for a pediatric patient in cardiac arrest includes: a. Ventricular fibrillation refractory to repeated shocks b. Torsades de pointes with suspected hypomagnesemia c. Monomorphic ventricular tachycardia d. No longer recommended for pediatric cardiac arrest. - ANS-B. There is no evidence to show that magnesium sulfate is useful for any condition other than torsades de pointes or hypomagnesemia. However, magnesium sulfate continues to be a recommended course of treatment for these two conditions. Which of the following is an abnormal heart sound that may be auscultated in a patient with heart failure? a. S b. S c. S
