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PCCN questions Test
Coronary artery perfusion is dependent upon: A. diastolic pressure B. systolic pressure C. afterload D. systemic vascular resistance (SVR) - answer A. diastolic pressure Diastolic pressure in the aortic root is higher than left ventricular end-diastolic pressure (LVEDP), the pressure exerted on the ventricular muscle at the end of diastole when the ventricle is full. This enables blood to flow from a higher pressure through open arteries to a lower pressure, a pressure gradient known as coronary artery prefusion pressure. As diastolic pressure drops, there is a decrease in coronary artery blood flow. Coronary artery perfusion is not affected by systolic pressure, afterload or SVR, but they all increase the demand of oxygen in the heart. A post-STEMI (ST elevation myocardial infarction) patient is started on an angiotensin- converting enzyme (ACE) inhibitor during his hospital stay. Which of the following is the most common serious side effect that may occur? A. a nonproductive cough B. pedal edema C. swelling of the tongue and face D. rhinorrhea - answer C. swelling of the tongue and face Although all of the answers may occur, swelling og the tongue and face is the most serious and may require intervention. Patients should be instructed to seek medical attention immediately for any signs of swelling in the tongue or throat. Which of the following best describes the fourth heart sound (S4): A. It occurs after ventricular contraction B. It is best heard with the diaphragm of the stethoscope C. It is a normal finding in children D. It occurs during late diastole when the atria contracts - answer D. It occurs during late diastole when the atria contracts The presence of the extra heart sound S4 signifies a poorly compliant (stiff) left ventricle. An S4 is also called an atrial heart sound since it occurs at the end of diastolic filling when the atria contracts and fully fills the left ventricle. Known as "atrial kick", this filling is important to cardiac output. The increased end-diastolic volume in the ventricle improves cardiac output. When the left ventricle is stiff (decreased compliance with long term hypertension, aortic stenosis or with acute STEMI), the atrium has to pump harder to move blood from the atrium to the ventricle, causing a turbulent blood flow and extra heart sound. This heart sound is always pathologic. It occurs before ventricular contraction, is best heard with the bell of the stethoscope and is never a normal heart sound, even in children.
Which pathologic changes found on the 12-lead ECG indicate myocardial ischemia? A. ST-segment elevation B. ST-segment depression and T-wave elevation C. Q-wave formation D. ST-segment depression and T-wave inversion - answer D. ST segment depression and T wave inversion Myocardial ischemia changes the repolarization of the ventricular muscle. That change is seen on the 12 lead ECG as ST-segment depression and T wave inversion, which demonstrate subendocardial ischemia -- the innermost layer of muscle in the myocardium. ST-segment elevation indicates acute injury or infarction, ST segment depression and T wave elevation may indicate an electrolyte abnormality, while Q wave formation indicates total infarction. Positive inotropic agents are used to: A. improve cardiac output and tissue perfusion B. decrease water loss through the kidneys C. increase heart rate D. vasodilate vessels - answer A. improve cardiac output and tissue perfusion The term "inotropic" refers to affecting the force of myocardial contraction. Improvement of cardiac muscle contraction leads to improved cardiac output and tissue perfusion. A patient in the ED is now being admitted to telemetry bwith complaint of chest pain and has been judged to be a possible candidate for therapy with alteplase (Activase). Which of the following is not considered a contraindication for the use of this medication? A. current antibiotic use B. recent abdominal surgery C. recent gastrointestinal bleed D. recent intracranial bleed - answer A. current antibiotic use Use of antibiotics is not a contraindication for the use of alteplase. All the other answers -- recent abdominal surgery, recent gastrointestinal bleeding and a recent intracranial bleed -- are contraindications for the use of any fibrinolytic. The two major components that determine blood pressure are: A. systemic vascular resistance (SVR) (afterload) and cardiac output B. contractility and SVR (afterload) C. preload and SVR (afterload) D. contractility and SVR (afterload) - answer A. SVR (afterload) and cardiac output The equation for BP is: BP = SVR x cardiac output. BP is determined by resistance of the arterial bed and the cardiac output. If the SVR (afterload) is high and the cardiac output low, the patient may still have a normal BP. the pulse pressure will be lower, but this is a compensatory response by the heart to maintain BP. If the SVR (afterload) is low (as in early septic shock), the cardiac output is very high, thereby trying to support BP.
With increasing left ventricular pressures, blood moves back into the left atrium, then to the pulmonary veins. When the pressure in the pulmonary veins increases, capillary function decreases, and fluid then shifts to the interstitial space, causing interstitial edema, thereby, increasing the thickness of the space oxygen must travel. When left ventricular pressures increase, the fluid then shifts to the alveolar space, causing pulmonary edema. This fluid acts as a deterrent to oxygen diffusion. Retention of CO does not impair diffusion. An elevated body temperature associated with pulmonary edema is not causing a diffusion abnormality; increased temperature shifts the oxyhemoglobin curve to the right, more quickly releasing oxygen to the tissues. Low barometric pressure has no effect on diffusion of gases in the lung. A patient with an anterior-wall STEMI is in cardiogenic shock. What would be the hemodynamic profile assessment? A. decreased cardiac index, increased preload, increased afterload B. decreased cardiac index, decreased preload, increased afterload C. decreased cardiac index, decreased preload, decreased afterload D. increased cardiac index, decreased preload, decreased afterload - answer A. decreased cardiac index, increased preload, increased afterload In a patient with cardiogenic shock, both preload and afterload are increased due to severe vasoconstriction on both the venous and arterial side. Arterial vasoconstriction increases afterload and therefore lowers cardiac index. Because the ventricle is failing and contractility is also low, the left ventricular pressures increase and cause blood to increase in the pulmonary bed, resulting in increased right ventricular pressures and preload. In heart failure, there is an increase in preload and afterload with a decrease in cardiac index and contractility. The other answers are incorrect. A patient is discharged with the diagnosis of severe peripheral vascular disease (PVD). In addition to medication and a walking regime, if applicable, which of the following is essential education at time of discharge? A. nutritional counseling B. smoking cessation counseling C. social work consult D. speech therapy consult - answer B. smoking cessation counseling Cessation of tobacco use is the most important non-pharmacological intervention that can be done to improve signs and symptoms of peripheral bvascular disease. Social work consult and speech therapy may not be indicated in this patient. All patients may benefit from nutrition counseling; however, this is not a primary concern for this patient. A medication that dilates both the venous and arterial beds will cause which of the following results? A. increased preload, decreased afterload B. increased preload, increased afterload C. decreased preload, decreased afterload D. decreased preload, increased afterload - answer C. decreased preload, decreased afterload
When both the venous and arterial beds are dilated, there will be less venous return, causing a decreased preload (ex. nitroglycerin). With arterial vasodilation, the afterload will decrease (ex nitroprusside, ACE-I). Afterload in this case is resistant to LV pumping. Stable angina is best defined as: A. pain that increases in severity B. pain that is new C. pain that occurs at rest D. pain that has a predictable pattern over time - answer D. pain that has a predictable pattern over time Stable angina is predictable -- the patient can describe the pain and how it is initiated accurately each time -- and occurs with exertion. Ex: The patient knows every time he or she climbs stairs, it will be accompanied by chest pain. The pain is relieved with rest and nitroglycerin (Nitrolingual). Pain that is new or occurs at rest is not stable angina. If the pain increases in severity, it is no longer stable. The gold standard diagnostic tool for the identification, location of disease and severity of coronary artery disease is: A. a stress test B. an echocardiography C. cardiac catheterization D. a spiral computer tomography (CT scan) - answer C. cardiac catheterization The gold standard, or best diagnostic tool, for the diagnosis, location and severity of coronary artery disease is the cardiac catheterization performed in the cath laboratory. Echocardiography is excellent in revealing structure changes, but not coronary artery disease. A stress test may be a good screening tool, but again, is not the gold standard, nor is CT scanning The most common complication after a STEMI is: A. heart failure B. dysrhythmia C. ventricular septal rupture D. ventricular wall rupture - answer B. dysrhythmia The most common complication after a STEMI is dysrhthmia due to irritability of the ischemic myocardium and the dead myocardium that does not transmit electrical stimuli. With interior-wall STEMI, the most common dysrhythmia is bradycardia and heart block. With anterior-wall STEMI, tachydysrhythmias such as ventricular tachycardia and/or ventricular fibrillation are most common. Heart failure, ventricular septal wall rupture and ventricular rupture are infrequent complications after STEMI and carry a very poor prognosis. The most common cause of heart failure in the US is: A. valvular disease B. ischemic heart disease C. renal failure D. hepatitis - answer B. ischemic heart disease
channel blockers are not used in heart failure since they tend to increase the absorption of sodium and water. Nitrates are used for treatment in conjunction with other drugs. Beta blockers are ACE-I are the foundation of treatments. Digoxin is also used but only after the beta blockers and ACE-I are started. The heart's primary compensatory response to chronic aortic stenosis includes: A. left arterial hypertrophy B. left ventricular hypertrophy C. left ventricular dilation D. right ventricular dysfunction - answer B. left ventricular hypertrophy With chronic aortic stenosis, the left ventricle hypertrophies over time due to the increased workload of pumping blood through a narrowed opening. This leads to diastolic dysfunction as well as hypertrophy. The left atrium will enlarge over time, but the primary result is left ventricular hypertrophy, not dilation. The right ventricle remains normal for a period of time. Patients with pericardial effusions should be assessed for the development of which of the following complications: A. thrombocytopenia B. tamponade C. low hemoglobin and hematocrit D. endocarditis - answer B. tamponade Any patient with a pericardial effusion should be assessed for cardiac tamponade physiology. Any accumulation of fluid in the pericardial sac can compress the myocardium, producing tamponade signs and symptoms. All patients are assessed for thrombocytopenia, low H+H and endocarditis; they are not the focus of complications with effusions but could be additional signs of tamponade (low H+H and thrombocytopenia). Nursing interventions in the patient with pericarditis include all the following except: A. providing comfort by administering pain medications and proper positioning B. auscultating heart sounds to assess for muffled heart sounds C. administering anticoagulants to prevent thrombus in the pericardium D. monitoring for jugular venous distention (JVD) and hypotension - answer C. administering anticoagulants to prevent thrombus in the pericardium A patient with pericarditis should have pain-relief medication. The nurse should auscultate heart sounds and assess if they are muffled (a sign of possible tamponade), and monitor for JVD and hypotension (more signs of tamponade physiology). Do not give anticoagulants to the patient since they may cause bloody pericardial effusions and tamponade. Epinephrine is indicated as the first-line drug for any pulseless condition because it has the following actions: A. inotropic and selectively shunts blood to brain and heart B. converts ventricular fibrillation to sinus rhythm C. slows the heart rate and improves contractility
D. causes decreased contractility, - answer A. inotropic and selectively shunts blood to brain and heart Epinephrine is a pure catecholamine that increases contractility and causes vasoconstriction that shunts blood to the heart, brain, and diaphragm. According to ACLS, it is the drug of choice for any pulseless arrest. Epinephrine does not convert VF to any rhythm, slow heart rates or cause decreased contractility. The most common postoperative complication of coronary artery bypass (CABG) surgery is: A. bleeding B. stroke C. atrial fibrillation D. ventricular fibrillation - answer C. atrial fibrillation The most common complication after CABG is the dysrhythmia atrial fibrillation. In approximately 33% of all patients who have atrial fibrillation, the mechanism is not completely understood. Postoperative myocardial edema may cause an atrial stretch, facilitating electrophysiological abnormalities. Other complications include bleeding, stroke, and ventricular fibrillation, but they are not the most common. An NSTEMI is differentiated from an unstable angina by: A. location of chest pain B. cardiac biomarker elevation C. ECG changes D. extent of cardiac history - answer B. cardiac biomarker elevation In the NSTEMI vs unstable angina patient, the location of pain may be the same. Regarding ECG changes, both may have ST-Twave depression in the associated leads. The history of a patient with myocardial ischemia may not be pertinent. In an unstable angina, the patient may have ECG changes, but no cardiac enzyme changes. In NSTEMI, the patient will have cardiac enzyme elevation. The nurse auscultates an S3 on a patient just admitted with NSTEMI. What does that indicate? A. normal heart sounds B. mitral valve stenosis C. fluid overload D. increased afterload - answer C. fluid overload The auscultation of an S3 is always abnormal in the adult patient. It indicates an overfilled left ventricle at the beginning of ventricular diastole and is a marker of poor ventricular function as well as fluid overload. S3 does not reflect mitral valve stenosis (diastolic murmur) or increased afterload The primary function of beta blocker therapy in heart failure is to: A. increase BP B. block compensatory vasoconstriction and increase heart rate C. increase urine output
A. vitamin A B. vitamin B C. vitamin C D. vitamin K - answer D. vitamin K Vitamin K is the antidote for warfarin overdose. None of the other vitamins are antagonists of warfarin. A physiologic reason for sinus tachycardia is: A. elevated serum potassium B. elevated creatinine C. decreased urine output D. tissue hypoxia - answer D. tissue hypoxia Sinus tachycardia is generally a compensatory mechanism for decreased tissue oxygenation. Fever, pain, anxiety, hypovolemia and decreased blood pressure all are reasons for tachycardia. The physiology in all is the lack of oxygen delivery at the tissue level. Elevated potassium does not increase heart rate, but if it is high enough, causes sinus bradycardia. Elevated creatinine is a marker of renal failure, and increased potassium would cause sinus bradycardia. Decreased urine output may or may not affect heart rate. A patient is admitted with decompensated heart failure. The patient is receiving furosemide (Lasix), digoxin (Lanoxin), metoprolol (Lopressor) and lisinopril (Zestril) at home. What drug can be added to reduce preload? A. spironolactone (Aldactone) b. verapamil (Calan) c. dabigatran etexilate (Pradaza) d. No other drugs are essential - answer A. spironolactone (Aldactone) When the heart failure patient continues to have volume overload on appropriate medications, an aldosterone inhibitor such as spironolactone or eplerenone (Inspera) should be added. Aldosterone inhibition will decrease sodium reabsorption from the kidneys and therefore decrease intravascular volume. The nurse would carefully monitor potassium since aldosterone blockers are potassium-sparing diuretics. Remember not to use verapamil in heart failure; it will increase sodium and water retention. Dabigatran etexilate is an anticoagulant used only for non-vascular atrial fibrillation. Which condition would stimulate renin production? A. increased blood supply to the renal tubules B. decreased blood pressure C. decreased sympathetic output D. increased sodium concentration - answer B. decreased blood pressure Renin secretion is regulated by blood flow to the juxtaglomerular apparatus. Decreased blood pressure would be identified, and renin secretion would occur. This begins a compensatory mechanism that causes vasoconstriction with increased blood pressure as well as sodium and water reabsorption in the kidneys, thereby effectively increasing blood pressure. Increased blood flow would maintain normal renin production.
Decreased sympathetic output would not affect renin secretion from the kidneys (it is stimulated by low renal blood flow). Low serum sodium concentrations would stimulate renin production due to decreased osmolality. Symptoms of acute endocarditis of the mitral valve cause: A. symptoms similar to heart failure B. severe chest pain mimicking STEMI C. Claudication-type pain D. pain that is relieved by sitting up - answer A. symptoms similar to heart failure Symptoms of acute endocarditis are very similar to heart failure. The mitral valve with infection may become incompetent and cause increased pulmonary pressures just like left ventricular heart failure. The pateint will need heart failure treatment as well as antibiotics. Claudication-type pain is caused by ischemia to the lower extremities. Pain relieved by sitting up is usually pericarditis in nature. With acute arterial insufficiency, the extremity will appear: A. warm with normal color B. warm with increased redness C. cool with pale color D. cool with normal color - answer C. cool with pale color The patient with acute arterial insufficiency will have a cool extremity and a pale appearance, both due to lack of blood flow. The 6 P's to arterial circulation are: pulse (palpation, Doppler), pain (pt's perception), pallor (color change), polar (decreased temperature), paresthesia (numbness, pins and needles in extremity) and paralysis (not feeling or moving). A patient who has sustained a septal wall infarction several days ago now is complaining of acute shortness of breath. The nurse auscultates rales bilaterally, notes decreasing O2 saturations and lowered blood pressure. These signs and symptoms may indicate: A. Deep vein thrombosis B. pneumonia C. anxiety D. acute ventricular septal defect (VSD) with heart failure - answer D. acute ventricular septal defect (VSD) with heart failure A complication of septal wall infarction is VSD. This may occur 3-7 days after infarction and appears as acute decompensated heart failure. DVT does not have a presentation of acute onset heart failure. Pneumonia may present with chest pain and rales on the affected side, but not acute decompensated heart failure. Anxiety usually does not change the patient's total physical exam with decreasing saturations, rales bilaterally and acute shortness of breath. An elderly patient with an abdominal aortic aneurysm decline surgery for the condition. What medication may be helpful in the prevention of rupture of this aneurysm? A. benazepril (Lotensin) B. captopril (Capoten)
C. Bradycardia and ST segment depression D. high degree AV blocks - answer B. tachycardia The most common ECG changes that occur with pulmonary embolism are tachycardia ( a good first clinical condition of almost anything) and atrial fibrillation due to increased pulmonary pressure, The other answers are incorrect. The anterior left ventricle receives blood via the: A. left circumflex artery B. right coronary artery C. posterior descending coronary artery D. left anterior descending coronary artery - answer D. left anterior descending coronary artery The left anterior descending coronary artery perfuses the entire left anterior section of the left ventricle, two-thirds of the septum and the apex of the left ventricle. The right coronary artery perfuses the right ventricle. The left circumflex perfuses the left lateral ventricular wall, and the posterior descending coronary artery perfuses the inferior right and left ventricular wall. Patients with occlusion of the right coronary artery are at high risk for the development of Mobitz type I heart blocks. This is because 90% of the population use the right coronary artery to supply which part of the conduction system? A. sinoarterial (SA) node B. artrioventricular (AV) node C. bundle branches D. Purkinje fibers - answer B. artrioventricular (AV) node Although the right coronary artery perfuses the SA node, it is the AV node ischemia that would cause a Mobitz Type 1 heart block. The bundle branches and the Purkinje fibers are perfused by the right and left circulation and if ischemic, would cause worse dysrhythmias such as complete heart block or idioventricular rhythm. The amount of oxygen delivered to the tissues is determined by what factor: A. cardiac output B. hemoglobin levels C. oxygen saturation D. all of the above - answer D. all of the above Cardiac output, hemoglobin levels and oxygen saturation all contribute to the amount of oxygen delivered to the tissues When assessing myocardial chest pain, which of the following is not a common characteristic of angina: A. discomfort that is precipitated by exercise B. discomfort that is described as pressure or tightness C. discomfort that is relieved with rest or nitroglycerin D. pain that is intermittent and that comes and goes - answer D. pain that is intermittent and that comes and goes
Myocardial ischemia causing pain has the usual characteristics of precipitation by exercise or exertion, described as pressure or tightness, and relief by rest and/or nitroglycerin. Intermittent pain that comes and goes is not the usual presentation of myocardial ischemia. Signs of venous peripheral vascular disease in the legs include: A. brown pigmentation at the ankles, warm legs, open area over the lateral malleolus B. normal color, severe pain, open sore at the end of the great toe C. shiny skin with no hair, pale extremities, pain with ambulation D. pitting edema, absent pulses, thick toenails, feet becoming cyanotic when dependent
- answer A. brown pigmentation at the ankles, warm legs, open area over the lateral malleolus Arterial insufficiency Etiology: arteriosclerosis Risk factors: smoking, DM, HTN Pain: severe muscle ischemia, intermittent claudication, worse with exercise, pain at rest, muscle fatigue, cramping, numbness Vascular: decreased or absent pulses, pallor and rubor Skin changes: shiny, dry, nail changes, coolness Venous insufficiency Pain: minimal to moderate steady pain, aching Skin: thickening in tissues, dark, cyanotic, thickened and brown, with ulceration at sides of ankles (a medial malleolus classic), and legs are warm since there is normal arterial circulation A patient presents with pulmonary edema characterized by tachycardia, hypertension and cough with frothy sputum. What initial treatments are most common? A. oxygen, nitroglycerin, loop diuretics, and morphine B. oxygen, thiazide diuretics, and ACE inhibitors C. oxygen and thiazide diuretics D. oxygen, morphine, and calcium channel blockers - answer A. oxygen, nitroglycerin, loop diuretics, and morphine The first line drugs of choice for acute pulmonary edema are oxygen, loop diuretics such as furosemide (Lasix), nitroglycerin (preload reducer and increased myocardial blood flow), and morphine (vasodilator to reduce preload, decrease pain and anxiety; pain and anxiety increase the oxygen needs of the myocardium). Thiazide diuretics, ACE inhibitors and calcium channel blockers are not used as first line drugs in treatment of pulmonary edema. A patient who experienced an episode of severe chest pain and weakness four days earlier is undergoing diagnostic tests. Which test would provide the most accurate information to diagnose a myocardial infarction after four days? A. an ECG B. creatine-kinase and isoenzyme (CK-MB) C. myoglobin
D. a history of angina - answer C. recent warfarin (Coumadin) therapy The use of abciximab is contraindicated with recent history of oral anticoagulation with warfarin, recent bleeding or stroke within the previous 2 years or a paltelet count of less than 100,000. Abciximab is used to prevent cardiac ischemia and re-occlusion of percutaneous transluminal coronary angioplasty and stent. Abciximab inhibits the aggregation of platelets and is used with aspirin and/or weight adjusted and low-dose heparin as it potentiates the action of anticoagulants. When assessing cardiac output in a normal heart, a decrease in heart rate should cause the stroke volume to: A. increase B. decrease C. remain the same D. vary - answer A. increase In the normal heart with normal volume, a decrease in the heart rate should increase stroke volume. With a decrease in heart rate, the filling time of the ventricle increases and thereby should improve cardiac output and stroke volume. The other answers are incorrect. Beck's triad, which includes hypotension, muffled heart sounds and jugular venous distention (JVD), is indicative of which condition? A. myocardial infarction B. aortic valve stenosis C. cardiac tamponade D. pulmonary embolism - answer C. cardiac tamponade The classic presentation of Beck's triad, or cardiac tamponade, is hypotension, JVD and muffled heart sounds. Also typically occurring are tachycardia (due to low cardiac output) and narrow pulse pressure (again, due to low cardiac output and high SVR). This classic presentation requires immediate action by the nurse caring for the patient: a stat echocardiogram, chest X-ray and continued vital signs as well as starting large-bore IV access for fluid resuscitation. On the 12 lead ECG, cardiac ischemia is characterized by: A. elevation of the ST segment and elevated peaked T waves B. inverted T wave C. development of Q waves D. abnormal Q wave or decreased R wave progression in the V leads - answer B. inverted T wave The first clinical ECG sign of myocardial ischemia is the tenting of the T wave; large tented T waves in 2 contiguous leads. This is often missed since it occurs so early in the ischemic period. The second sign is the inverted T wave. If ischemia persists and infarction occurs, the ST segment elevates, and later a Q wave forms. Not all STEMIs develop Q waves, however, so the best answer is the T wave. An atrial septal defect is characterized by:
A. shunting of blood returning from the lungs through the left atrium back to the right atrium and then returns to the pulmonary circulation B. left to right shunt, increased pulmonary hypertension and right-sided heart failure C. right ventricular hypertrophy from increased pressure in the right ventricle and decreased pulmonary flow D. Left ventricular wall hypertrophy - answer A. shunting of blood returning from the lungs through the left atrium back to the right atrium and then returns to the pulmonary circulation An arterial septal defect (ASD) allows blood from the left atrium (due to higher pressure gradient in the left atrium) to return to the right atrium and then the right ventricle before returning to the lungs. This causes a shunting of oxygenated blood to go through the pulmonary circulation again. This may cause pulmonary congestion. A ventricular septal defect (VSD) causes blood to cross from the left ventricle to the right ventricle, causing pulmonary hypertension and right ventricular failure. The other answers are incorrect. The jugular venous pulse is particularly valuable for assessing: A. right atrial function B. left atrial function C. right ventricular function D. left ventricular function - answer A. right atrial function The jugular venous pulse is an excellent tool to assess the right ventricle. The right atrium is filled by the superior vena cava; the jugular comes off the SVC. The jugular vein will have increased pulsations when the right atrium is overloaded or overfilled. With acute right ventricular failure, the patient will have jugular venous distention. With prolonged right ventricular failure, the patient may exhibit JVD, but only when the right artria is involved. Which of the following vasodilators primarily dilates coronary arteries and is used to treat angina and supraventricular tachycardia? A. diltiazem (Cardizem) B. captopril (Capoten) C. nitroglycerin D. sodium nitroprusside (Nipride) - answer A. diltiazem Diltiazem is an excellent vasodilator (classified as a non-dihydropyridine calcium channel blocker) with the property to dilate the coronary arteries and to treat supraventricular tachycardia. It is also a selective coronary vasodilator. It dilates coronary vessels better than it does systemic vascular beds. It is also used to decrease heart rate and treat supraventricular arrhythmias, inculding SVT. Captopril, an ACE-I, is also a vasodilator but has no affect on coronary circulation. Nitroglycerin, a well known coronary artery dilator, and nitroprusside, an excellent arterial and venous vasodilator, have no affect on SVT. A 70 year old female presents in cardiogenic shock secondary to myocardial infarction. Which of the following symptoms are consistent with cardiogenic shock? A. hypertension with systolic blood pressure greater than 90 mm Hg, bradycardia, chest pain and tachypnea
consumption, but not delivery. Arterial bicarbonate is a way to measure metabolic characteristics. A patient who is postoperative day 2 after a pancreatic resection for hemorrhagic pancreatitis is now complaining of acute shortness of breath with rales bilaterally and increasing oxygen requirements. This could be the beginning of: A. acute respiratory distress syndrome B. asthma C. postoperative pain syndrome D. gastric bleed - answer A. acute respiratory distress syndrome Any patient with an inflammatory disorder (such as postoperative abdominal surgery) can develop acute respiratory distress syndrome approximately 24-36 hrs post event. The signs and symptoms include acute shortness of breath, rales bilaterally, diffuse bilateral ground-glass appearance, or white-out, on chest x-ray and increased requirements for oxygen. Asthma would include wheezing. Postoperative pain would not likely cause rales. A gastric bleed would not cause rales. A patient presents with acute decompensated heart failure and pulmonary edema. The patient has rales, dyspnea, tachycardia and cyanosis. Oxygen therapy is instituted. What other therapies will be started? A. oxygen therapy only B. diuretic therapy C. oxygen therapy and inotropic therapy D. fluid resuscitation will be required - answer B. diuretic therapy The initial therapy for acute decompensated heart failure (pulmonary edema) is diuretic therapy and oxygen supplementation. The patient is fluid oveerloaded and requires diuresis with oxygen therapy for increased oxygen needs. Administering fluid will worsen the heart failure and increase the patient's work of breathing. A patient is admitted to your floor with the following arterial blood gas. pH 7.55 CO2 28 PaO2 88 HCO3 26 What is the interpretation? A. respiratory acidosis B. compensated metabolic alkalosis C. non-compensated respiratory alkalosis D. metabolic alkalosis - answer C. non-compensated respiratory alkalosis The patient has a rapid respiratory rate with low CO2. The pH is alkalotic (a pH grater than 7.45), the PaO2 is within the normal range, and the bicarbonate is normal. Since the pH is abnormal, this ABG shows non-compensated changes. A patient with chronic obstructive lung disease now has respiratory failure with a PaCO of 65 and a pH of 7.30. The patient has dyspnea and is experiencing cardiac dysrhythmias, confusion and hypotension. These findings are consistent with: A. respiratory alkalosis B. respiratory acidosis C. metabolic alkalosis
D. metabolic acidosis - answer B. respiratory acidosis To evaluate an arterial blood gas in a patient with chronic disease, address the pH first. In this case, the pH is abnormal. It is 7.30, which is acidotic, and an acute finding. The PaCO2 is also elevated, meaning that this is a respiratory acidosis. This finding is important and the patient requires immediate care. Respiratory alkalosis would include a pH greater than 7.45; metabolic acidosis would require a base deficit (less than -2.2) or a bicarbonate of less than 22; metabolic alkalosis would require a base excess (greater than +2.2) or a bicarbonate of greater than 26. The major physiologic derangements in acute respiratory distress syndrome (ARDS) are the systemic effects of the inflammatory system. They include: A. movement of fluid out of the capillary bed B. release of histamine C. vasodilation D. all of the above - answer D. all of the above The systemic effects of acute inflammatory response are histamine release, which causes the vasodilation and edema, then movement of fluid out of the capillary bed and into tissues. The term "non-cardiac pulmonary edema" was a common way to describe ARDS, a very wet lung that became noncompliant and stiff not related to left ventricular function. A hallmark of acute respiratory distress syndrome (ARDS) is: A. refractory hypercapnia B. refractory hypoxemia C. refractory hypotension D. refractory acidosis - answer B. refractory hypoxemia Early in ARDS, the patient begins to have pulmonary hypertension secondary to increased pulmonary water and vasodilation. Early on, the patient would have respiratory alkalosis and increase his or her respiratory rate. This is also secondary to a decrease partial pressure of oxygen in the blood. This hypoxemia does not respond to increased levels of inhaled oxygen. Therefore, the definition is refractory (cannot make better) hypoxemia. Hypercapnia is not the primary problem in ARDS; it is a problem of hypoxia. Hypotension may occur, but ARDS is primarily a lung problem that causes severe hypoxia. Refractory acidosis is also incorrect. The primary goal in treatment of acute respiratory distress syndrome (ARDS) is to: A. restore oxygenation B. restore blood pressure C. restore temperature regulation D. restore normal respiratory rate - answer A. restore oxygenation Remember, with questions like this, the question asks. "What is the primary goal in treatment?". With all patients. the nurse would control blood pressure, temperature, and respiratory rate. The primary goal in ARDS is to restore oxygenation since this is the major derangement. The major early signs and symptoms of acute respiratory failure include:
