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A 59 year old male is admitted complaining of chest pain and dyspnea. ST clevation and T wave inversion were seen on the EKG in V2,V3 and V4. IV thrombolytic therapy was started in ED. Indications of successful reperfusion would include all of the following except: (A) pain cessation (B) decrease in CK or troponin (C) reversal of ST segment clevation with return to bascline (D) short runs of ventricular tachycardia ANS WERV ¥ (B)Coronary artery reperfusion due to PCI or fibrinolysis results in an ELEVATION of creatinine kinase (CK) or troponin, not decrease. The theory is that the return of blood flow distal to the occlusion can result in ‘reperfusion injury’ of the muscle, elevating cardiac biomarkers. The other 3 choices are indicators of reperfusion: Pain cessation. reversal of ST segment elevation with return to baseline, short runs of ventricular tachycardia. Which of the following medication orders should the nurse question for the patient in question |-reperfusion question-patient having an MI? (A) metoprolol (Lopressor) (B) aspirin (C) propranolol (Inderal) (D) heparin ANS WERV ¥ (C) The patient in the scenario is having an acute anterior wall ML. A beta blocker is beneficial for an acute MI as these agents decrease the work of the heart and increase the threshold for ventricular fibrillation. Propranolol, although a beta- andrenergic blocker like metoprolol, is NOT a cardioselective beta blocker. It affects beta receptors in heart muscle AND lung tissue. Therefore, it is more likely to cause bronchoconstriction than a cardioselective beta blocker. The other 3- cardiosclective beta blocker, antiplatelet, and anticoagulation-are indicated in an acute MI. If heart block develops while caring for the patient in question | (pt with an MI who went through reperfusion from PCL or fibrinolytic therapy), which of the following would it most likely be? (A) sinoatrial block (B) second degree, Type I (C) second degree, Type II (D) third degree, complete ANSWERV ¥ (C) The patient is having an acute anterior MI, which is generally due to LAD occlusion. The LAD supplies the IIIS bundle, which could result in a second-degree, type II heart block. The other 3 types are due to SA node or AV node ischemia, which generally occur with an RCA occlusion — interior wall MI. Appropriate drug therapy for dilated cardiomyopathy is aimed toward: (A) decreasing contractility and decreasing preload and afterload (B) decreasing contractility and increasing preload and afterload (C) increasing contractility and increasing both preload and afterload (D) increasing contractility and decreasing both preload and afterload ANSWERV ¥ (DP) Dilated cardiomyopathy is likely to result in systolic dysfunction, which decreases contractility, causes compensatory arterial constriction , and results in a higher left ventricular preload. To treat this, therapy is aimed al increasing contractility, decreasing afterload (arterial constriction), and decreasing preload that is too high. An 18 year old is admitted with a history of syncopal episode at the mall and has a history of an eating disorder. The nurse notes a prolonged QT on the 12-lead EKG and anticipates a reduction in an electrolyte to be the cause. Which of the following is LEAST likely to cause this patient's problems? (A) sodium (B) magnesium Your patient admitted with an NSTEMI develops acute shortness of breath, recurrence of chest pain, and a loud systolic murmur at the apex of the heart. Which of the following has most likely occurred? (A) the patient has developed acute mitral valve regurgitation (B) the patient has developed acute infarction (C) the patient has developed acute mitral wave stenosis (D) the patient has developed acute ventricular septal defect ANS WERV ¥ (A) The location of the murmur, at the apex of the heart (midclavicular, 5th ICS), is one clue to this answer. In addition, regurgitation occurs when the valve should be closed and the mitral valve should be closed during systole. Mitral stenosis. choice (C), occurs when the mitral valve is open. Additionally, mitral stenosis cannot be acute, it develops gradually. A patient has just returned from the OR after insertion of a VVI pacemaker. In order to assess function of this pacemaker accurately, the nurse needs to understand that: (A) both atrium and ventricle are paced and sensed and may either inhibit or pace in response to sensing (B) the ventricle is paced, ventricular activity is sensed and pacing is inhibited in response to ventricular sensing. (C) both 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. ANS WERV ¥ (B) the first letter indicates chamber paced (ventricle). The second letter indicates chamber sensed (ventricle). The third letter indicates the response to sensing (inhibited in response to sensing). A patient complains of sudden dyspnea 5 days S/P acute MI (ST elevation in II, III, and aVF, with ST depression in | and aVL). ‘The patient is anxious, diaphoretic, and hypotensive. Examination reveals the development of a loud holosystolic murmur at the apex. What is the most likely cause of this patient's deterioration? (A) right ventricular failure related to right ventricular MI (B) ventricular septal defect (C) left ventricular failure due to extension of MI (D) acute mitral regurgitation due to papillary muscle rupture or dysfunction ANSWERV 4 (D) The scenario describes a patient having an acute inferior wall MI, which is generally due to occlusion of the RCA. The RCA occlusion may result in papillary muscle dysfunction or rupture of the mitral valve because it supplies the arca of the Icft ventricle where this valve is attached. Although RV infarct could result with RCA occlusion, RV infarct does not result in a systolic murmur at apex of the heart or lung crackles. ‘The patient with diagnosis of cardiogenic shock now requires high dose dopamine (greater than 10 meg/kg/min) to maintain blood pressure, and the cardiologist is planning to start IABP therapy. This therapy will benefit the patient because it will: (A) increase afterload with balloon inflation and decrease diastolic augmentation with balloon deflation. (B) decrease afterload with balloon deflation and increase diastolic augmentation with balloon inflation. (C) decrease afterload with balloon inflation and decrease diastolic augmentation with balloon deflation (D) increase afterload with balloon deflation and decrease diastolic augmentation with balloon inflation. ANS WERV ¥ (B) Cardiogenic shock results in a decrease in cardiac output with a resultant drop in coronary artery perfusion and compensatory vasoconstriction. The deflation of the balloon placed into the descending aorta is beneficial. Deflation decreases afterload and work of the left ventricle. Inflation of the balloon is beneficial because it "boluses" blood into the coronary arteries, increasing perfusion. dysfunction does NOT cause a problem with ejection, and the EF is normal. The other 3 choices may be indicated for systolic dysfunction. A patient is admitted with ST elevation in V2, V3, and V4. Four days after admission, the patient suddenly developed a holosystolic murmur at the lower Iefi sternal border, chest pain, and hypotension. What complication should the nurse expect? (A) papillary muscle rupture (B) ventricular septal defect (C) acute mitral stenosis (D) acute reinfarction ANS WERV V The scenario describes an acute anterior STEMI. generally caused by an occlusion of the LAD. This type of MI is most likely to result in a VSD. Additionally, the location of the murmur is important. Mitral valve discase-related problems do NOT cause murmurs to be loudest at the lefi sternal border, whereas a VSD would result in a murmur at this location. A postoperative patient on the surgical unit suddenly develops chest pain, extreme weakness, and dyspnea and is found to have ST elevation in II, II], and aVF on the stat EKG. B/P is 92/62, heart rate 58, respiratory rate 28, lungs are clear, and heart sound assessment reveals an $4, no murmurs. In addition to preparing the patient for PCI. which of the following interventions would you anticipate’? (A) nitroglycerin drip, aspirin (B) furosemide, atropine (C) transcutaneous pacing, morphine (D) aggressive fluid administration, right-sided EKG. ANSWERV ¥ (D) The scenario describes a patient having an acute inferior STEMI, generally duc to RCA occlusion. An RCA occlusion may result in RV infarct, which this patient has signs of (hypotension with clear lungs). The definitive treatment is emergent PCI. Fluid administration will help increase coronary artery perfusion by correcting hypotension and ensure adequate RV preload. The right-sided EKG may help confirm the RV infarct. Nitroglycerin, diuretics, and morphine may decrease preload, which would worsen hypotension. A 52 year old male presents with complaints of blurred vision and shortness of breath. B/P is 232/136, heart rate 102, respiratory rate 28 with crackles in lower lung fields bilaterally, with 33 and S4 heart sounds on auscultation. Which of the following would be indicated for this patient? (A) nitroprusside drip, admit to critical care unit (B) digoxin, furosemide (C) labetalol drip, admit to a medical unit (D) lisinopril, calcium channel blocker ANS WERV V (A) The patient has signs of organ dysfunction (heart failure) secondary to cxtreme hypertension. Therefore, he has hypertension crisis or emergency. The B/P needs to be emergently decreased. Most often this treatment is best done in an ICU. An 80 year old female presents with chief complaint of acute shortness of breath. Clinical exam reveals B/P 182/102, heart rate 105/minute, respiratory rate 32/minute, lungs with crackles bilaterally, pulse oximetry of 88%, $4 on auscultation. EKG revealed sinus tachycardia, left ventricular hypertrophy pattern, chest radiograph showed normal heart size, pulmonary vascular congestion, and echocardiogram showed EF of 55%. Which of the following should be avoided in this patient's treatment plan? (A) calcium channel blocker (B) digoxin (C) low-dose diuretics (D) oxygen ANSWERV ¥ (B) The patient presents with signs of heart failure due to diastolic dysfunction (hypertension, left ventricular hypertrophy, EF > 40%). These patients have a problem with FILLING, not ejecting. Digoxin, a positive inotrope, may increase wall stress and worsen filling of the left ventricle. return to the OR to drain the pericardial fluid that has accumulated. Development of the problem in other patient population would necessitate an emergent pericardiocentesis to drain the fluid. Physical assessment findings indicative of a significant right ventricular (RV) infarction would include: (A) bibasilar crackles (B) flat neck veins with the patient in a Semi-Fowler's position (C) jugular vein distention (D) tachypnea and frothy sputum ANSWERY ¥ (C) A right ventricular infarction large enough to cause RV failure causes a problem with RV emptying. leading to an elevated right atrial pressure causing distended jugular vein distention. Choices (A) and (D) are signs of left ventricular failure. Voice (B) is a sign of dehydration What pulse change might the nurse expect associated with cardiac tamponade? (A) pulsus alternans (B) pulsus paradoxus (C) pulsus magnus (D) pulsus bisferiens ANSWERV ¥ (B) Pulsus paradoxus is fluctuation of the systolic blood pressure with inspiration and expiration by more than 12 mmHg, best seen when an artcrial line is in place. Inspiration increases thoracic pressure. When combined with fluid surrounding the heart in cardiac tamponade, inspiration further decreases venous return to the heart, leading to drop systolic pressure by > 12 mmHg during the inspiratory phase of breathing. Choice (A) pulsus alternans is characterized by a change in amplitude of the systolic waveform from beat to beat, usually indicative of severe lefi ventricular failure. Choice (C), pulsus magnus, is a bounding pulse. Choice (D), pulsus bisferiens, is a double pulse and is not covered by the CCRN test. A patient with mitral regurgitation develops atrial fibrillation with a rate of 88, B/P of 118/75. Which of the following may be indicated? (A) beta blockers and vasopressors (B) cardiac glycosides and calcium-channel blockers (C) beta blockers and calcium-channel blockers (D) antiarrhythmics and angiotensin-converting enzyme inhibitors ANS WERV ¥ (B) The scenario describes development of atrial fibrillation with a controlled ventricular response and stable B/P. Even with a normal B/P, the development of atrial fibrillation drops the cardiac output by 20% to 25% due to a loss in "atrial kick" provided by normal sinus rhythm. A cardiac glycoside (such as digoxin) may be beneficial as it is a weak positive inotrope that may compensate for the loss of atrial kick and calcium-channel blockers will kcep the rate controlled. Pressors are not needed in this case. Use of beta blockers and calcium-channel blockers would decrease the rate too much. ACE inhibitors would offer no benefit in this case. Which of the following are predominant signs of left ventricular systolic dysfunction? (A) pedal cdema, ascites, hepatomegaly, weight gain, ejection fraction less than 40% (B) S4, bibasilar crackles, hypertension, ejection fraction greater than 40% (C) $3, frequent new cough, bibasilar crackles, ejection fraction less than 40% (D) hypertension, murmur, chest pain, weight gain, ejection fraction greater than 40% ANSWERV ¥ (C) $3 heart sound in an adult is indicative of high left ventricular pressure, cough, and lung crackles are signs of pulmonary edema secondary to elevated left ventricular end-diastolic pressure (PAOP). The EF is less than 40% in systolic heart failure. The nurse was preparing a patient with the diagnosis of STEMI for a percutancous coronary intervention (PCI). The monitor had previously shown normal sinus rhythm (NSR) and the /P had been 128/78, chest pain improved from a "9" to a "2" on a 0-10 scale. The monitor alarm sounded, and the rhythm below (complete heart block) was observed by the nurse: What statement below is TRUE: The location or type of acute MI is often associated with specific clinical findings. Which of the following statements related to location of MI is TRUE? (A) anterior MI is often associated with heart blocks and bradyarrythmias (B) inferior MI is often associated with right ventricular wall infarction (C) lateral MI is most likely to be associated with posterior MI (D) posterior MI is most likely to lead to the complication of heart failure ANSWERVJ/ (B) Because most inferior MI are due to RCA occlusion and the RCA also supplies blood to the right ventricular muscle wall, inferior MI is associated with RV infarct. Which of following statements is accurate regarding heart valves? (A) the aortic valve is closed during systole (B) the mitral valve is closed during systole (C) the mitral valve is closed during diastole (D) the aortic valve is open during diastole ANSWERV ¥ (B) During systole (left ventricular ejection) the aortic valve is open, allowing for ejection, and the mitral valve is closed at this time. The mitral valve is open during filling (diastole). The following drugs are all considered positive inotropic drugs primarily affecting the beta-1 reception in the heart, EXCEPT for: (A) dopamine drip at 12 meg/kg/min dose (B) dopamine drip at 5 meg/kg/min dose (C) dobutamine drip at 7 meg/kg/min dose (D) milrinone at 7 meg/kg/min dose ANS WERV ¥ (A) At high doses (> 10 meg/kg/min), dopamine stimulates alpha receptors in arteries and causes vasoconstriction. The other 3 drugs/doses affect mainly beta-1 receptors in the heart, producing a positive inotropic effect. 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 ANSWERV V (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. Nitrate therapy is indicated for the treatment of unstable angina and acute heart failure because it: (A) decreases preload and increases myocardial O2 demand (B) increases preload and increases myocardial O2 demand (C) increases preload and decreases myocardial O2 demand (D) decreases preload and decreases myocardial O2 demand ANSWERV V (D) Nitrates cause venodilation, which results in a decrease in venous return to the heart (left ventricular preload reduction). The deercase in preload decreases the work of the left ventricle and myocardial oxygen demand. 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 CKR ANSWERV ¥ The pulse pressure NARROWS with cardiac tamponade. The other 3 choices ARE seen with cardiac tamponade. EKG changes associated with ST-clevation myocardial infarction (STEMI) affecting the lateral wall would include changes in which of the following leads? injury) due to compression of cranial nerve III against the transtentorial notch. Motor changes are contralateral (opposite the side of injury) due to motor fiber crossing in the brain stem. Which of the following interventions would the nurse consider to be inappropriate for the patient with increased intracranial pressure? (A) maintaining oxygenation and normal PaCO2 (B) feeding the patient via an NGT (C) administering 5% dextrose in water (DSW) at 75 ml/hour (D) log roll when turing the patient ANS WERV ¥V (C) 5% dextrose in water is a hypotonic solution. When administered, it will cause movement of the D5W into the brain cells, causing swelling and increased intracranial pressure. The other 3 choices are acceptable interventions for the patient with increased ICP. You know that research supports unrestricted access of a designated support person to the patient, but your unit restricts all patient visitors to set times. Your best response would be to: (A) gather the facts and propose a policy change to your manager for the unit (B) tell patients/visitors that the unit's policy is outdated but there is nothing you can do about it (C) continue to follow the unit policy (D) complain to colleagues about the unit's outdated policy. ANSWERV V (A) The AACN Synergy Model supports paticnt advocacy. Unrestricted access of a designated support person is evidence-based practice included in the Patient Visitation AACN Practice Alert. Choice (A) is an effective strategy for change. Your patient has just consented to a bedside chest tube insertion and requests that his wife be allowed to be present during the procedure. You should: (A) explain to the patient that this is against infection control practice (B) tell the patient he will be able to see his wife as soon as the procedure is completed (C) tell the patient it would be too much for his wife to handle (D) prepare the wife for what to expect and allow her to be present ANSWERV ¥ (D) The AACN Synergy Model supports caring practice and family presence. An AACN practice alert indicates family presence may improve patient outcome. Which of the following laboratory findings are most specifically indicative of disseminated intravascular coagulation (DIC) as the cause of bleeding? (A) elevated fibrin split products and d-dimer (B) prolonged PT, PTT, and bleeding time (C) decreased platelet count (D) decreased hemoglobin and hematocrit ANSWERV ¥ (A) DIC is a clotting problem, with massive coagulation. As clots break down, fibrin split products are produced. Therefore with DIC, FSPs will be high. In fact, this is the most specific test result for DIC. D-dimer is present due to the presence of clots. While not specific for DIC, it is a good rule-out test. A 29 year old female has been in the critical care unit for 2 days after a motor vehicle crash and has developed acute tubular necrosis (ATN). She was normotensive on admission. What would be the most likely cause of ATN? (A) hemorrhage (B) rhabdomyolysis (C) creatinine release (D) cardiac dysthymias ANS WERV ¥ (B) The motor vehicle crash most likely resulted in a crash injury with destruction of skeletal muscle cells (rhabdomyolysis). This results in the release of massive amounts of creatinine kinase (CK) that, in turn, may CLOG renal tubules and lead to acute tubular necrosis (ATN). Choice (A) is not correct as there is no history of bleeding. Choice (C), creatinine release, is too vague, could be minor, and does not cause ATN. Arrhythmias, choice (D), are not included in the scenario. 
