Chapter 25

A nurse is describing the process by which blood is ejected into circulation as the chambers of the heart
become smaller. The instructor categorizes this action of the heart as what?
A) Systole
B) Diastole
C) Repolarization
D) Ejection fraction
Ans: Systole
Systole is the action of the chambers of the heart becoming smaller and ejecting blood. This action of
the heart is not diastole (relaxations), ejection fraction (the amount of blood expelled), or repolarization
(electrical charging).

During a shift assessment, the nurse is identifying the client's point of maximum impulse (PMI). Where
will the nurse best palpate the PMI?
A) Left midclavicular line of the chest at the level of the nipple
B) Left midclavicular line of the chest at the fifth intercostal space
C) Midline between the xiphoid process and the left nipple
D) Two to three centimeters to the left of the sternum
Ans: Left midclavicular line of the chest at the fifth intercostal space
The left ventricle is responsible for the apical beat or the point of maximum impulse, which is normally
palpated in the left midclavicular line of the chest wall at the fifth intercostal space.

The nurse is calculating a cardiac patient's pulse pressure. If the patient's blood pressure is 122/76 mm
Hg, what is the patient's pulse pressure?
A) 46 mm Hg
B) 99 mm Hg
C) 198 mm Hg
D) 76 mm Hg
Ans: 46 mm Hg
Pulse pressure is the difference between the systolic and diastolic pressure. In this case, this value is 46
mm Hg.

The nurse is caring for a patient admitted with unstable angina. The laboratory result for the initial
troponin I is elevated in this patient. The nurse should recognize what implication of this assessment
finding?
A) This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours.
B) Because the patient has a history of unstable angina, this is a poor indicator of myocardial injury.
C) This is an accurate indicator of myocardial injury.
D) This result indicates muscle injury, but does not specify the source.
Ans: This is an accurate indicator of myocardial injury.
Troponin I, which is specific to cardiac muscle, is elevated within hours after myocardial injury. Even
with a diagnosis of unstable angina, this is an accurate indicator of myocardial injury.

The nurse is conducting patient teaching about cholesterol levels. When discussing the patient's
elevated LDL and lowered HDL levels, the patient shows an understanding of the significance of these
levels by stating what?
A) "Increased LDL and decreased HDL increase my risk of coronary artery disease."
B) "Increased LDL has the potential to decrease my risk of heart disease."
C) "The decreased HDL level will increase the amount of cholesterol moved away from the artery walls."
D) "The increased LDL will decrease the amount of cholesterol deposited on the artery walls."
Ans: Increased LDL and decreased HDL increase my risk of coronary artery disease.
Elevated LDL levels and decreased HDL levels are associated with a greater incidence of coronary artery
disease.

The physician has placed a central venous pressure (CVP) monitoring line in an acutely ill patient so right
ventricular function and venous blood return can be closely monitored. The results show decreased CVP.
What does this indicate?
A) Possible hypovolemia
B) Possible myocardial infarction (MI)
C) Left-sided heart failure
D) Aortic valve regurgitation
Ans: Possible hypovolemia
Hypovolemia may cause a decreased CVP. MI, valve regurgitation and heart failure are less likely causes
of decreased CVP.

While auscultating a patient's heart sounds, the nurse hears an extra heart sound immediately after the
second heart sound (S2). An audible S3 would be considered an expected finding in what patient?
A) An older adult
B) A 20-year-old patient
C) A patient who has undergone valve replacement
D) A patient who takes a beta-adrenergic blocker
Ans: A 20-year-old patient
S3 represents a normal finding in children and adults up to 35 or 40 years of age. In these cases, it is
called a physiologic S3. It is an abnormal finding in a patient with an artificial valve, an older adult, or a
patient who takes a beta blocker.

The physical therapist notifies the nurse that a patient with coronary artery disease (CAD) experiences a
much greater-than-average increase in heart rate during physical therapy. The nurse recognizes that an
increase in heart rate in a patient with CAD may result in what?
A) Development of an atrial-septal defect
B) Myocardial ischemia
C) Formation of a pulmonary embolism
D) Release of potassium ions from cardiac cells
Ans: Myocardial ischemia
Unlike other arteries, the coronary arteries are perfused during diastole. An increase in heart rate
shortens diastole and can decrease myocardial perfusion. Patients, particularly those with CAD, can
develop myocardial ischemia. An increase in heart rate will not usually result in a pulmonary embolism
or create electrolyte imbalances. Atrial-septal defects are congenital.

The nurse is caring for a patient who has a history of heart disease. What factor should the nurse
identify as possibly contributing to a decrease in cardiac output?
A) A change in position from standing to sitting
B) A heart rate of 54 bpm
C) A pulse oximetry reading of 94%
D) An increase in preload related to ambulation
Ans: A heart rate of 54 bpm
Cardiac output is computed by multiplying the stroke volume by the heart rate. Cardiac output can be
affected by changes in either stroke volume or heart rate, such as a rate of 54 bpm. An increase in
preload will lead to an increase in stroke volume. A pulse oximetry reading of 94% does not indicate
hypoxemia, as hypoxia can decrease contractility. Transitioning from standing to sitting would more
likely increase rather than decrease cardiac output.

The nurse is caring for an 82-year-old patient. The nurse knows that changes in cardiac structure and
function occur in older adults. What is a normal change expected in the aging heart of an older adult?
A) Decreased left ventricular ejection time
B) Decreased connective tissue in the SA and AV nodes and bundle branches
C) Thinning and flaccidity of the cardiac values
D) Widening of the aorta
Ans: Widening of the aorta
Changes in cardiac structure and function are clearly observable in the aging heart. Aging results in
decreased elasticity and widening of the aorta, thickening and rigidity of the cardiac valves, increased
connective tissue in the SA and AV nodes and bundle branches, and an increased left ventricular ejection
time (prolonged systole).

A resident of a long-term care facility has complained to the nurse of chest pain. What aspect of the
resident's pain would be most suggestive of angina as the cause?
A) The pain is worse when the resident inhales deeply.
B) The pain occurs immediately following physical exertion.
C) The pain is worse when the resident coughs.
D) The pain is most severe when the resident moves his upper body.
Ans: The pain occurs immediately following physical exertion.
Chest pain associated with angina is often precipitated by physical exertion. The other listed aspects of
chest pain are more closely associated with noncardiac etiologies.

The critical care nurse is caring for a patient with a central venous pressure (CVP) monitoring system.
The nurse notes that the patient's CVP is increasing. Of what may this indicate?
A) Psychosocial stress
B) Hypervolemia
C) Dislodgment of the catheter
D) Hypomagnesemia
Ans: Hypervolemia
CVP is a useful hemodynamic parameter to observe when managing an unstable patient's fluid volume
status. An increasing pressure may be caused by hypervolemia or by a condition, such as heart failure,
that results in decreased myocardial contractility. Stress, dislodgement of the catheter, and low
magnesium levels would not typically result in increased CVP.

The critical care nurse is caring for a patient with a pulmonary artery pressure monitoring system. The
nurse is aware that pulmonary artery pressure monitoring is used to assess left ventricular function.
What is an additional function of pulmonary artery pressure monitoring systems?
A) To assess the patient's response to fluid and drug administration
B) To obtain specimens for arterial blood gas measurements
C) To dislodge pulmonary emboli
D) To diagnose the etiology of chronic obstructive pulmonary disease
Ans: To assess the patient's response to fluid and drug administration
Pulmonary artery pressure monitoring is an important tool used in critical care for assessing left
ventricular function (cardiac output), diagnosing the etiology of shock, and evaluating the patient's
response to medical interventions, such as fluid administration and vasoactive medications. Pulmonary
artery monitoring is preferred for the patient with heart failure over central venous pressure
monitoring. Arterial catheters are useful when arterial blood gas measurements and blood samples
need to be obtained frequently. Neither intervention is used to clear pulmonary emboli.

The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that
electrical conduction of the heart usually originates in the SA node and then proceeds in what
sequence?
A) SA node to bundle of His to AV node to Purkinje fibers
B) SA node to AV node to Purkinje fibers to bundle of His
C) SA node to bundle of His to Purkinje fibers to AV node
D) SA node to AV node to bundle of His to Purkinje fibers
Ans: SA node to AV node to bundle of His to Purkinje fibers
The normal electrophysiological conduction route is SA node to AV node to bundle of HIS to Purkinje
fibers.

A patient has had a myocardial infarction and has been diagnosed as having damage to the layer of the
heart responsible for the pumping action. You are aware that the damage occurred where?
A) Endocardium
B) Pericardium
C) Myocardium
D) Visceral pericardium
Ans: Myocardium
The myocardium is the layer of the heart responsible for the pumping action.

The nurse working on a cardiac care unit is caring for a patient whose stroke volume has increased. The
nurse is aware that afterload influences a patient's stroke volume. The nurse recognizes that afterload is
increased when there is what?
A) Arterial vasoconstriction
B) Venous vasoconstriction
C) Arterial vasodilation
D) Venous vasodilation
Ans: Arterial vasoconstriction
Arterial vasoconstriction increases the systemic vascular resistance, which increases the afterload.
Venous vasoconstriction decreases preload thereby decreasing stroke volume. Venous vasodilation
increases preload.

A nurse is preparing a patient for scheduled transesophageal echocardiography. What action should the
nurse perform?
A) Instruct the patient to drink 1 liter of water before the test.
B) Administer IV benzodiazepines and opioids.
C) Inform the patient that she will remain on bed rest following the procedure.
D) Inform the patient that an access line will be initiated in her femoral artery.
Ans: Inform the patient that she will remain on bed rest following the procedure.
During the recovery period, the patient must maintain bed rest with the head of the bed elevated to 45
degrees. The patient must be NPO 6 hours preprocedure. The patient is sedated to make him or her
comfortable, but will not be heavily sedated, and opioids are not necessary. Also, the patient will have a
peripheral IV line initiated preprocedure.

The nurse is caring for a patient admitted with angina who is scheduled for cardiac catheterization. The
patient is anxious and asks the reason for this test. What is the best response?
A) "Cardiac catheterization is usually done to assess how blocked or open a patients coronary arteries
are."
B) "Cardiac catheterization is most commonly done to detect how efficiently a patient's heart muscle
contracts."
C) "Cardiac catheterization is usually done to evaluate cardiovascular response to stress."
D) "Cardiac catheterization is most commonly done to evaluate cardiac electrical activity."
Ans: Cardiac catheterization is usually done to assess how blocked or open a patients coronary arteries
are.
Cardiac catheterization is usually used to assess coronary artery patency to determine if
revascularization procedures are necessary. A thallium stress test shows myocardial ischemia after
stress. An ECG shows the electrical activity of the heart.

The critical care nurse is caring for a patient who has had an MI. The nurse should expect to assist with
establishing what hemodynamic monitoring procedure to assess the patient's left ventricular function?
A) Central venous pressure (CVP) monitoring
B) Pulmonary artery pressure monitoring (PAPM)
C) Systemic arterial pressure monitoring (SAPM)
D) Arterial blood gases (ABG)
Ans: Pulmonary artery pressure monitoring (PAPM)
PAPM is used to assess left ventricular function. CVP is used to assess right ventricular function; SAPM is
used for continual assessment of BP. ABG are used to assess for acidic and alkalotic levels in the blood.

A critically ill patient is admitted to the ICU. The physician decides to use intra-arterial pressure
monitoring. After this intervention is performed, what assessment should the nurse prioritize in the plan
of care?
A) Fluctuations in core body temperature
B) Signs and symptoms of esophageal varices
C) Signs and symptoms of compartment syndrome
D) Perfusion distal to the insertion site
Ans: Perfusion distal to the insertion site
The radial artery is the usual site selected. However, placement of a catheter into the radial artery can
further impede perfusion to an area that has poor circulation. As a result, the tissue distal to the
cannulated artery can become ischemic or necrotic. Vigilant assessment is thus necessary. Alterations in
temperature and the development of esophageal varices or compartment syndrome are not high risks.
The nurse is caring for an acutely ill patient who has central venous pressure monitoring in place. What
intervention should be included in the care plan of a patient with CVP in place?
A) Apply antibiotic ointment to the insertion site twice daily.
B) Change the site dressing whenever it becomes visibly soiled.
C) Perform passive range-of-motion exercises to prevent venous stasis.
D) Aspirate blood from the device once daily to test pH.
Ans: Change the site dressing whenever it becomes visibly soiled.
Gauze dressings should be changed every 2 days or transparent dressings at least every 7 days and
whenever dressings become damp, loosened, or visibly soiled. Passive ROM exercise is not indicated and
it is unnecessary and inappropriate to aspirate blood to test it for pH. Antibiotic ointments are
contraindicated.

A patient is brought into the ED by family members who tell the nurse the patient grabbed his chest and
complained of substernal chest pain. The care team recognizes the need to monitor the patient's cardiac
function closely while interventions are performed. What form of monitoring should the nurse
anticipate?
A) Left-sided heart catheterization
B) Cardiac telemetry
C) Transesophageal echocardiography
D) Hardwire continuous ECG monitoring
Ans: Hardwire continuous ECG monitoring
Two types of continuous ECG monitoring techniques are used in health care settings: hardwire cardiac
monitoring, found in EDs, critical care units, and progressive care units; and telemetry, found in general
nursing care units or outpatient cardiac rehabilitation programs. Cardiac catheterization and
transesophageal echocardiography would not be used in emergent situations to monitor cardiac
function.

The nurse is performing an intake assessment on a patient with a new diagnosis of coronary artery
disease. What would be the most important determination to make during this intake assessment?
A) Whether the patient and involved family members understand the role of genetics in the etiology of
the disease
B) Whether the patient and involved family members understand dietary changes and the role of
nutrition
C) Whether the patient and involved family members are able to recognize symptoms of an acute
cardiac problem and respond appropriately
D) Whether the patient and involved family members understand the importance of social support and
community agencies
Ans: Whether the patient and involved family members are able to recognize symptoms of an acute
cardiac problem and respond appropriately
During the health history, the nurse needs to determine if the patient and involved family members are
able to recognize symptoms of an acute cardiac problem, such as acute coronary syndrome (ACS) or HF,
and seek timely treatment for these symptoms. Each of the other listed topics is valid, but the timely
and appropriate response to a cardiac emergency is paramount.

The nurse is relating the deficits in a patient's synchronization of the atrial and ventricular events to his
diagnosis. What are the physiologic characteristics of the nodal and Purkinje cells that provide this
synchronization? Select all that apply.
A) Loop connectivity
B) Excitability
C) Automaticity
D) Conductivity
E) Independence
Ans: Excitability, Automaticity, Conductivity
Three physiologic characteristics of two types of specialized electrical cells, the nodal cells and the
Purkinje cells, provide this synchronization: automaticity, or the ability to initiate an electrical impulse;
excitability, or the ability to respond to an electrical impulse; and conductivity, the ability to transmit an
electrical impulse from one cell to another. Loop connectivity is a distracter for this question.
Independence of the cells has nothing to do with the synchronization described in the scenario.
The nurse's assessment of an older adult client reveals the following data: Lying BP 144/82 mm Hg;
sitting BP 121/69 mm Hg; standing BP 98/56 mm Hg. The nurse should consequently identify what
nursing diagnosis in the patient's plan of care?
A) Risk for ineffective breathing pattern related to hypotension
B) Risk for falls related to orthostatic hypotension
C) Risk for ineffective role performance related to hypotension
D) Risk for imbalanced fluid balance related to hemodynamic variability
Ans: Risk for falls related to orthostatic hypotension
Orthostatic hypotension creates a significant risk for falls due to the dizziness and lightheadedness that
accompanies it. It does not normally affect breathing or fluid balance. The patient's ability to perform
normal roles may be affected, but the risk for falls is the most significant threat to safety.

A brain (B-type) natriuretic peptide (BNP) sample has been drawn from an older adult patient who has
been experienced vital fatigue and shortness of breath. This test will allow the care team to investigate
the possibility of what diagnosis?
A) Pleurisy
B) Heart failure
C) Valve dysfunction
D) Cardiomyopathy
Ans: Heart failure
The level of BNP in the blood increases as the ventricular walls expand from increased pressure, making
it a helpful diagnostic, monitoring, and prognostic tool in the setting of HF. It is not specific to
cardiomyopathy, pleurisy, or valve dysfunction.

A lipid profile has been ordered for a patient who has been experiencing cardiac symptoms. When
should a lipid profile be drawn in order to maximize the accuracy of results?
A) As close to the end of the day as possible
B) After a meal high in fat
C) After a 12-hour fast
D) Thirty minutes after a normal meal
Ans: After a 12-hour fast
Although cholesterol levels remain relatively constant over 24 hours, the blood specimen for the lipid
profile should be obtained after a 12-hour fast.

When hemodynamic monitoring is ordered for a patient, a catheter is inserted into the appropriate
blood vessel or heart chamber. When assessing a patient who has such a device in place, the nurse
should check which of the following components? Select all that apply.
A) A transducer
B) A flush system
C) A leveler
D) A pressure bag
E) An oscillator
Ans: A transducer, A flush system, A pressure bag
To perform hemodynamic monitoring, a CVP, pulmonary artery, or arterial catheter is introduced into
the appropriate blood vessel or heart chamber. It is connected to a pressure monitoring system that has
several components. Included among these are a transducer, a flush system, and a pressure bag. A
pressure monitoring system does not have a leveler or an oscillator.

The critical care nurse is caring for a patient who has been experiencing bradycardia after cardiovascular
surgery. The nurse knows that the heart rate is determined by myocardial cells with the fastest inherent
firing rate. Under normal circumstances where are these cells located?
A) SA node
B) AV node
C) Bundle of His
D) Purkinje cells
Ans: SA node
The heart rate is determined by the myocardial cells with the fastest inherent firing rate. Under normal
circumstances, the SA node has the highest inherent rate (60 to 100 impulses per minute).

The nurse is doing discharge teaching with a patient who has coronary artery disease. The patient asks
why he has to take an aspirin every day if he doesn't have any pain. What would be the nurse's best
response?
A) "Taking an aspirin every day is an easy way to help restore the normal function of your heart."
B) "An aspirin a day can help prevent some of the blockages that can cause chest pain or heart attacks."
C) "Taking an aspirin every day is a simple way to make your blood penetrate your heart more freely."
D) "An aspirin a day eventually helps your blood carry more oxygen that it would otherwise."
Ans: An aspirin a day can help prevent some of the blockages that can cause chest pain or heart attacks.
An aspirin a day is a common nonprescription medication that improves outcomes in patients with CAD
due to its antiplatelet action. It does not affect oxygen carrying capacity or perfusion. Aspirin does not
restore cardiac function.

The physician has ordered a high-sensitivity C-reactive protein (hs-CRP) drawn on a patient. The results
of this test will allow the nurse to evaluate the role of what process that is implicated in the
development of atherosclerosis?
A) Immunosuppression
B) Inflammation
C) Infection
D) Hemostasis
Ans: Inflammation
High-sensitivity CRP is a protein produced by the liver in response to systemic inflammation.
Inflammation is thought to play a role in the development and progression of atherosclerosis.

The patient has a homocysteine level ordered. What aspects of this test should inform the nurse's care?
Select all that apply.
A) A 12-hour fast is necessary before drawing the blood sample.
B) Recent inactivity can depress homocysteine levels.
C) Genetic factors can elevate homocysteine levels.
D) A diet low in folic acid elevates homocysteine levels.
E) An ECG should be performed immediately before drawing a sample.
Ans: A 12-hour fast is necessary before drawing the blood sample, Genetic factors can elevate
homocysteine levels, A diet low in folic acid elevates homocysteine levels
Genetic factors and a diet low in folic acid, vitamin B6, and vitamin B12 are associated with elevated
homocysteine levels. A 12-hour fast is necessary before drawing a blood sample for an accurate serum
measurement. An ECG is unnecessary and recent inactivity does not influence the results of the test.

A patient with a complex cardiac history is scheduled for transthoracic echocardiography. What should
the nurse teach the patient in anticipation of this diagnostic procedure?
A) The test is noninvasive, and nothing will be inserted into the patient's body.
B) The patient's pain will be managed aggressively during the procedure.
C) The test will provide a detailed profile of the heart's electrical activity.
D) The patient will remain on bed rest for 1 to 2 hours after the test.
Ans: The test is noninvasive, and nothing will be inserted into the patient's body.
Before transthoracic echocardiography, the nurse informs the patient about the test, explaining that it is
painless. The test does not evaluate electrophysiology and bed rest is unnecessary after the procedure.

A critical care nurse is caring for a patient with a hemodynamic monitoring system in place. For what
complications should the nurse assess? Select all that apply.
A) Pneumothorax
B) Infection
C) Atelectasis
D) Bronchospasm
E) Air embolism
Ans: Pneumothorax, Infection, Air embolism
Complications from use of hemodynamic monitoring systems are uncommon, but can include
pneumothorax, infection, and air embolism. Complications of hemodynamic monitoring systems do not
include atelectasis or bronchospasm.

The nurse is caring for a patient who has central venous pressure (CVP) monitoring in place. The nurse's
most recent assessment reveals that CVP is 7 mm Hg. What is the nurse's most appropriate action?
A) Arrange for continuous cardiac monitoring and reposition the patient.
B) Remove the CVP catheter and apply an occlusive dressing.
C) Assess the patient for fluid overload and inform the physician.
D) Raise the head of the patient's bed and have the patient perform deep breathing exercise, if possible.
Ans: Assess the patient for fluid overload and inform the physician.
The normal CVP is 2 to 6 mm Hg. Many problems can cause an elevated CVP, but the most common is
due to hypervolemia. Assessing the patient and informing the physician are the most prudent actions.
Repositioning the patient is ineffective and removing the device is inappropriate.

A critical care nurse is caring for a patient with a pulmonary artery catheter in place. What does this
catheter measure that is particularly important in critically ill patients?
A) Pulmonary artery systolic pressure
B) Right ventricular afterload
C) Pulmonary artery pressure
D) Left ventricular preload
Ans: Left ventricular preload
Monitoring of the pulmonary artery diastolic and pulmonary artery wedge pressures is particularly
important in critically ill patients because it is used to evaluate left ventricular filling pressures (i.e., left
ventricular preload). This device does not directly measure the other listed aspects of cardiac function.

A patient's declining cardiac status has been attributed to decreased cardiac action potential.
Interventions will be aimed at restoring what aspect of cardiac physiology?
A) The cycle of depolarization and repolarization
B) The time it takes from the firing of the SA node to the contraction of the ventricles
C) The time between the contraction of the atria and the contraction of the ventricles
D) The cycle of the firing of the AV node and the contraction of the myocardium
Ans: The cycle of depolarization and repolarization
This exchange of ions creates a positively charged intracellular space and a negatively charged
extracellular space that characterizes the period known as depolarization. Once depolarization is
complete, the exchange of ions reverts to its resting state; this period is known as repolarization. The
repeated cycle of depolarization and repolarization is called the cardiac action potential.

A patient has been scheduled for cardiovascular computed tomography (CT) with contrast. To prepare
the patient for this test, what action should the nurse perform?
A) Keep the patient NPO for at least 6 hours prior to the test.
B) Establish peripheral IV access.
C) Limit the patient's activity for 2 hours before the test.
D) Teach the patient to perform incentive spirometry.
Ans: Establish peripheral IV access.
An IV is necessary if contrast is to be used to enhance the images of the CT. The patient does not need
to fast or limit his or her activity. Incentive spirometry is not relevant to this diagnostic test.

The student nurse is preparing a teaching plan for a patient being discharged status post MI. What
should the student include in the teaching plan? (Mark all that apply.)
A) Need for careful monitoring for cardiac symptoms
B) Need for carefully regulated exercise
C) Need for dietary modifications
D) Need for early resumption of prediagnosis activity
E) Need for increased fluid intake
Ans: Need for careful monitoring for cardiac symptoms, Need for carefully regulated exercise, Need for
dietary modifications
Dietary modifications, exercise, weight loss, and careful monitoring are important strategies for
managing three major cardiovascular risk factors: hyperlipidemia, hypertension, and diabetes. There is
no need to increase fluid intake and activity should be slowly and deliberately increased.

The nurse is caring for a patient who is undergoing an exercise stress test. Prior to reaching the target
heart rate, the patient develops chest pain. What is the nurse's most appropriate response?
A) Administer sublingual nitroglycerin to allow the patient to finish the test.
B) Initiate cardiopulmonary resuscitation.
C) Administer analgesia and slow the test.
D) Stop the test and monitor the patient closely.
Ans: Stop the test and monitor the patient closely.
Signs of myocardial ischemia would necessitate stopping the test. CPR would only be necessary if signs
of cardiac or respiratory arrest were evident.