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High Acuity Ex. 2 Practice Questions > Shock & Hemodynamics > Flashcards

Flashcards in Shock & Hemodynamics Deck (56):
1

The nurse is caring for a patient with sepsis. On completing the hemodynamic assessment the nurse notes that the patient's afterload, measured by the systemic vascular resistance, is 400 dynes/sec/cm-5. The nurse evaluates this finding to be primarily the result of which change associated with sepsis?

1. Decreased circulating volume

2. Reaction to antibiotics used to treat sepsis

3. Marked vasodilation

4. Decreased ventricular contractility

Correct Answer: 3

Rationale 1: Hemodynamic changes associated with sepsis are not caused by low circulating volume.

Rationale 2: The primary reason for decreased vascular resistance is not related to reaction to medications.

Rationale 3: Sepsis, through its release of inflammatory mediators, causes vasodilation, resulting in the markedly low systemic vascular resistance.

Rationale 4: Ventricular contractility may be reduced following the release of myocardial depressant factor as a result of sepsis. However, this is not the primary cause of decreased vascular resistance.

1

A patient is admitted to the emergency department with severe burn injuries. The nurse’s priority actions are to prevent development of which type of shock?

1. Cardiogenic

2. Hypovolemic

3. Distributive

4. Obstructive

Correct Answer: 2

Rationale 1: Cardiogenic shock may develop in this patient if injury stress results in myocardial infarction. However, immediate actions are focused on a different type of shock.

Rationale 2: Hypovolemic shock states are a result of a decrease in vascular volume, which leads to a decrease in cardiac output. Severe burns will cause loss of intravascular fluids from the skin and may lead to this shock state. This is a critical issue in the emergent care of the patient with burn injury and is the priority.

Rationale 3: Distributive shock, particularly septic shock, is a potential complication for patients with burn injury and the nurse will take measures to prevent wound contamination. However, this is not the highest priority in emergent burn care.

Rationale 4: Depending upon other injuries the patient with burns may develop obstructive shock, but this is not the nurse’s highest priority in emergent care.

3

The nurse is caring for a patient whose pulmonary artery wedge pressure is 16 mm Hg. The patient’s neck veins are flat, lungs are clear, and the pulse pressure is low. Which intervention would the nurse anticipate?

1. Administer a 500 mL normal saline fluid bolus.

2. Repeat the reading after recalibrating the system.

3. Repeat the reading after repositioning the patient.

4. Administer a diuretic and a vasodilator.

Correct Answer: 4

Rationale 1: Administering a 500 mL normal saline fluid bolus would be expected if preload were low.

Rationale 2: The assessment findings presented match the PAWP reading, so no repeat of the measurement is necessary.

Rationale 3: The patient should be placed in the supine position whenever completing a hemodynamic assessment. Repositioning the patient is unlikely to affect the reading.

Rationale 4: The normal pulmonary artery wedge pressure is 4 to 12 mm Hg. A reading of 16 mm Hg indicates high preload, and the nurse can anticipate administering a diuretic and a vasodilator to help reduce preload.

3

A patient in shock has been sedated using a propofol (Diprivan) drip. How will the nurse assess this patient’s mental status?

1. Temporarily discontinue the drip and assess mental status within a few minutes.

2. Temporarily discontinue the drug and plan to assess mental status in an hour.

3. Use “train of four” testing while the medication is still infusing.

4. This assessment will have to wait until the sedating drug is no longer needed.

Correct Answer: 1

Rationale 1: Propofol has a very short half-life, so assessment of mental status can occur within a few minutes of the drugs discontinuation.

Rationale 2: Benzodiazepines used for sedation require discontinuation of the drug for a longer time in order for mental status assessment to be valid.

Rationale 3: “Train of four” testing is used when the patient is receiving neuromuscular blocking agents.

Rationale 4: Mental status should be assessed frequently and cannot be safely deferred until sedation is no longer needed.

3

A patient is being treated with acetaminophen and a cooling blanket for persistent hyperthermia. Which assessment finding would the nurse evaluate as indicating therapy has been too aggressive?

1. The patient complains of a severe headache.

2. The patient’s urine output has dropped.

3. The patient begins to shiver.

4. The patient develops a cough.

Correct Answer: 3

Rationale 1: Development of a severe headache should be evaluated, but is not associated with treatment for hyperthermia.

Rationale 2: Decreased urine output is not associated with treatment for hyperthermia.

Rationale 3: Shivering increases metabolism and oxygen consumption and should be avoided. It may indicate that efforts at decreasing hyperthermia have been too aggressive and should be modified.

Rationale 4: Development of a cough is not associated with treatment for hyperthermia.

4

A patient is admitted for evaluation of hypotension. Which assessment by the nurse would require immediate attention?

1. Pulmonary artery wedge pressure of 2 mm Hg

2. Heart rate of 112

3. Urine output of 25 mL/hr

4. Presence of rales at both lung bases

Correct Answer: 1

Rationale 1: The normal pulmonary artery wedge pressure is 4 to 12 mm Hg. A wedge pressure of 2 mm Hg is indicative of significant hypovolemia. Additional assessment is critical.

Rationale 2: Although a heart rate of 112 is abnormal it is not the most significant of the findings provided.

Rationale 3: Urine output of 25 mL/hr is low to low normal, but is not the most significant finding provided.

Rationale 4: Rales at lung bases are an abnormal finding, but unless the patient has significant respiratory distress, they would not require immediate intervention. This is not the most significant finding provided.

4

A patient requires insertion of a pulmonary artery catheter. Which nursing action is indicated?

1. Instill air in all stopcocks.

2. Prime the pressure monitoring system.

3. Call for the rapid response team.

4. Obtain sterile gowns, gloves, caps, and masks for all persons who will be present during the insertion.

Correct Answer: 2

Rationale 1: Air should be removed from all stopcocks.

Rationale 2: The pressure monitoring system should be primed to remove all air.

Rationale 3: There is no need for rapid response team intervention.

Rationale 4: The people inserting the catheter will wear sterile gowns, gloves, caps, and masks. Others in the room should wear a cap and mask.

4

A patient’s cardiac index will be calculated. What nursing interventions are necessary before this calculation is completed?  Select all that apply.

Standard Text: Select all that apply.

1. Assure that there is an accurate current weight on the medical record.

2. Compare fluid input and output for the last 12 hours.

3. Measure the patient’s height.

4. Figure the patient’s age in years and months.

5. Obtain the patient’s current heart rate.

Correct Answer: 1,3,5

Rationale 1: Weight is a component of cardiac index.

Rationale 2: There is no need to compare fluid intake and output in order to calculate cardiac index.

Rationale 3: Height is used to calculate cardiac index.

Rationale 4: Age is not a consideration when calculating cardiac index.

Rationale 5: Heart rate is a component of cardiac index.

4

A patient, with a steadily increasing preload, was experiencing a corresponding increase in stroke volume but it has now begun to decrease. Which rationale would the nurse provide for this occurrence?

1. This fluctuation will occur until maximum preload has been reached.

2. The patient’s heart rate is increasing, which causes a drop in stroke volume.

3. The patient’s preload has reached a critical point and now stroke volume will decrease.

4. It is necessary to assess for a secondary pathophysiological event causing the stroke volume to decrease.

Correct Answer: 3

Rationale 1: There is a point of maximum preload, but the cardiac output does not fluctuate until it is reached.

Rationale 2: The information in this question does not support increase in the heart rate.

Rationale 3: Until a critical point is reached, as preload increases, so does stroke volume. An optimal preload leads to an optimal stroke volume. Once past this point, an increase in preload results in a decrease in stroke volume. If the heart receives too much preload, it cannot effectively pump out that volume and stroke volume decreases. Stroke volume decreases because too much volume causes excessive stretching of the myocardial fibers and the ventricles cannot effectively contract.

Rationale 4: There is no need to look for a different pathophysiological event as the event at present is sufficient to cause decrease in cardiac output.

5

A patient is admitted with the complaint of chest pain. Questions about which history will best help the nurse determine if the pain is from cardiac or pulmonary origin?

1. Deficits in movement, timing of the pain, and dietary changes in the last 24 hours

2. What precipitated the pain, what it feels like, and where it is located

3. Changes in dietary habits, smoking history, and presence of cough       

4. What home remedies were tried, activity level, and fluid intake changes

Correct Answer: 2

Rationale 1: Deficits in movement, timing of the pain, and dietary changes in the last 24 hours are not associated with either cardiac or pulmonary pain.

Rationale 2: Precipitating factors, quality, and location will help the health care team discriminate between pain of cardiac origin and pain of respiratory origin.

Rationale 3: This is important information to obtain, but would not help differentiate between pain of cardiac origin and pain of respiratory origin.

Rationale 4: This is important information, but will not help to differentiate between pain of cardiac origin and pain of respiratory origin.

6

A patient being evaluated for septic shock has a serum lactate level of 5 mmol/L. What intervention does the nurse anticipate?

1. Decreasing the amount of oxygen being given

2. Immediate initiation of fluid resuscitation

3. Repeat of the testing in 4 hours

4. Bedside fingerstick level of blood glucose

Correct Answer: 2

Rationale 1: An increased serum lactate calls for increased oxygenation.

Rationale 2: A lactate level of 4 mmol/L is suspicious of significant tissue hypoperfusion and requires immediate fluid resuscitation.

Rationale 3: There is no need to repeat this test before intervening.

Rationale 4: Measuring blood glucose is not indicated by this lab result.

7

The nurse is caring for a patient who is being monitored with a pulmonary artery catheter. Which change requires immediate intervention?

1. Systemic vascular resistance of 900 dynes/sec/cm5

2. Appearance of an "a" wave on the pulmonary artery waveform

3. Pulmonary artery wedge pressure of 10 mm Hg

4. Spontaneous development of a pulmonary artery wedge pressure waveform

Correct Answer: 4

Rationale 1: A systemic vascular resistance of 900 is normal.

Rationale 2: The "a" wave is indicative of the rise in atrial pressure produced by left atrial contraction and is normal.

Rationale 3: A pulmonary arterial wedge pressure of 10 mm Hg is within normal limits.

Rationale 4: A permanent wedge waveform is an indication of catheter migration further into the pulmonary artery causing occlusion. Immediate intervention is needed to prevent pulmonary infarction.

8

Which assessment techniques will the nurse use to evaluate the patient’s cardiac output?  Select all that apply

1. Inspection of color changes in the periphery

2. Strength of pulses

3. Percussion of heart borders

4. Auscultation of heart sounds

5. Pulse pressure determination

Correct Answer: 1,2,4,5

Rationale 1: Color changes in the periphery can indicate decreased cardiac output.

Rationale 2: Strength of pulse is an indirect measure of cardiac output and contractility.

Rationale 3: Percussion is incorrect because it measures heart size very crudely but not output.

Rationale 4: Auscultation helps the nurse assess heart rate and rhythm which can alter cardiac output.

Rationale 5: Determination of pulse pressure is an indirect measure of stroke volume which is a component of cardiac output.

9

A patient is admitted with a decrease in cardiac output. Which assessment findings would the nurse attribute to that condition?

1. Increased output of very clear urine

2. Changes in skin color

3. Localized edema in the calf

4. Skin that is warm and damp

Correct Answer: 2

Rationale 1: A decrease in cardiac output generally results in a decrease in urine output.

Rationale 2: Changes in skin color can be a sign of hemodynamic compromise and a decrease in cardiac output.

Rationale 3: Localized edema in the calf is indicative of obstruction of venous blood flow from a clot in a leg vein.

Rationale 4: Cool skin is a finding associated with decreased cardiac output.

10

A patient with congestive heart failure is receiving scheduled doses of an intravenous diuretic. After administering the drug, which finding would indicate to the nurse that the drug was effective?

1. A pulmonary artery wedge pressure of 16 mm Hg

2. Pulmonary artery pressure of 34/16 mm Hg

3. Systemic vascular resistance of 1,400 dynes/sec/cm-5

4. A right atrial pressure of 5 mm Hg

Correct Answer: 4

Rationale 1: Normal pulmonary arterial wedge pressure is 4 to 12; 16 is high and would indicate high preload.

Rationale 2: Normal pulmonary artery pressure is 20 to 30 mm Hg/8 to 15 mm Hg. These pressures should decrease with diuretic administration.

Rationale 3: Normal systemic vascular resistance is 800 to 1,200 dynes/sec/cm-5. With diuretic use, the systemic vascular resistance should also normalize.

Rationale 4: A right atrial pressure of 5 is a normal reading and would indicate the diuretic is having its intended effect.

10

Which nursing interventions are indicated when measuring pulmonary artery wedge pressure (PAWP)?  Select all that apply.

1. Use no more than 1.25 mL of air to inflate the balloon.

2. Pull back on the syringe to deflate the balloon.

3. Leave the balloon slightly inflated to maintain integrity.

4. Maintain balloon inflation for 3 to 5 minutes to obtain a stable reading.

5. If there is any resistance during inflation do not continue.

Correct Answer: 1,5

Rationale 1: Using the smallest inflation volume possible, typically less than 1.25 mL, reduces the risk of balloon rupture.

Rationale 2: Passive deflation should be used to avoid damage to the balloon.

Rationale 3: The balloon should be completely deflated to avoid a continuous wedge, which could lead to pulmonary infarction.

Rationale 4: The balloon should be inflated only long enough to obtain a stable reading.

Rationale 5: Resistance may indicate that the balloon is compromising the artery. The nurse should stop inflation, allow the balloon to passively deflate and call the health care provider.

10

A patient hospitalized for treatment of a severe urinary tract infection may be developing septic shock. The nurse would monitor for the development of which finding associated with early septic shock?

1. Cold extremities

2. Increase in serum lactate levels

3. Decreased SCVO2

4. Widening of pulse pressure

Correct Answer: 4

Rationale 1: Cold and mottled extremities are associated with later stages of septic shock.

Rationale 2: Increased serum lactate levels indicate a later stage of shock.

Rationale 3: Decreased SCVO2 indicates a later stage of shock.

Rationale 4: Since the patient’s diastolic blood pressure decreases, the pulse pressure increases. This finding is associated with early stages of septic shock

11

A patient is being prepared for impedance cardiography. Which information will the nurse provide?

1. “This technology will use ultrasound to measure your heart rate and blood flow.”

2. “We are preparing to measure the oxygenation of your peripheral tissues.”

3. “A catheter will be inserted into a vein in your neck.”

4. “Electrodes will be placed on your neck and your lateral chest.”

Correct Answer: 4

Rationale 1: Doppler technology uses ultrasound through a probe to measure heart rate and blood flow.

Rationale 2: Pulse oximetry is used to measure peripheral oxygenation of tissues.

Rationale 3: Cannulation of the right subclavian or internal jugular vein is necessary for placement of a central venous catheter.

Rationale 4: Impedance cardiography is used to assess cardiac function through the use of a high-frequency, low-amplitude current to measure the resistance to flow of the electrical current. The procedure includes placing electrodes bilaterally at the base of the neck and on the lateral chest at the level of the diaphragm.

12

A patient who sustained a gunshot wound walks into the emergency department and collapses. Which priority directions should the nurse who assumes this patient’s care give to those coming to assist?  Select all that apply.

1. Check the airway.

2. Bring a wheelchair.

3. Put direct pressure on the leg wound.

4. Check for identification.

5. Check the pulse.

Correct Answer: 1,3,5

Rationale 1: Airway patency is the most important intervention for this patient.

Rationale 2: This patient will likely need to be transported by stretcher.

Rationale 3: Controlling the source of the fluid loss is imperative.

Rationale 4: Checking for identification can wait until more pertinent interventions are performed.

Rationale 5: The patient may have collapsed due to cardiac arrest from hypovolemia. Checking the pulse is part of the immediate assessment.

13

The nurse is caring for a patient having a transesophageal echocardiogram (TEE). What is an appropriate nursing intervention for the care of this patient?

1. Dim the lights in the room.

2. Monitor for bradycardia and hypotension.

3. Assess pedal pulses bilaterally.

4. Apply pressure to the puncture site.

Correct Answer: 2

Rationale 1: There is no specific reason to dim the room lights.

Rationale 2: The TEE is done under conscious sedation. During and immediately after the procedure, the nurse assesses for bradycardia and hypotension because of possible stimulation of the patient's vagus nerve.

Rationale 3: There is no specific indication that assessing pedal pulses is necessary during this procedure.

Rationale 4: There is no puncture site in a TEE.

14

A patient is scheduled for an echocardiogram with measurement of ejection fraction. The nurse explains to the patient that this test will provide the most information about which cardiac characteristic?

1. The amount of blood the heart pumps every minute

2. The strength of the heartbeat

3. The amount of resistance the heart beats against

4. The amount of blood in the heart before it beats

Correct Answer: 2

Rationale 1: The amount of blood the heart pumps every minute is the cardiac output. Ejection fraction is related to cardiac output, but describing cardiac output does not fully explain ejection fraction.

Rationale 2: Contractility is defined as the force of myocardial contraction and reflects the ability of the heart muscle to work independently of preload and afterload; the ability to function as a pump. Ejection fraction is a measure of the percent of blood ejected with each stroke volume and is used as an index of myocardial function.

Rationale 3: Afterload is the amount of resistance the heart must beat against. Increasing afterload will affect both ejection fraction and cardiac output.

Rationale 4: Preload represents the volume of blood in the ventricle at the end of diastole. A low preload can result in low cardiac output and may also affect ejection fraction.

16

The preceptor nurse is assisting a newly hired nurse with completion of hemodynamic assessment using a pulmonary artery catheter. Which action would require the preceptor to intervene?

1. Inflating the pressure bag to 300 mm Hg

2. Infusing a vasoactive drug through the proximal injectate port

3. Obtaining a pulmonary artery wedge pressure reading through the distal port

4. Using iced normal saline to obtain a cardiac output

Correct Answer: 2                  

Rationale 1: In order to overcome arterial pressure and prevent blood from backing up into the pressure tubing, the pressure bag placed around the flush solution should be inflated to 300 mm Hg.

Rationale 2: The proximal injectate port is the primary port used for obtaining cardiac output via boluses of iced or room temperature normal saline. Because of the risk of inadvertent bolus of potent medications, neither vasopressor nor vasodilators should be administered through the same port used for obtaining cardiac output. It would be safer to infuse vasoactive drugs through the proximal infusion port.

Rationale 3: The distal port is the designated port for continuous monitoring of the pulmonary artery pressure and for obtaining the pulmonary artery wedge pressure.

Rationale 4: Either iced or room temperature normal saline can effectively be used to obtain accurate cardiac output measurements.

17

A patient who has a pulmonary artery catheter in place is to receive the drug nitroprusside. The nurse would assess for which indicator of the drug’s effectiveness?

1. Decreased systemic vascular resistance

2. Decreased cardiac output

3. Increased right atrial pressure

4. Increased pulmonary artery wedge pressure

Correct Answer: 1

Rationale 1: Nitroprusside is a potent systemic vasodilator with primary action on decreasing afterload, which is measured by systemic vascular resistance.

Rationale 2: Nitroprusside should decrease cardiac workload and increase stroke volume which will increase cardiac output.

Rationale 3: Nitroprusside administration should result in right atrial pressure decrease.

Rationale 4: Pulmonary artery wedge pressure should decrease.

18

A patient is scheduled for an exercise electrocardiogram. The nurse will ensure that which objects are in the room prior to the beginning of the test?

1. Oral fluids

2. A defibrillator

3. External pacemaker

4. Portable chest x-ray machine

Correct Answer: 2

Rationale 1: There is no reason that oral fluids are required for this test.

Rationale 2: Emergency medications and a defibrillator should be present in the room during an exercise electrocardiogram test. The patient may respond poorly to the stress placed on the heart during exercise and may require an emergency response with this equipment.

Rationale 3: There is no specific indication that it is necessary to have an external pacemaker present when this testing is taking place.

Rationale 4: There is no reason for a portable x-ray machine to be present in the room during this test.

20

A patient who has a radial artery catheter in place is complaining of numbness and tingling in the fingers. What is the nurse’s priority assessment?

1. Is there a palpable pulse?

2. Is blood is easily obtained from the catheter?

3. Does the patient have a fever?

4. Does the waveform have a characteristic appearance?

Correct Answer: 1

Rationale 1: Monitoring circulation distal to the arterial insertion site is the priority nursing function. Skin color and temperature and all pulses should be regularly assessed and documented.

Rationale 2: It is important to be able to easily access blood from the catheter, but this is not the priority assessment.

Rationale 3: Fever might indicate an infection at the insertion site, but if this is occurring it will take time to treat. This is a very important assessment, but is not the highest priority.

Rationale 4: An appropriate and normal waveform is an assurance that the system is functioning and measurements would be accurate. However, this is not the most important for the patient's safety and prevention of complications.

21

A patient in shock has just been started on IV Dopamine at 5 mcg/kg/min. Which findings would the nurse evaluate as indication of a possible adverse effect of this therapy?  Select all that apply.

1. Persistent hypotension

2. Heart rate 118

3. Development of a bundle branch block

4. Drop in urine output

5. Mottling of extremities

Correct Answer: 2,3,4,5

Rationale 1: The rate of infusion of dopamine can be increased above that which is being given if hypotension is not resolved. This is not an adverse effect but may be a case of not getting enough drug. If the patient remains hypotensive at higher infusion rates (50 mcg/kg/min), an adverse effect may be occurring.

Rationale 2: Tachycardia can be an adverse effect of dopamine.

Rationale 3: Aberrant cardiac conduction may indicate an adverse drug effect is occurring.

Rationale 4: Tissue ischemia is an adverse effect of dopamine. Decreased blood flow to the kidney will cause decrease in urine output.

Rationale 5: Mottling of extremities indicates peripheral ischemia.

23

The nurse is preparing to use a patient’s pulmonary artery catheter to obtain hemodynamic measurements. Which nursing action is indicated?

1. Zero the transducer at the phlebostatic axis.

2. Place the patient in Trendelenburg position.

3. Warm cardiac output injectate fluid to body temperature.

4. Prepare 20 mL of injectate.

Correct Answer: 1

Rationale 1: The phlebostatic axis approximates the level of the right atrium and is considered to represent the level of the catheter tip.

Rationale 2: Trendelenburg position or the head down position may be used during insertion of the catheter to make visualization of the jugular approach easier. However, supine is the recommended position for hemodynamic readings.

Rationale 3: Injectate should be iced or room temperature but not warmed.

Rationale 4: The traditional method of thermodilution cardiac output uses a 10mL bolus of injectate.

24

Testing reveals that a patient’s myocardial infarction damaged the papillary muscles of the mitral valve. The nurse plans care based on the knowledge that the patient is at high risk for which complication?

1. Extension of the myocardial damage

2. Catastrophic left heart failure

3. Pulmonary edema from right heart failure

4. Pulmonary embolism from clots in the left atrium

Correct Answer: 2

Rationale 1: All patients who have MI are at risk for extension of the damage. It is not specific to this patient.

Rationale 2: The mitral valve is between the left ventricle and the left atrium. If the mitral valve suddenly becomes incompetent because of papillary muscle failure, catastrophic left heart failure will occur.

Rationale 3: The mitral valve is on the left side of the heart.

Rationale 4: The blood that goes through the mitral valve has already returned from the lungs and is about to be pumped to the systemic circulation.

25

Cardiac catheterization reveals that a patient has an isolated lesion in the right coronary artery that occludes 90% of the vessels’ lumen. The nurse plans care for this patient based on the knowledge that total occlusion of the artery will result in damage to which portion of the heart?

1. Right ventricle

2. Anterior aspect of the left ventricle

3. The septum

4. The lateral wall of the left ventricle

Correct Answer: 1

Rationale 1: The right coronary artery supplies the right ventricle.

Rationale 2: The left anterior descending artery supplies the anterior aspect of the left ventricle.

Rationale 3: The left anterior descending artery supplies the septum.

Rationale 4: The left circumflex artery supplies the lateral wall of the left ventricle.

26

A patient with left-sided heart failure is hospitalized with pulmonary edema. The nurse providing this patient’s care would consider which physiology when explaining this disorder to the patient’s family?

1. The normally high-pressure pulmonary circuit can damage lung tissue and cause pulmonary edema.

2. Since pulmonary veins have no valves, blood can back up into the lungs causing pulmonary edema.

3. The oxygen-rich blood that enters the pulmonary circuit tends to increase pressures in the tissue, causing pulmonary edema.

4. The arteries of the pulmonary circuit are single layer.

A patient with left-sided heart failure is hospitalized with pulmonary edema. The nurse providing this patient’s care would consider which physiology when explaining this disorder to the patient’s family?

1. The normally high-pressure pulmonary circuit can damage lung tissue and cause pulmonary edema.

2. Since pulmonary veins have no valves, blood can back up into the lungs causing pulmonary edema.

3. The oxygen-rich blood that enters the pulmonary circuit tends to increase pressures in the tissue, causing pulmonary edema.

4. The arteries of the pulmonary circuit are single layer.

27

A patient was admitted to the emergency room for treatment of severe infection. Which objective parameters would increase the nurse’s concern that shock is developing?  Select all that apply.

1. Serum lactate level is 5.4 mmol/L.

2. Base deficit is -12 mmol/L.

3. SvO2 is 68%.

4. pHi is 6.9.

5. Arterial pH of 7.38

Correct Answer: 1,2,4

Rationale 1: Lactate is the metabolic byproduct of pyruvate, which is formed as the result of anaerobic metabolism. Elevated levels mean that the body is depending, at least to some part, on anaerobic metabolism rather than the normal aerobic metabolism.

Rationale 2: This is a moderate base deficit and indicates buildup of lactic acidosis resulting from impaired tissue oxygenation.

Rationale 3: Normally, when oxygen supply and demand are in balance, hemoglobin is about 60% to 80% saturated after leaving the tissues.

Rationale 4: Low mucosal pH indicates development of acidosis.

Rationale 5: This is a normal arterial pH.

28

Which nursing actions are necessary to collect information needed to figure the patient’s cardiac index?  Select all that apply.

1. Weigh the patient.

2. Take the patient’s temperature.

3. Measure the patient’s blood pressure.

4. Measure the patient’s height.

5. Determine the patient’s age

Correct Answer: 1,4

Rationale 1: Calculating cardiac index requires knowledge of the patient’s weight.

Rationale 2: Body temperature is not used to figure cardiac index.

Rationale 3: Blood pressure is not used to figure cardiac index.

Rationale 4: In order to figure the cardiac index, the nurse must know that patient’s height.

Rationale 5: It is not necessary to know the patient’s age in order to determine cardiac index.

29

A patient has been admitted to the emergency department with bleeding from a traumatic amputation of the leg. Which findings would the nurse interpret as indicating this patient’s blood loss is severe?  Select all that apply.

1. Heart rate is 120.

2. Blood has soaked the dressing applied by first responders.

3. Blood pressure is 78/50.

4. Mild anxiety is present.

5. Heart rate is 50.

Correct Answer: 1,3

Rationale 1: Marked tachycardia, greater than 110 bpm, indicates severe volume loss.

Rationale 2: It is not possible to characterize blood loss by the appearance of a bandage. Blood may have been lost prior to the application of the bandage.

Rationale 3: Marked hypotension indicates severe blood loss.

Rationale 4: Presence of mild anxiety indicates moderate hypovolemia.

Rationale 5: As exsanguination occurs, heart rate will drop and the condition becomes life-threatening. This indicates massive blood loss.

30

A patient is admitted to the emergency department after fainting. Vital signs are blood pressure 86/60, heart rate 160 bpm, and respirations 20. The patient’s skin is cool to the touch. Which nursing diagnosis (NDX) is priority?

1. Risk for Falls

2. Fluid Volume Deficient

3. Decreased Cardiac Output

4. Impaired Gas Exchange

Correct Answer: 3

Rationale 1: This patient does have risk for injury from falling, but this NDX is not the current priority. Interventions to reverse the primary NDX will help to reduce this risk.

Rationale 2: Hypovolemia may result in syncope, but there is not enough information to evaluate whether this is occurring with this patient.

Rationale 3: Loss of consciousness, cool skin, low blood pressure, and increased heart rate all indicate decreased cardiac output. Tachycardia can result in decreased cardiac output by shortening ventricular filling time during diastole.

Rationale 4: The scenario does not present arterial blood gases, so a diagnosis of impaired gas exchange is not supported.

31

A patient who has been receiving norepinephrine (Levophed) at a rate of 10 mcg/min will have the drug discontinued. How should the nurse plan to manage this intervention?

1. Stop the infusion, but leave normal saline infusing at a rate to keep the vein open.

2. Stop the infusion and place an intermittent infusion cap on the IV access device.

3. Decrease the rate to 5 mcg/min for 30 minutes before discontinuing the infusion.

4. Decrease the rate by 1 mcg/min every 30 minutes while monitoring the patient’s response

Correct Answer: 4

Rationale 1: Abrupt withdrawal of this medication is not indicated.

Rationale 2: Abrupt withdrawal of this drug is not indicated.

Rationale 3: The infusion rate should not be abruptly lowered.

Rationale 4: The nurse should decrease the infusion slowly, while monitoring the patient’s response. This is the only response that does not result in abrupt withdrawal of the medication.

32

Review of the medical record reveals that a patient has a summation gallop. Which pattern of heart sounds would the nurse expect?

1. S1 followed closely by S2

2. S1 followed closely by S2 followed closely by S3

3. S1 followed closely by a split S2

4. S4 followed by S1 followed by S2 followed by S3 followed by S4

Correct Answer: 4

Rationale 1: S1-S2 is the normal lub-dub sound of the heart and does not represent a summation gallop.

Rationale 2: Presence of a third heart sound is documented as a ventricular gallop.

Rationale 3: Splitting of S2 does occur, but this is not documented as a summation gallop.

Rationale 4: The S4 heart sound is heart during atrial contraction, so it sounds as if it occurs before S1.

33

Which finding would cause the nurse to be concerned that a patient who sustained chest trauma is experiencing cardiac tamponade?

1. Distant heart sounds

2. Decrease of right arterial pressure

3. Sudden development of hypertension

4. Development of an S3 heart sound

Correct Answer: 1

Rationale 1: The presence of blood in the pericardial space makes the heart tones sound muffled or distant.

Rationale 2: Right arterial pressure increases with cardiac tamponade.

Rationale 3: Hypotension is associated with cardiac tamponade due to the heart’s inability to fill.

Rationale 4: S3 heart sounds are not associated with cardiac tamponade.

34

A patient being treated for a severe infection has a temperature of 35.8°C. Which additional finding would indicate to the nurse that initiation of treatment for sepsis is likely?

1. A shift to the left on the white blood cell differential

2. Heart rate 88

3. Respiratory rate 10

4. Acute alteration in mental status

Correct Answer: 1

Rationale 1: Greater than 10% bands on the white blood cell differential, or a shift to the left, along with this temperature would indicate sepsis has developed.

Rationale 2: Heart rate over 90, along with this temperature, indicates sepsis is present.

Rationale 3: Respiratory rate greater than 20, along with this temperature, indicate sepsis is present.

Rationale 4: Acute alteration in mental status is related to development of septic shock.

35

A nurse is providing care to a patient with progressive shock. Which nursing diagnosis is priority in guiding the selection of interventions for this patient?

1. Ineffective Airway Clearance

2. Ineffective Tissue Perfusion

3. Stress Overload

4. Impaired Skin Integrity

Correct Answer: 2

Rationale 1: Without additional assessment findings, it is not possible to determine if this patient has ineffective airway clearance.

Rationale 2: Shock occurs when oxygen delivery does not support tissue oxygen demands. This is a state of ineffective tissue perfusion and is the priority nursing diagnosis for all patients in shock.

Rationale 3: Undoubtedly this patient is experiencing stress, but this is not the highest priority nursing diagnosis.

Rationale 4: This patient may have impaired skin integrity, but not enough assessment data is provided to make that determination.

36

Testing indicates that a patient has a high preload. What changes would the nurse expect in this patient’s cardiac function?  Select all that apply

1. Heart rate will decrease.

2. Afterload will increase.

3. Stroke volume will decrease.

4. Stoke volume will increase.

5. Blood pressure will decrease.

Correct Answer: 3,4

Rationale 1: It is not possible to predict what change in heart rate will occur in the face of increased preload. Depending upon the pathophysiology causing the increased preload, the rate may increase, may decrease, or may stay the same.

Rationale 2: Afterload represents the force the heart must overcome to pump blood. It is not affected by preload.

Rationale 3: If the increase in preload is high enough that a critical point is reached stroke volume will decrease.

Rationale 4: The greater the volume of blood in the ventricle, the greater the amount of stretch that the fibers experience. To a point, this increase in stretch will result in an increase in stroke volume.

Rationale 5: It is not possible to determine if an increase in preload will cause a decrease in blood pressure. In most cases, increased preload will result in increased stroke volume which will result in increased blood pressure.

37

A patient who had a myocardial infarction this morning is now developing cardiogenic shock. Which nursing intervention is indicated?

1. Increase IV fluids.

2. Administer vasoconstricting drugs.

3. Provide care in a calm, reassuring manner.

4. Withhold oral fluids and nutrition.

Correct Answer: 3

Rationale 1: Increasing IV fluids is not indicated when the patient’s heart is already damaged. The physiological issue is not lack of fluid, but inability to pump fluid efficiently.

Rationale 2: It is more likely that vasodilating drugs like nitroglycerin will be administered.

Rationale 3: Providing care in a calm and quiet manner helps to decrease the patient’s anxiety, thereby reducing oxygen consumption.

Rationale 4: There is no reason to withhold oral fluids and nutrition that is evidenced by this scenario. If the patient appears to be deteriorating rapidly, withholding food may be indicated.

38

A patient is diagnosed with septic shock and has a decrease in afterload. The nurse would expect which initial changes in the patient’s cardiac status?  Select all that apply

1. Increase in cardiac output

2. Increase in blood pressure

3. Decrease in cardiac output

4. Decrease in blood pressure

5. No change in blood pressure or cardiac output

Correct Answer: 1,4

Rationale 1: Decreased afterload causes cardiac output to increase. This will occur initially in septic shock, but will change as sepsis continues.

Rationale 2: Since blood pressure is a product of cardiac output and afterload, a decrease in afterload causes a decrease in blood pressure.

Rationale 3: Initially the decrease in afterload will increase cardiac output.

Rationale 4: Decrease in afterload results in decrease in blood pressure.

Rationale 5: Changes in afterload will change both blood pressure and cardiac output.

39

The nurse is reviewing the results of a patient’s cardiac output curve and notes that the size of the curve is small. Which of the following does this finding indicate?

1. A low cardiac output

2. Poor injection technique

3. Incorrect placement of the catheter

4. A high cardiac output      

Correct Answer: 4

Rationale 1: A large curve indicates a slow return to baseline temperature and, therefore, a low cardiac output.

Rationale 2: The size of the curve does not indicate poor injection technique.

Rationale 3: A small cardiac output curve does not indicate incorrect placement of the catheter.

Rationale 4: A small curve indicates a rapid return of the blood to its baseline temperature and, therefore, a high cardiac output.

40

A patient has been admitted with chest pain and generalized discomfort. Which assessment is essential in order for the nurse to set realistic goals for patient therapy and education?

1. The patient's functional status prior to illness

2. Family history of disease, diet history, and prior medical history

3. Demographic data including age, sex, race, and weight of patient

4. Cardiovascular risk factors, such as history of smoking and stress level

Correct Answer: 1

Rationale 1: Knowledge of the patient's functional status prior to illness assists the nurse in setting goals that are realistic for the patient. The nurse must know the patient’s pre-illness capabilities.

Rationale 2: Family history, diet history, and prior medical history are important assessment components but do not directly indicate the patient’s capabilities.

Rationale 3: Demographic data is not as important as other assessment components for use in determining realistic goals.

Rationale 4: Cardiovascular risk factors, smoking history, and stress level may indicate areas in which education is needed but does not specifically address goals of therapy.

41

An adult patient is demonstrating anaphylaxis from an insect sting. What is the nurse’s priority intervention?

1. Benadryl (diphenhydramine) 50 mg intravenously

2. Oxygen at 3 liters via nasal cannula

3. Epinephrine 1:1000 0.5 mg sq

4. Normal saline at 150 mL/hr

Correct Answer: 3

Rationale 1: Administration of diphenhydramine is appropriate but is not the initial therapy.

Rationale 2: Oxygen should be administered, but is not the priority intervention.

Rationale 3: The patient in anaphylaxis experiences bronchial spasm and constriction. The administration of epinephrine is necessary to reverse this process and facilitate an open airway. This is the priority intervention.

Rationale 4: After experiencing anaphylaxis the patient will likely be hospitalized and given IV fluids. This is not the immediate priority.

42

The nurse is performing an assessment on a patient whose right atrial pressure is 12 mm Hg. Which findings would the nurse anticipate?

 

Standard Text: Select all that apply.

1. Jugular vein distention

2. Weak, thready pulse

3. Presence of rales and rhonchi

4. Poor skin turgor

5. Hepatomegaly

Correct Answer: 1,5

Rationale 1: Elevation of right arterial pressure indicates high right ventricular preload which results in fluid back up into the venous system. Jugular vein distention is a sign of increased right ventricular preload.

Rationale 2: The pulse is usually full and bounding when right atrial pressure is increased.

Rationale 3: Rales and rhonchi are signs of left-sided heart failure.

Rationale 4: Skin turgor is a manifestation of hydration status.

Rationale 5: Elevation of right arterial pressure indicates high right ventricular preload, which results in fluid back up into the venous system. Hepatomegaly is a sign of increased right ventricular preload.

43

The nurse is assessing a patient being treated for neurogenic shock after a spinal cord injury. Which assessment would the nurse evaluate as patient improvement?

1. Temperature of 97.8°F

2. Heart rate of 70 bmp

3. Resistance to ventilator-assisted breaths.

4. Pink skin tone

Correct Answer: 2

Rationale 1: Hypothermia is one of the triad of expected signs of neurogenic shock. This patient remains hypothermic.

Rationale 2: Bradycardia is one of the triad of expected signs of neurogenic shock. Return to a normal heart rate is a sign of improvement.

Rationale 3: Respiratory rate is not one of the triad of expected findings associated with neurogenic shock. The patient may be mechanically ventilated, but a change in acceptance of this assistance is not indicative of an improved shock status.

Rationale 4: Peripheral vasodilation produces a pink skin tone so this finding does not indicate improvement.

44

The nurse has auscultated the patient’s heart sounds and has measured vital signs. Which finding would the nurse evaluate as indicating greatest need for additional assessment?

1. Pulse pressure of 38 mm Hg

2. Bounding, vigorous pulse

3. Split of S2

4. Apical pulse of 66

Correct Answer: 3

Rationale 1: The pulse pressure reflects how much the heart is able to raise the pressure in the arterial system with each beat. Pulse pressure of 30 to 40 mm Hg does not indicate cause for concern because it is within the normal pulse pressure range.

Rationale 2: A bounding vigorous pulse indicates increased myocardial contractility and would require additional assessment. This is not the priority need for reassessment.

Rationale 3: The split of S2 indicates that one ventricle is emptying earlier or later than another and that contractility may, therefore, be diminished. This may be a result of a structural defect, a mechanical defect, or an electrical defect. This is the priority need for additional assessment.

Rationale 4: The normal range of apical pulse is 60 to 80, so this is not a priority for additional assessment.

45

A patient with cardiac decompensation is started on dobutamine at 1 mcg/kg/min with an order to titrate to effect. After receiving this dose for several minutes the patient develops tachycardia and occasional premature ventricular contractions. What nursing intervention is indicated?

1. Increase the dose to 1.5 mcg/kg/min.

2. Discontinue the infusion.

3. Decrease the infusion to 0.5 mcg/kg/min.

4. Contact the prescriber immediately.

Correct Answer: 3

Rationale 1: There is no indication to increase the dose.

Rationale 2: Discontinuing the infusion is not the first intervention.

Rationale 3: Decreasing the infusion rate may reverse these adverse cardiac effects.

Rationale 4: The order is given to titrate the drug to effect. There is no reason to contact the prescriber at this point.

46

A patient admitted to the emergency department following chest trauma has tracheal deviation to the left. The nurse would prepare for which emergency medical intervention?

1. Open thoracotomy

2. Placement of a chest tube

3. Open excision of the pericardial sac

4. Immediate cardiopulmonary resuscitation

Correct Answer: 2

Rationale 1: Open thoracotomy is not indicated for this complication.

Rationale 2: Tracheal deviation can result from mediastinal shifting due to a tension pneumothorax. Treatment is placement of a chest tube or a needle thoracotomy.

Rationale 3: Excision of the pericardial sac may be indicated when cardiac tamponade exists. There is no indication that this complication has developed.

Rationale 4: There is no indication that cardiopulmonary resuscitation is needed at this point.

47

A patient who was stabbed multiple times in the chest and abdomen has just returned from emergency surgery. Hemodynamic monitoring was initiated during surgery and now reveals that the patient’s right atrial pressure has dropped to 2 mmHg. The nurse would assess for findings of which conditions?

 

Standard Text: Select all that apply.

1. Internal hemorrhage

2. Fluid loss during surgery

3. Vasodilation from drugs administered during surgery

4. Left heart failure

5. Cardiac tamponade

Correct Answer: 1,2,3

Rationale 1: Hemorrhage is a cause of absolute fluid deficit and will be reflected in a low right atrial pressure.

Rationale 2: If the patient lost a significant amount of blood or other fluids during surgery the right atrial pressure could drop.

Rationale 3: Vasodilation reduces venous return to the right atrium, resulting in decrease of right atrial pressure.

Rationale 4: Left heart failure results in an increased volume in the pulmonary circulation which increases right atrial pressure.

Rationale 5: Cardiac tamponade or rapid fluid buildup in the pericardial space increases pressures on the heart and would result in increased right atrial pressure.

48

The nurse is assessing a patient's arterial waveform and notes a notch on the descending portion of the waveform. The nurse associates this notch with which physiological events?  Select all that apply.

1. Closure of the aortic valve

2. The highest systolic pressure

3. Systolic ejection of blood

4. The diastolic pressure

5. Beginning of ventricular diastole

Correct Answer: 1,5

Rationale 1: This “dicrotic” notch represents closure of the aortic valve.

Rationale 2: When the aortic valve opens, blood is ejected into the aorta. This forms a steep upstroke on the arterial waveform, called the anacrotic limb. The top of this limb represents the peak, or highest systolic pressure.

Rationale 3: After the waveform reaches its peak, it begins to descend. This descent forms the dicrotic limb and represents systolic ejection of blood that is continuing at a reduced force.

Rationale 4: The lowest portion of the waveform represents the diastolic pressure and is reflected digitally on the monitor.

Rationale 5: This “dicrotic notch” represents the beginning of ventricular diastole.

49

It is determined that a patient has poor cardiac contractility. The nurse would anticipate administering which type of drugs to improve contractility?  Select all that apply

1. Cardiac glycosides

2. Loop diuretics

3. Sympathomimetic agents

4. Phosphodiesterase inhibitors

5. Ace-inhibitors

Correct Answer: 1,3,4

Rationale 1: Cardiac glycosides such as digoxin are positive inotropes and improve cardiac contractility.

Rationale 2: Diuretics are given to decrease the work load on the heart by decreasing fluid overload. They are not given to specifically improve cardiac contractility.

Rationale 3: Dopamine and dobutamine are sympathomimetic agents given to improve cardiac contractility.

Rationale 4: Phosphodiesterase inhibitors such as inamrinone and milrinone improve cardiac contractility.

Rationale 5: ACE inhibitors affect afterload and preload, but do not directly affect myocardial contractility.

51

Question 7

Type: MCSA

While evaluating a patient's pulmonary artery waveforms, the nurse notes a sudden onset of right ventricular waves. Which nursing intervention is indicated?

1. Assist the patient to a left side-lying position.

2. Notify the physician for repositioning.

3. Increase intravenous fluids.                       

4. Nothing, since this is an expected occurrence.

Correct Answer: 2

Rationale 1: Assisting the patient to a left side-lying position is not going to reposition the catheter.

Rationale 2: The right ventricular waveform will appear when the catheter tip retreats from the pulmonary artery into the right ventricle. Should the waveform appear, as in the case with the patient, the nurse should notify the physician for repositioning.

Rationale 3: There is nothing to indicate that the patient needs an increase in intravenous fluids.

Rationale 4: This is not an expected occurrence and should not be ignored.

52

While caring for a patient being hemodynamically monitored the nurse notices that the systemic vascular resistance has risen to 1,800 dynes/sec/cm5, whereas the patient's cardiac output remains at 6.0 liters per minute. What would the nurse expect the patient's blood pressure to be?

1. Increased                 

2. Unchanged

3. Decreased

4. Initially decreased, and then increased

Correct Answer: 1

Rationale 1: Systemic vascular resistance or afterload is the pressure the heart pumps against to get volume out to the lungs or the body. If that pressure is increased, but volume, measured by cardiac output stays the same, it means that the heart is working harder to get volume out and the blood pressure will go up.

Rationale 2: Increasing systemic vascular resistance with no change in cardiac output does indicate a change in blood pressure.

Rationale 3: Since the heart is working harder, blood pressure will not decrease immediately.

Rationale 4: The blood pressure would increase initially in response to the increased workload. If treatment is not initiated, the heart will eventually tire, and a decrease in blood pressure could be expected.

53

The nurse is monitoring a patient at risk for development of left ventricular failure and cardiogenic shock. Which findings would the nurse immediately discuss with the primary health care provider?  Select all that apply.

1. Development of an S3 heart sound

2. Sustained systolic hypertension

3. Development of bilateral crackles

4. Decrease in PAWP

5. Decrease in cardiac index

Correct Answer: 1,3,5

Rationale 1: Development of third or fourth heart sounds may indicate development of left ventricular failure.

Rationale 2: Sustained systolic hypotension would indicate development of left ventricular failure.

Rationale 3: Increased pulmonary congestion, as manifested by development of bilateral crackles, may indicate that left ventricular failure is developing.

Rationale 4: Left ventricular failure would be manifested by elevation of PAWP.

Rationale 5: Low cardiac index can indicate development of left ventricular failure.