Cardiac/Vascular Nurse Exam Secrets Study Guide (41 page)

4. C. Symptoms typical of obstructive sleep apnea (OSA) include daytime somnolence, headache, depression, forgetfulness, overweight, and impotence. An electrocardiogram may indicate bradydysrhythmia during apnea and tachydysrhythmia during respiration. Erythrocytosis, hypertension, and heart failure are common. Narcolepsy is characterized by brief, sudden episodes of falling asleep, loss of muscle tone, and sleep paralysis. Patients with insomnia complain of inadequate sleep; they are either unable to fall asleep easily, or they wake up and are unable to fall back to sleep easily. Hypothyroidism can cause symptoms similar to those of OSA and thus should be ruled out with thyroid function tests.

5. A. The most common initial treatment of acute pulmonary edema is oxygen to relieve dyspnea, nitroglycerine to reduce preload, loop diuretics (usually furosemide-Lasix) to promote diuresis and venodilation, and morphine to reduce associated anxiety (although some physicians avoid morphine because of side effects). Angiotensin-converting enzyme inhibitors are also sometimes used to reduce afterload, but thiazide diuretics are not used to treat acute pulmonary edema. Calcium channel blockers may induce acute pulmonary edema if used with tocolytics.

6. B. Patient-focused goal-setting should be reasonable, measurable, and achievable. Patients are more motivated if they establish their own goals. The goals do not have to be simple, but they should be very specific. While patients may have long-term goals, reaching these by a series of short-term goals is often more effective because the patient is able to see results. For example, losing weight 5 pounds at a time is a more achievable goal than losing 50 pounds. Patients should have confidence that they can achieve their goals because this, turn, motivates them.

7. D. The daughter should be advised that cardiopulmonary resuscitation must be withheld in accordance with the advance directive and desires of the mother. A valid do-not-resuscitate order is in place and does not require verification. Family members often panic at the time of death and want to institute life-saving measures against the wishes of the patient, but this does not override the patient’s explicit directions. The staff should provide emotional support for the family. While this is an ethical issue, there is no time to contact an ethics committee.

8. A. An echocardiogram is a form of ultrasound used to determine the size, shape, and movement of cardiac structures. High-frequency sound waves are transmitted into the heart by a handheld transducer that is held against the chest wall, but images are often poor because of interference caused by tissue and bone. The transesophageal echocardiogram, in which a small transducer is fed through the mouth and down the esophagus, is more effective. The electrocardiogram (ECG), chest x-ray, and computed tomography scan do not provide visual information about movement. The ECG shows a record of the heart’s electrical activity.

9. B. Emergency defibrillation is usually performed in patients with ventricular tachycardia (VT) who are also unconscious. Ventricular tachycardia is characterized by three premature ventricular contractions or more in a row and a ventricular rate of 100–200 bpm. The rapid rate of contractions makes VT dangerous as the ineffective beats may render the person unconscious with no palpable pulse. A detectable rate is usually regular and the QRS complex is ³ 0.12 second and (often) abnormally shaped. The P wave may be undetectable with an irregular PR interval if the P wave is present. The P:QRS ratio is difficult to ascertain if the P wave is missing.

10. C. Cardiac tamponade may result in decreased chest tube drainage, muffled heart sounds, tachycardia, pulsus paradoxus, and decreased urinary output. The pulmonary artery wedge pressure, central venous pressure, and pulmonary artery diastolic pressure equalize. The cause is fluid accumulating in the pericardial sac, compressing the heart. In some cases, it can be caused by kinks or obstructions in the drainage tube. These tubes may be gently milked to remove obstructions, but the nurse should avoid the creation of negative pressure (through stripping), which can damage the surgical site.

11. D. After cardiac catheterization and removal of the sheath, pressure must be applied for 5 to 10 minutes to prevent bleeding and hematoma formation. A manual compression device is usually applied by a belt around the hips with a pad over the insertion site that is inflated to 20 mm Hg above the patient’s systolic pressure to promote hemostasis. Digital compression may also be used. Sometimes lidocaine is administered at the site to relieve discomfort, but this may result in a vasovagal response, so atropine (0.6–1.0 mg IV) should be available.

12. B. Ischemia is characterized by inverted T waves. As the cardiac muscle is damaged, the ST segment is elevated with elevated symmetrical T waves. With a Q-wave myocardial infarction, Q or QS waves develop as repolarization is altered or absent. Changes in the Q waves are usually permanent, so an old myocardial infarction (MI) is evidenced by abnormal Q waves or decreased elevation of the R waves without alterations of ST and T waves. A non-Q-wave MI does not cause Q-wave changes.

13. C. The nurse should announce his or her presence in a normal tone of voice, explaining actions and movements. Visual impairment is unrelated to hearing or intelligence, so speaking loudly or using simple sentences is not necessary. If the central field of vision is impaired, the patient may have better peripheral vision, so the nurse should ask the patient which position is best so the nurse can position himself to the patient’s advantage. Braille materials, enlarged text, or manipulatives may be helpful.

14. D. The sudden onset of intermittent substernal pain that is referred to the neck, arms, and back is typical of pericarditis. Angina pain, usually related to exertion, lasts 5–15 minutes and is substernal or retrosternal, radiating across chest and sometimes to the inside of the arm, neck, or jaw. Myocardial pain lasts over 15 minutes and occurs spontaneously or after an episode of unstable angina. It is substernal or over the pericardium. It may spread across the chest and into shoulders and hands. Anxiety pain lasts 2–3 minutes and tends to occur across the chest but does not radiate; however, some patients complain of numbness of the hands and mouth.

15. A. An ankle systolic pressure of 90 divided by a brachial systolic pressure of 120 equals 0.75. Blood pressure at the ankle should be equal to or slightly higher than that of the arm. With peripheral arterial disease, the ankle pressure falls. The degree of disease relates to the score:

· 1.3: Abnormally high, may indicate calcification of vessel wall

· 1 to 1.1: Normal

· < 0.05: Narrowing of one or more leg blood vessels

· < 0.8: Moderate, associated with intermittent claudication

· < 0.6 to 0.8: Borderline perfusion

· 0.5 to 0.75: Severe disease, ischemia

· < 0.5: Pain even at rest. Limb threatened

· 0.25: Critical limb-threatening condition

16. B. Once an entry is made in a chart, it must be left in place and remain legible. The correct procedure is to draw a single line through the incorrect entry and write “error” after the entry. It is illegal to whiteout an entry or otherwise make it illegible. Hand entries should always be made with blue or black permanent ink, and no erasable pen or pencil should be used for any documentation on a patient’s permanent record. Recopying the page is unacceptable.

17. D. S4 is an extra beat (atrial gallop), occurring just before S1 and producing a triple “Tennessee” rhythm. It is often associated with left ventricular hypertrophy, hypertension, or aortic stenosis. S1 and S2 are normal heart sounds. S1 indicates the onset of systole with closure of both the tricuspid and mitral valves. S2 is the end of systole and indicates closure of the pulmonary and aortic valves. S3 is an extra beat, producing a triple rhythm (“Kentucky”), and indicates decreased ventricular compliance, often related to left ventricular failure and mitral regurgitation.

18. C. Anticoagulation therapy is given before direct current cardioversion and also before chemical cardioversion in most cases. There is no time to start anticoagulation when emergency defibrillation is needed. With fibrillation, blood clots may form within the heart, and when the pulse rate converts to normal, these clots can travel, increasing the risk of heart attack or stroke; thus, the patient is usually maintained on anticoagulation (commonly warfarin [Coumadin]) for up to 6 months after cardioversion.

19. D. Drinking heavily on only one occasion can result in cardiovascular impairment. While the affect of alcohol on the heart is more severe if there is underlying cardiac disease, an overdose of alcohol even with no underlying disorder weakens cardiac contractions, causing the heart rate to increase. Alcohol depresses the autonomic nervous system, which can lead to heart failure, cardiac dysrhythmias (most commonly atrial fibrillation), and cardiac arrest. Chronic drinking can severely damage the heart and blood vessels, resulting in hypertension and cardiomyopathy.

20. B. Urinary output after surgery varies, according to fluid intake, but should be more than 25 mL/hr. Urinary output less than 25 mL/hr indicates decreased renal function. Urine specific gravity should be maintained at 1.105–1.025, indicating the ability of the kidneys to concentrate urine in the renal tubules. Blood urea nitrogen, creatinine, urine, and serum electrolytes are monitored to ensure that the kidneys can excrete waste products. Urinary output is usually monitored every half hour while the patient is in the critical care unit.

21. A. Most cocaine users typically demonstrate hypertension and an increased heart rate. Chest pain may mimic a myocardial infarction. Vasoconstriction occurs both within the coronary arteries and the peripheral circulation, resulting in hypertension and episodes of cardiac ischemia that may cause infarcts. In some cases, multiple infarcts may occur even with normal coronary arteries. Cardiomyopathy with enlargement of the left ventricular muscle is common in chronic users.

22. C. All staff members are responsible for identifying performance improvement projects. Performance improvement must be a continuous process. Continuous Quality Improvement is a management philosophy that emphasizes the organization and systems and processes within that organization rather than individuals. Total Quality Management is a management philosophy that espouses a commitment to meeting the needs of the customers (patients, staff) at all levels within an organization. Both management philosophies recognize that change can be made in small steps and should involve staff at all levels

23. B. Venous ulcers are typically superficial irregular ulcers on the medial or lateral malleolus and sometimes the anterior tibial area and cause varying degrees of pain. Surrounding skin often has a brownish discoloration. Edema is moderate to severe. Arterial ulcers are painful, deep, circular, often necrotic ulcers found on toe tips, toe webs, heels or other pressure areas. There is often rubor on dependency but pallor on foot elevation, and skin is pale, shiny, and cool. Edema is minimal.

24. A. No special preparation is needed for a radionuclide ventriculogram. A sample of blood is withdrawn, labeled with a technetium 99m radionuclide and then is injected back into the patient. With electrocardiogram (ECG) guidance, images are obtained during the cardiac cycle. The video display provides images similar to that of a contrast angiogram. The radionuclide ventriculogram is used to evaluate diastolic and systolic function for patients with heart failure from valvular heart disease or to monitor the toxic effects of chemotherapeutic drugs.

25. C. Central cyanosis of the tongue and buccal mucosa indicates severe cardiovascular disease, such as pulmonary edema or congestive heart failure. Pallor is the result of decreased levels of oxyhemoglobin, usually resulting from anemia or decreased perfusion. Peripheral cyanosis of the nails, nose, and extremities indicates decreased circulation and can occur with heart failure or other causes of vasoconstriction (e.g., cold). Xanthelasma is a yellowish plaque, usually on the eyelids, indicating high levels of cholesterol.

26. D. Angiotensin-converting enzyme (ACE) inhibitors are contraindicated in patients with renal failure, as one of the most serious side effects of these drugs is renal impairment, especially in patients also taking diuretics and nonsteroidal anti-inflammatory drugs. The ACE inhibitors are commonly used to treat hypertension and heart failure. They are often combined with diuretics, such as the thiazide diuretics (hydrochlorothiazide) for hypertension or furosemide (Lasix) for heart failure. The ACE inhibitors are sometimes given to patients with diabetes mellitus to prevent diabetic neuropathy.

27. B. Mechanical ventilation can cause hypoventilation and carbon dioxide retention, resulting in respiratory acidosis. Renal compensatory actions include retention of bicarbonate (HCO3) and increased excretion of hydrogen (H). Serum pH and PCO2 are decreased. Symptoms include flushed skin, ventricular fibrillation, and hypotension. Patients may develop drowsiness, headaches, disorientation, seizures, and coma.

28. A. The risks associated with sexual activity after recovery from a myocardial infarction are very low, and most heart recovery programs encourage exercise. However, before a sexual encounter, it is important to consider the following:

· The person should be well rested.

· The person should wait 1–3 hours after eating.

· A comfortable position should be used to minimize stress.

· Foreplay is important so that the heart rate increases and strengthens in preparation for intercourse.

· If the person takes nitroglycerine for angina, this medication should be taken before sexual activity.