Cardiac Surgery CSC, AACN CSC- Therapeutic
Interventions Version 2 Final Exam
Preparation Newest With Complete 300
Questions And Correct Detailed Answers|
Brand New Version!
You are caring for a patient with an intra-aortic balloon pump and note blood in the tubing. Your initial
action should be:
A. Stop the balloon pump and notify the physician.
B. Administer 100% oxygen to help displace the helium and notify the physician
C. Leave the IABP running and notify the physician.
D. Purge the IABP manually to clear the blood from the tubing. - Correct Answer-A. Blood in the IABP
tubing indicates a balloon rupture which can cause gas embolus. However, helium is thought to be easily
absorbed in the presence of balloon rupture and oxygen is not generally indicated. The appropriate
action is to disconnect the balloon from the console or turn it on standby so the movement of helium is
stopped and notify the physician. The nurse will need to prepare for IABP removal and replacement if
needed.
When caring for a patient immediately post CABG the nurse recognizes that the most likely cause of
hypotension in the immediate post-operative period is
A. Decreased circulating volume requiring no intervention unless persistent > 12 hours.
B. LV failure requiring an inotrope as first line treatment for any hypotension.
C. Decreased circulating volume representing the need for increased fluid administration.
D. LV failure requiring an assist device. - Correct Answer-C. Hypotension in the immediate postoperative
period is usually caused by low circulating volume and responds to treatment with fluids. Volume is the
first line treatment for hypotension. If there is no immediate response to volume administration, 500
mg of IV calcium chloride is often given. Existing vasopressors, such as norepinephrine, can also be
adjusted. It is important for hypotension to be promptly treated. Persistent hypotension can result in
hypoperfusion and end organ damage.
LV failure is not the most common cause of hypotension in the immediate post-operative period and
therefore inotropic agents are not first line agents used in the treatment of hypotension. Hypotension
that does not respond to fluid administration may require an inotrope.
1
,Preoperative clopidogrel should be held for how many days in the elective surgery patient:
A.It does not need to be held.
B. 1-2 days.
C. 5-7 days.
D. 30 days. - Correct Answer-C. Clopidogrel inhibits the P2Y12 receptor on the platelet for the lifetime of
the platelet (10 days). Inhibited platelets cannot participate in clotting, so the risk of bleeding increases
with antiplatelet drugs. Most clinical trials have identified an increased risk in bleeding, transfusion, and
re-exploration when clopidogrel is taken within 5 days of surgery, and no increase in bleeding or
transfusions when clopidogrel is stopped for > 5 days prior to surgery. Therefore, clopidogrel should be
stopped for 5 to 7 days prior to elective surgery. Emergent surgery can be done regardless of when the
last dose of clopidogrel was taken, but will be associated with increased bleeding and need for platelet
transfusions.
The term OPCAB refers to:
A. combination open heart surgery and percutaneous procedure.
B. CABG surgery without the use of cardiopulmonary bypass (CPB).
C. the use of thoracotomy instead of sternotomy.
D. patients who are fast tracked to be discharged in less than 5 days. - Correct Answer-B. OPCAB refers
to off-pump coronary artery bypass. Surgery is done without CPB but it still involves a median
sternotomy.
MIDCAB (minimally invasive direct coronary artery bypass) is performed on a beating heart without CPB
and without the use of a median sternotomy. MIDCAB is commonly done through an anterior
thoracotomy incision and is used to bypass the mid to distal LAD with a left internal mammary artery
(LIMA) graft. A ministernotomy can also be used to gain access during MIDCAB.
Which of the following patients is at highest risk for neurological complications after CABG?
A. A 63-year- old patient with a BMI of 30 undergoing OPCAB
B. A 85-year-old patient with an atherosclerotic aorta undergoing CPB
C. A previously healthy 50-year-old woman undergoing CPB
D. A 67-year-old man having a MIDCAB to the LAD with no known history of hypertension - Correct
Answer-B. Severe atherosclerosis of the aorta, advanced age, use of CPB, aortic cross-clamping,
diabetes, hypertension, female sex, and history of stroke place patients at high risk for neurological
2
,complications following cardiac surgery. Other factors contributing to neurological complications include
alcohol abuse, heart failure, arrhythmias, and hyperglycemia.
The nurse caring for the post operative cardiac surgery patient recognizes the following as potential
contributors to post-operative vasodilation that can cause hypotension:
A. Cooling that occurs while on cardiopulmonary bypass, and use of vasodilators post op.
B. Use of norepinephrine or dopamine to support BP immediately post-op.
C. Inflammatory response due to CPB and use of norepinephrine to support BP
D. Rewarming that occurs after return to the ICU, and the inflammatory response to use of
cardiopulmonary bypass during surgery - Correct Answer-D. Intraoperative cooling results in
vasoconstriction; rewarming after surgery causes vasodilation and can contribute to hypotension if
volume administration is inadequate for the increased size of the vascular space caused by vasodilation.
The use of CPB stimulates an inflammatory response that results in vasodilation that contributes to
hypotension.
Norepinephrine and dopamine cause peripheral vasoconstriction, not vasodilation.
A characteristic of a fast-track pathway after CABG would include:
A. anticipated discharge between post-op days 7 and 8.
B. a defined medication strategy to prevent postoperative atrial fibrillation.
C. liberal use of opioid medications to increase patient comfort during the ventilator weaning
process.
D. extubation by the third post-op day - Correct Answer-C. Low-risk patients can be selected for fast
tracking after CABG. These patients are targeted for early extubation, early ambulation, and early
discharge. Patients who are fast tracked receive sedation and analgesia to allow for early extubation.
Pharmacological strategies to prevent atrial fibrillation and early phase I cardiac rehabilitation are also
key components of fast tracking.
You are caring for an early post-operative CABG patient who remains hypotensive despite treatment
with adequate fluid administration and an alpha constricting agent. You know that one potential post-
operative complication responsible for this persistent hypotension could be:
A. Acute kidney injury.
B. Acute saphenous vein graft closure.
C. Acute respiratory distress syndrome (ARDS).
3
, D. Vasoplegia. - Correct Answer-D. Vasoplegia is a form of vasodilatory shock that can occur after
separation from CPB. It is characterized by significant hypotension despite adequate fluid resuscitation,
low SVR(due to vasodilation), and is resistant to vasopressors. When vasopressors (norepinephrine,
epinephrine, high dose dopamine, or vasopressin) are not able to maintain blood pressure in the
presence of adequate filling pressures, then vasoplegia may be present. There are several theories
behind the cause of vasoplegia, including leukocyte activation and the release of pro-inflammatory
mediators during cardiopulmonary bypass, and vasoplegia has been associated with long-term use of
ACE inhibitors, calcium channel blockers, amiodarone, and heparin. Patients with EF <35%, heart failure
and diabetes are at higher risk. Vasoplegia can also be seen after OPCAB.
Acute respiratory distress syndrome (ARDS) and acute kidney failure can both be complications in the
cardiac surgery patient, but do not typically occur early in the post-operative course and are not
necessarily associated with hypotension and failure to respond to vasopressors.
An acute saphenous vein occlusion can occur as a result of persistent hypotension. The most direct
clinical signs of acute saphenous vein graft closure would be those of ischemia.
Mediastinal drainage in the following amount meets criteria for re-exploration:
A. > 300 ml/hr for 2-3 hours.
B. > 200 ml/hr for 4 hours.
C. > 400 ml to 500 ml for 1 hour.
D. All of the above. - Correct Answer-D. Chest tube drainage criteria for surgical re-exploration:
• > 400 to 500 ml for 1 hour
• > 300 ml/hr for 2 to 3 hours
• > 200 ml/hr for 4 hours
• Acute onset of bleeding >300 ml/hr after period of stable and minimal bleeding
Patients with prolonged CPB times are likely to experience:
A. An increased likelihood of early extubation.
B. An increase in coagulopathies.
C. A decrease in total body fluid due to dehydration.
D. A decrease in chest tube drainage. - Correct Answer-B. Coagulopathy is present to some degree with
all CPB. During CPB, blood contacts the non-physiological surfaces of the bypass circuit and an
inflammatory response is initiated. A coagulopathy can develop from activation of platelets and the
fibrinolytic system. Clotting factors, platelets, and RBCs are diluted during CPB. A longer pump time is
associated with increased coagulopathies.
4
Interventions Version 2 Final Exam
Preparation Newest With Complete 300
Questions And Correct Detailed Answers|
Brand New Version!
You are caring for a patient with an intra-aortic balloon pump and note blood in the tubing. Your initial
action should be:
A. Stop the balloon pump and notify the physician.
B. Administer 100% oxygen to help displace the helium and notify the physician
C. Leave the IABP running and notify the physician.
D. Purge the IABP manually to clear the blood from the tubing. - Correct Answer-A. Blood in the IABP
tubing indicates a balloon rupture which can cause gas embolus. However, helium is thought to be easily
absorbed in the presence of balloon rupture and oxygen is not generally indicated. The appropriate
action is to disconnect the balloon from the console or turn it on standby so the movement of helium is
stopped and notify the physician. The nurse will need to prepare for IABP removal and replacement if
needed.
When caring for a patient immediately post CABG the nurse recognizes that the most likely cause of
hypotension in the immediate post-operative period is
A. Decreased circulating volume requiring no intervention unless persistent > 12 hours.
B. LV failure requiring an inotrope as first line treatment for any hypotension.
C. Decreased circulating volume representing the need for increased fluid administration.
D. LV failure requiring an assist device. - Correct Answer-C. Hypotension in the immediate postoperative
period is usually caused by low circulating volume and responds to treatment with fluids. Volume is the
first line treatment for hypotension. If there is no immediate response to volume administration, 500
mg of IV calcium chloride is often given. Existing vasopressors, such as norepinephrine, can also be
adjusted. It is important for hypotension to be promptly treated. Persistent hypotension can result in
hypoperfusion and end organ damage.
LV failure is not the most common cause of hypotension in the immediate post-operative period and
therefore inotropic agents are not first line agents used in the treatment of hypotension. Hypotension
that does not respond to fluid administration may require an inotrope.
1
,Preoperative clopidogrel should be held for how many days in the elective surgery patient:
A.It does not need to be held.
B. 1-2 days.
C. 5-7 days.
D. 30 days. - Correct Answer-C. Clopidogrel inhibits the P2Y12 receptor on the platelet for the lifetime of
the platelet (10 days). Inhibited platelets cannot participate in clotting, so the risk of bleeding increases
with antiplatelet drugs. Most clinical trials have identified an increased risk in bleeding, transfusion, and
re-exploration when clopidogrel is taken within 5 days of surgery, and no increase in bleeding or
transfusions when clopidogrel is stopped for > 5 days prior to surgery. Therefore, clopidogrel should be
stopped for 5 to 7 days prior to elective surgery. Emergent surgery can be done regardless of when the
last dose of clopidogrel was taken, but will be associated with increased bleeding and need for platelet
transfusions.
The term OPCAB refers to:
A. combination open heart surgery and percutaneous procedure.
B. CABG surgery without the use of cardiopulmonary bypass (CPB).
C. the use of thoracotomy instead of sternotomy.
D. patients who are fast tracked to be discharged in less than 5 days. - Correct Answer-B. OPCAB refers
to off-pump coronary artery bypass. Surgery is done without CPB but it still involves a median
sternotomy.
MIDCAB (minimally invasive direct coronary artery bypass) is performed on a beating heart without CPB
and without the use of a median sternotomy. MIDCAB is commonly done through an anterior
thoracotomy incision and is used to bypass the mid to distal LAD with a left internal mammary artery
(LIMA) graft. A ministernotomy can also be used to gain access during MIDCAB.
Which of the following patients is at highest risk for neurological complications after CABG?
A. A 63-year- old patient with a BMI of 30 undergoing OPCAB
B. A 85-year-old patient with an atherosclerotic aorta undergoing CPB
C. A previously healthy 50-year-old woman undergoing CPB
D. A 67-year-old man having a MIDCAB to the LAD with no known history of hypertension - Correct
Answer-B. Severe atherosclerosis of the aorta, advanced age, use of CPB, aortic cross-clamping,
diabetes, hypertension, female sex, and history of stroke place patients at high risk for neurological
2
,complications following cardiac surgery. Other factors contributing to neurological complications include
alcohol abuse, heart failure, arrhythmias, and hyperglycemia.
The nurse caring for the post operative cardiac surgery patient recognizes the following as potential
contributors to post-operative vasodilation that can cause hypotension:
A. Cooling that occurs while on cardiopulmonary bypass, and use of vasodilators post op.
B. Use of norepinephrine or dopamine to support BP immediately post-op.
C. Inflammatory response due to CPB and use of norepinephrine to support BP
D. Rewarming that occurs after return to the ICU, and the inflammatory response to use of
cardiopulmonary bypass during surgery - Correct Answer-D. Intraoperative cooling results in
vasoconstriction; rewarming after surgery causes vasodilation and can contribute to hypotension if
volume administration is inadequate for the increased size of the vascular space caused by vasodilation.
The use of CPB stimulates an inflammatory response that results in vasodilation that contributes to
hypotension.
Norepinephrine and dopamine cause peripheral vasoconstriction, not vasodilation.
A characteristic of a fast-track pathway after CABG would include:
A. anticipated discharge between post-op days 7 and 8.
B. a defined medication strategy to prevent postoperative atrial fibrillation.
C. liberal use of opioid medications to increase patient comfort during the ventilator weaning
process.
D. extubation by the third post-op day - Correct Answer-C. Low-risk patients can be selected for fast
tracking after CABG. These patients are targeted for early extubation, early ambulation, and early
discharge. Patients who are fast tracked receive sedation and analgesia to allow for early extubation.
Pharmacological strategies to prevent atrial fibrillation and early phase I cardiac rehabilitation are also
key components of fast tracking.
You are caring for an early post-operative CABG patient who remains hypotensive despite treatment
with adequate fluid administration and an alpha constricting agent. You know that one potential post-
operative complication responsible for this persistent hypotension could be:
A. Acute kidney injury.
B. Acute saphenous vein graft closure.
C. Acute respiratory distress syndrome (ARDS).
3
, D. Vasoplegia. - Correct Answer-D. Vasoplegia is a form of vasodilatory shock that can occur after
separation from CPB. It is characterized by significant hypotension despite adequate fluid resuscitation,
low SVR(due to vasodilation), and is resistant to vasopressors. When vasopressors (norepinephrine,
epinephrine, high dose dopamine, or vasopressin) are not able to maintain blood pressure in the
presence of adequate filling pressures, then vasoplegia may be present. There are several theories
behind the cause of vasoplegia, including leukocyte activation and the release of pro-inflammatory
mediators during cardiopulmonary bypass, and vasoplegia has been associated with long-term use of
ACE inhibitors, calcium channel blockers, amiodarone, and heparin. Patients with EF <35%, heart failure
and diabetes are at higher risk. Vasoplegia can also be seen after OPCAB.
Acute respiratory distress syndrome (ARDS) and acute kidney failure can both be complications in the
cardiac surgery patient, but do not typically occur early in the post-operative course and are not
necessarily associated with hypotension and failure to respond to vasopressors.
An acute saphenous vein occlusion can occur as a result of persistent hypotension. The most direct
clinical signs of acute saphenous vein graft closure would be those of ischemia.
Mediastinal drainage in the following amount meets criteria for re-exploration:
A. > 300 ml/hr for 2-3 hours.
B. > 200 ml/hr for 4 hours.
C. > 400 ml to 500 ml for 1 hour.
D. All of the above. - Correct Answer-D. Chest tube drainage criteria for surgical re-exploration:
• > 400 to 500 ml for 1 hour
• > 300 ml/hr for 2 to 3 hours
• > 200 ml/hr for 4 hours
• Acute onset of bleeding >300 ml/hr after period of stable and minimal bleeding
Patients with prolonged CPB times are likely to experience:
A. An increased likelihood of early extubation.
B. An increase in coagulopathies.
C. A decrease in total body fluid due to dehydration.
D. A decrease in chest tube drainage. - Correct Answer-B. Coagulopathy is present to some degree with
all CPB. During CPB, blood contacts the non-physiological surfaces of the bypass circuit and an
inflammatory response is initiated. A coagulopathy can develop from activation of platelets and the
fibrinolytic system. Clotting factors, platelets, and RBCs are diluted during CPB. A longer pump time is
associated with increased coagulopathies.
4
