PCCN QUESTIONS WITH ANSWERS

PCCN QUESTIONS WITH ANSWERS



Coronary artery perfusion is dependent upon: xc xc xc xc xc




A. diastolic pressure
xc xc




B. systolic pressure
xc xc




C. afterload
xc




D. systemic vascular resistance (SVR) - ans-A. diastolic pressure
xc xc xc xc xc xc xc xc




Diastolic pressure in the aortic root is higher than left ventricular end-
xc xc xc xc xc xc xc xc xc xc xc




diastolic pressure (LVEDP), the pressure exerted on the ventricular muscle at the end of di
xc xc xc xc xc xc xc xc xc xc xc xc xc xc




astole when the ventricle is full. This enables blood to flow from a higher pressure through o
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




pen arteries to a lower pressure, a pressure gradient known as coronary artery prefusion pr
xc xc xc xc xc xc xc xc xc xc xc xc xc xc




essure. As diastolic pressure drops, there is a decrease in coronary artery blood flow. Coro
xc xc xc xc xc xc xc xc xc xc xc xc xc xc




nary artery perfusion is not affected by systolic pressure, afterload or SVR, but they all incre
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




ase the demand of oxygen in the heart.
xc xc xc xc xc xc xc




A post-STEMI (ST elevation myocardial infarction) patient is started on an angiotensin-
xc xc xc xc xc xc xc xc xc xc xc




converting enzyme (ACE) inhibitor during his hospital stay. Which of the following is the mo
xc xc xc xc xc xc xc xc xc xc xc xc xc xc




st common serious side effect that may occur?
xc xc xc xc xc xc xc




A. a nonproductive cough
xc xc xc




B. pedal edema
xc xc




C. swelling of the tongue and face
xc xc xc xc xc xc




D. rhinorrhea - ans-C. swelling of the tongue and face
xc xc xc xc xc xc xc xc xc




Although all of the answers may occur, swelling og the tongue and face is the most serious
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




and may require intervention. Patients should be instructed to seek medical attention imme
xc xc xc xc xc xc xc xc xc xc xc xc




diately for any signs of swelling in the tongue or throat.
xc xc xc xc xc xc xc xc xc xc




Which of the following best describes the fourth heart sound (S4):
xc xc xc xc xc xc xc xc xc xc




A. It occurs after ventricular contraction
xc xc xc xc xc




B. It is best heard with the diaphragm of the stethoscope
xc xc xc xc xc xc xc xc xc xc




C. It is a normal finding in children
xc xc xc xc xc xc xc




D. It occurs during late diastole when the atria contracts - ans-
xc xc xc xc xc xc xc xc xc xc xc




D. It occurs during late diastole when the atria contracts
xc xc xc xc xc xc xc xc xc




The presence of the extra heart sound S4 signifies a poorly compliant (stiff) left ventricle. An
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




S4 is also called an atrial heart sound since it occurs at the end of diastolic filling when the a
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




tria contracts and fully fills the left ventricle. Known as "atrial kick", this filling is important to c
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




ardiac output. The increased end- xc xc xc xc




diastolic volume in the ventricle improves cardiac output. When the left ventricle is stiff (dec
xc xc xc xc xc xc xc xc xc xc xc xc xc xc




reased compliance with long term hypertension, aortic stenosis or with acute STEMI), the a
xc xc xc xc xc xc xc xc xc xc xc xc xc




trium has to pump harder to move blood from the atrium to the ventricle, causing a turbulent
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




blood flow and extra heart sound. This heart sound is always pathologic. It occurs before ve
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




ntricular contraction, is best heard with the bell of the stethoscope and is never a normal he
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




art sound, even in children.
xc xc xc xc

,Which pathologic changes found on the 12-lead ECG indicate myocardial ischemia?
xc xc xc xc xc xc xc xc xc xc




A. ST-segment elevation
xc xc




B. ST-segment depression and T-wave elevation
xc xc xc xc xc




C. Q-wave formation
xc xc




D. ST-segment depression and T-wave inversion - ans-
xc xc xc xc xc xc xc




D. ST segment depression and T wave inversion
xc xc xc xc xc xc xc




Myocardial ischemia changes the repolarization of the ventricular muscle. That change is s
xc xc xc xc xc xc xc xc xc xc xc xc




een on the 12 lead ECG as ST-
xc xc xc xc xc xc xc




segment depression and T wave inversion, which demonstrate subendocardial ischemia --
xc xc xc xc xc xc xc xc xc xc




the innermost layer of muscle in the myocardium. ST-
xc xc xc xc xc xc xc xc xc




segment elevation indicates acute injury or infarction, ST segment depression and T wave
xc xc xc xc xc xc xc xc xc xc xc xc xc




elevation may indicate an electrolyte abnormality, while Q wave formation indicates total inf
xc xc xc xc xc xc xc xc xc xc xc xc




arction.

Positive inotropic agents are used to: xc xc xc xc xc




A. improve cardiac output and tissue perfusion
xc xc xc xc xc xc




B. decrease water loss through the kidneys
xc xc xc xc xc xc




C. increase heart rate
xc xc xc




D. vasodilate vessels - ans-A. improve cardiac output and tissue perfusion
xc xc xc xc xc xc xc xc xc xc




The term "inotropic" refers to affecting the force of myocardial contraction. Improvement of
xc xc xc xc xc xc xc xc xc xc xc xc xc




cardiac muscle contraction leads to improved cardiac output and tissue perfusion.
xc xc xc xc xc xc xc xc xc xc




A patient in the ED is now being admitted to telemetry bwith complaint of chest pain and has
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc x




been judged to be a possible candidate for therapy with alteplase (Activase). Which of the f
c xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




ollowing is not considered a contraindication for the use of this medication?
xc xc xc xc xc xc xc xc xc xc xc




A. current antibiotic use
xc xc xc




B. recent abdominal surgery
xc xc xc




C. recent gastrointestinal bleed
xc xc xc




D. recent intracranial bleed - ans-A. current antibiotic use
xc xc xc xc xc xc xc xc




Use of antibiotics is not a contraindication for the use of alteplase. All the other answers --
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




recent abdominal surgery, recent gastrointestinal bleeding and a recent intracranial bleed -
xc xc xc xc xc xc xc xc xc xc xc xc




- are contraindications for the use of any fibrinolytic.
xc xc xc xc xc xc xc xc




The two major components that determine blood pressure are:
xc xc xc xc xc xc xc xc




A. systemic vascular resistance (SVR) (afterload) and cardiac output
xc xc xc xc xc xc xc xc




B. contractility and SVR (afterload)
xc xc xc xc




C. preload and SVR (afterload)
xc xc xc xc




D. contractility and SVR (afterload) - ans-A. SVR (afterload) and cardiac output
xc xc xc xc xc xc xc xc xc xc xc




The equation for BP is: BP = SVR x cardiac output.
xc xc xc xc xc xc xc xc xc xc




BP is determined by resistance of the arterial bed and the cardiac output. If the SVR (afterlo
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




ad) is high and the cardiac output low, the patient may still have a normal BP. the pulse pres
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




sure will be lower, but this is a compensatory response by the heart to maintain BP. If the SV
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




R (afterload) is low (as in early septic shock), the cardiac output is very high, thereby trying t
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




o support BP.
xc xc

,The layer of the arterial vessel wall responsible for changes in the diameter of the artery is t
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




he:
A. media
xc




B. intima
xc




C. externa
xc




D. adventitia - ans-A. media
xc xc xc xc




The media layer of the arterial wall contains vascular smooth muscle cells and is responsibl
xc xc xc xc xc xc xc xc xc xc xc xc xc xc




e for arterial tone. Vasoactive substances released in response to the sympathetic nervous
xc xc xc xc xc xc xc xc xc xc xc xc xc




system and/or the renin- xc xc xc




angiotensin system determine arterial tone. Intima, externa and adventitia are incorrect.
xc xc xc xc xc xc xc xc xc xc




A patient presents in acute distress with rales halfway up bilaterally; cool and clammy extre
xc xc xc xc xc xc xc xc xc xc xc xc xc xc




mities; elevated jugular venous distention (JVD); oxygen saturations at 95%, down from 99
xc xc xc xc xc xc xc xc xc xc xc xc




%; and complaints of shortness of breath. Which of the following findings correspond to the
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




patient's cardiac status? xc xc




A. no pulmonary congestion, normal perfusion
xc xc xc xc xc




B. no pulmonary congestion, low perfusion
xc xc xc xc xc




C. pulmonary congestion, normal perfusion
xc xc xc xc




D. pulmonary congestion, low perfusion - ans-D. pulmonary congestion, low perfusion
xc xc xc xc xc xc xc xc xc xc




Rales indicate fluid in the alveolar sacs, possibly secondary to pulmonary edema, causing
xc xc xc xc xc xc xc xc xc xc xc xc xc




pulmonary congestion. Pneumonia can also cause fluid in the alveolar sacs. The patient is
xc xc xc xc xc xc xc xc xc xc xc xc xc xc




complaining of shortness of breath, and the oxygen saturations are lowering, also indicatin
xc xc xc xc xc xc xc xc xc xc xc xc




g that the patient has pulmonary congestion. The patient's skin is cool and clammy, indicati
xc xc xc xc xc xc xc xc xc xc xc xc xc xc




ng that the skin is poorly perfused. Skin does not require oxygen and shunts blood away in d
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




ecreased cardiac function; therefore, this patient has pulmonary congestion and low perfus
xc xc xc xc xc xc xc xc xc xc xc




ion state. The other answers are incorrect.
xc xc xc xc xc xc




When listening to heart sounds, S1 signifies which of the following?
xc xc xc xc xc xc xc xc xc xc




A. the beginning of ventricular systole
xc xc xc xc xc




B. the beginning of ventricular diastole
xc xc xc xc xc




C. the propulsion of blood into a non-compliant ventricle
xc xc xc xc xc xc xc xc




D. the blood going in the wrong direction - ans-A. the beginning of ventricular systole
xc xc xc xc xc xc xc xc xc xc xc xc xc xc




The heart sound of S1 indicates the opening of the aortic and pulmonic valves and marks th
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




e beginning of ventricular systole or ejection. The beginning of diastole is after S2, propulsi
xc xc xc xc xc xc xc xc xc xc xc xc xc xc




on of blood into a noncompliant chamber is S4, and blood going in the wrong direction will c
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




ause a murmur. xc xc




A patient with pulmonary edema has impaired diffusion due to:
xc xc xc xc xc xc xc xc xc




A. increased thickness of the alveolar capillary membrane
xc xc xc xc xc xc xc




B. retaining CO2
xc xc




C. an elevated body temperature associated with pulmonary edema
xc xc xc xc xc xc xc xc




D. low barometric pressure - ans-
xc xc xc xc xc




A. increased thickness of the alveolar capillary membrane
xc xc xc xc xc xc xc




With increasing left ventricular pressures, blood moves back into the left atrium, then to the
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




pulmonary veins. When the pressure in the pulmonary veins increases, capillary function d
xc xc xc xc xc xc xc xc xc xc xc xc




ecreases, and fluid then shifts to the interstitial space, causing interstitial edema, thereby, i
xc xc xc xc xc xc xc xc xc xc xc xc xc

, ncreasing the thickness of the space oxygen must travel. When left ventricular pressures in
xc xc xc xc xc xc xc xc xc xc xc xc xc




crease, the fluid then shifts to the alveolar space, causing pulmonary edema. This fluid acts
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




as a deterrent to oxygen diffusion. Retention of CO2 does not impair diffusion. An elevated
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




body temperature associated with pulmonary edema is not causing a diffusion abnormality;
xc xc xc xc xc xc xc xc xc xc xc




increased temperature shifts the oxyhemoglobin curve to the right, more quickly releasing
xc xc xc xc xc xc xc xc xc xc xc xc xc




oxygen to the tissues. Low barometric pressure has no effect on diffusion of gases in the lun
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




g.

A patient with an anterior-
xc xc xc xc




wall STEMI is in cardiogenic shock. What would be the hemodynamic profile assessment?
xc xc xc xc xc xc xc xc xc xc xc xc




A. decreased cardiac index, increased preload, increased afterload
xc xc xc xc xc xc xc




B. decreased cardiac index, decreased preload, increased afterload
xc xc xc xc xc xc xc




C. decreased cardiac index, decreased preload, decreased afterload
xc xc xc xc xc xc xc




D. increased cardiac index, decreased preload, decreased afterload - ans-
xc xc xc xc xc xc xc xc xc




A. decreased cardiac index, increased preload, increased afterload
xc xc xc xc xc xc xc




In a patient with cardiogenic shock, both preload and afterload are increased due to severe
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




vasoconstriction on both the venous and arterial side. Arterial vasoconstriction increases af xc xc xc xc xc xc xc xc xc xc xc




terload and therefore lowers cardiac index. Because the ventricle is failing and contractility i
xc xc xc xc xc xc xc xc xc xc xc xc xc




s also low, the left ventricular pressures increase and cause blood to increase in the pulmon
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




ary bed, resulting in increased right ventricular pressures and preload. In heart failure, ther
xc xc xc xc xc xc xc xc xc xc xc xc xc




e is an increase in preload and afterload with a decrease in cardiac index and contractility. T
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




he other answers are incorrect.
xc xc xc xc




A patient is discharged with the diagnosis of severe peripheral vascular disease (PVD). In a
xc xc xc xc xc xc xc xc xc xc xc xc xc xc




ddition to medication and a walking regime, if applicable, which of the following is essential
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




education at time of discharge? xc xc xc xc




A. nutritional counseling
xc xc




B. smoking cessation counseling
xc xc xc




C. social work consult
xc xc xc




D. speech therapy consult - ans-B. smoking cessation counseling
xc xc xc xc xc xc xc xc




Cessation of tobacco use is the most important non- xc xc xc xc xc xc xc xc




pharmacological intervention that can be done to improve signs and symptoms of peripher xc xc xc xc xc xc xc xc xc xc xc xc




al bvascular disease. Social work consult and speech therapy may not be indicated in this p
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




atient. All patients may benefit from nutrition counseling; however, this is not a primary conc
xc xc xc xc xc xc xc xc xc xc xc xc xc xc




ern for this patient. xc xc xc




A medication that dilates both the venous and arterial beds will cause which of the following
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




results?
A. increased preload, decreased afterload
xc xc xc xc




B. increased preload, increased afterload
xc xc xc xc




C. decreased preload, decreased afterload
xc xc xc xc




D. decreased preload, increased afterload - ans-
xc xc xc xc xc xc




C. decreased preload, decreased afterload
xc xc xc xc




When both the venous and arterial beds are dilated, there will be less venous return, causin
xc xc xc xc xc xc xc xc xc xc xc xc xc xc xc




g a decreased preload (ex. nitroglycerin). With arterial vasodilation, the afterload will decre
xc xc xc xc xc xc xc xc xc xc xc xc




ase (ex nitroprusside, ACE-I). Afterload in this case is resistant to LV pumping.
xc xc xc xc xc xc xc xc xc xc xc xc