PCCN Cardiac Exam 127 Questions with Verified Answers,100% CORRECT

PCCN Cardiac Exam 127 Questions with Verified Answers Which of the following is the outermost lining of the heart? A. Endocardium B. Myocardium C. Transcardium D. Pericardium - CORRECT ANSWER D. Pericardium "Endo" meaning "within" is associated with the innermost lining of the heart, so eliminate A. The myocardium is associated with the heart's middle layer, so eliminate option B. The "transcardium" is somewhat of a contrived term, so eliminate C as well. The prefix in pericardium, "peri" means "outside". Option D is the best answer. Which of the following statements regarding the coronary sinus is correct? A. It provides arterial blood flow to the lateral LV wall B. It provides arterial blood flow to the sinus node C. It is the main venous drainage vessel of the heart D. It stimulates secretion of the atrial natriuretic factor - CORRECT ANSWER C. It is the main venous drainage vessel of the heart The lateral LV wall is supplied by the circumflex and the sinus node is supplied by the RCA, so eliminate options A and B. It is atrial distension that stimulates the secretion of atrial natriuretic factor, so eliminate D as well. The coronary sinus is best known as the main venous drainage vessel of the heart. C is the best answer. Of the following four factors, three determine stroke volume. Identify the factor that does NOT affect stroke volume. A. Preload B. Afterload C. Contractility D. Capillary permeability - CORRECT ANSWER D. Capillary permeability Options A, B. and C all influence stroke volume (i.e. the mLs of blood the LV ejects with each beat). Preload reflects the filling of the LV, afterload is associated with the resistance of LV ejection, and contractility impacts the strength of which that volume is ejected. Secondarily, capillary permeability may ultimately affect the mLs pumped by the LV with each beat, but the impact will be indirect. Choose D. Which of the following are atrioventricular (AV) valves? A. Mitral and tricuspid B. Pulmonic and aortic C. Mitral and aortic D. Tricuspid and pulmonic - CORRECT ANSWER A. Mitral and tricuspid This is a straight knowledge question. The mitral and tricuspid valves (Choice A) are called the AV valves because they separate the atriums and the ventricles. An easy way to remember these is to remember that L (left) and M (mitral) are close to one another in the alphabet and are on the left side of the heart. R (right) and T (tricuspid) are also close in the alphabet and are on the right side of the heart. The aortic and pulmonic valves (all mentioned in B, C, and D) are called the semilunar valves. Choose A. Two circumstances may produce a systolic murmur. One exists when backward flow of blood (regurgitant flow) occurs through a valve that is normal closed during systole. The second exists when blood has difficulty getting past a valve (stenosis) that is normally easily opened. Which two situations may produce a systolic murmur? A. Aortic stenosis and mitral regurgitation B. Pulmonic regurgitation and tricuspid stenosis C. Aortic and tricuspid stenosis D. Pulmonic and mitral regurgitation - CORRECT ANSWER A. Aortic stenosis and mitral regurgitation During ventricular systole, the semilunar valves (aortic and pulmonic) should be open and the AV (mitral and tricuspid) valves should be closed. Option A provides the only scenario where this should be occurring. A quick test-taking strategy would be to identify that both options C and D identify situations where both types of valves are in stenosis or regurgitation at the same time, allowing you to rule out C and D options quickly. All of the following but one are considered key treatments in the management of HF. Which one is NOT a key treatment in HF? A. Angiotensin-converting enzyme (ACE) inhibitors B. Beta blockers C. Diuretics D. Nitroprusside - CORRECT ANSWER D. Nitroprusside Remember, in these negatively stated questions, the question is essentially asking, "These are all key treatments EXCEPT ..." ACE inhibitors and beta blockers (such as carvedilol) are standards of care in HF, so options A and B can be eliminated quickly. Although diuretics are not associated with mortality benefit in HF, they are frequently administered in HF and key to preload reduction and symptom relief in acute HF, so eliminate C. Although afterload reducers are often adjunctive treatment in HF, nitroprusside is less commonly administered compared to the other options and not considered a standard of care in HF. Choose D. Pericardial tamponade presents with all but one of the following symptoms. Identify the symptom NOT associated with pericardial tamponade. A. Equalization of left and right atrial pressures (CVP and PAOP) B. LV failure without RV involvement C. Hypotension D. Distended neck veins - CORRECT ANSWER B. LV failure without RV involvement In this negatively stated question, it suggests that all options are characteristics of pericardial tamponade EXCEPT one option. An equalization of all cardiac filling pressures, option A, is a classic finding due to circumferential external pressure on the myocardium. Due to the fact that the pressure distribution is circumferential, both ventricles WOULD BE involved, making option B the best answer. Hypotension (option C) is a classic finding due to decreased LV filling, and distended neck veins (option D) is a classic finding due to a compressed RA. Choose B. Phase 0 of cellular impulse transmission refers to which phase of electrical action? A. Depolarization B. Early repolarization C. End repolarization D. Myocardial relaxation - CORRECT ANSWER A. Depolarization Even if you were unsure of the correct choice initially, notice that options B, C, and D all relate to repolarization and rest. Option A is the only option that refers to depolarization as suggested by phase 0. Choose A. Spontaneous diastolic repolarization occurs during which phase of the cardiac action potential? A. Phase 0 B. Phase 1 C. Phase 3 D. Phase 4 - CORRECT ANSWER D. Phase 4 Even if you are unsure of which phase of cardiac potential and ion movement were associated with each option, option D (phase 4) is the only option indicating the complete resting interval between action potentials. Think of the action potential wave as "steps" with the lowest, "bottom" step (-90 mV, electronegativity) suggesting diastole and repolarization. Which electrolyte is responsible for initial depolarization? A. Sodium B. Potassium C. Chloride D. Calcium - CORRECT ANSWER A. Sodium The electrolyte responsible is sodium (option A), which rushes into the cell to depolarize it. An easy way to remember this is to remember that sodium is the cation (positively charged) that is available in the highest extracellular quantities (135-145 mEq/L), just waiting to rush into the cell. Potassium is largely intracellular, so eliminate B. Chloride is an ion of rapid repolarization in phase 1, so eliminate C. Calcium, option D, is more involved in the slow calcium channels of phase 2, the plateau phase of repolarization. Choose A Which cation activates the second (slow-channel) inward flow of ions during cardiac depolarization? A. Sodium B. Potassium C. Chloride D. Calcium - CORRECT ANSWER D. Calcium The sodium-potassium pumps are associated with rapid channel movement, so A and B can be eliminated initially. Chloride is an anion, so eliminate C as well. Calcium is the "slow channel" cation of phase 2 (the plateau phase). It is by working on this phase that calcium chloride IVP administration can increase contractility and protect the myocardium. Choose D. Which ion leaves the cell during depolarization to counter the inward flow of sodium? A. Phosphate B. Potassium C. Chloride D. Calcium - CORRECT ANSWER B. Potassium The cell membrane will always favor exchanging a "positive for a positive" or a "negative for a negative." Since sodium is positive and phosphate (option A) and chloride (Option C) are negative, they can be eliminated quickly. The "sodium-potassium pump" suggests that sodium largely exchanges with potassium, making option B the best answer. Calcium is more associated with the slow-channel phase 2, so eliminate D. Which of the following cardiac chambers contains deoxygenated blood? A. Right ventricle B. Left ventricle C. Pulmonary veins D. Left atrium - CORRECT ANSWER A. Right ventricle Left-sided cardiac chambers carry oxygenated blood, so options B and D can be eliminated quickly. The only right-sided chamber mentioned here is A, making option A the best answer. Even though the word "veins" is mentioned in option C, the pulmonary veins carry oxygenated blood to the right atrium from the lungs, thus eliminating option C as well. Where is the sinoatrial (SA) node located? A. Right atrium B. Left atrium C. Right ventricle D. Superior vena cava - CORRECT ANSWER A. Right atrium The conduction pathway begins in the right atrium, travels through the bundle of His in the septum, then the apex of the LV and throughout the His-Purkinje system. The conduction impulse also begins with the sinoatrial (SA) node, so choose A. The superior vena cava, option D, is not even a cardiac chamber and can be eliminated quickly. Options B and C refer to either the incorrect side or the cardiac chamber in order to confuse the reader. Which component of blood pressure regulation has the strongest effect on controlling the blood pressure? A. Stroke volume B. Cardiac output C. SVR D. Mean arterial pressure - CORRECT ANSWER C. SVR Cardiac output and stroke volume relate more to blood flow than blood pressure, so option A and B can be eliminated quickly. Mean arterial pressure is just another way to measure blood pressure, so D can be eliminated as well. Consider the formula MAP = CO x SVR. SVR measures the degree of afterload that compensates for changes in cardiac output (CO). SVR is also one of the primary parameters targeted for treatment of primary systemic HTN. Choose C. Which of the following corresponds most closely to the normal ejection fraction? A. 10% to 20% B. 25% to 35% C. 40% to 50% D. >60% - CORRECT ANSWER D. >60% 10-20% is associated with severe systolic HF, so eliminate A (also, careful not to confuse with atrial "kick", which is approximately 10-15%). A 25-35% ejection fraction would suggest advanced HF and 40-50% wold suggest a depressed EF, so eliminate options B and C as well. A normal ejection fraction is 60-65%, so choose D. Starling's law involves which of the following relationships? A. As fluid fills the lungs, gas exchange decreases B. As coronary blood flow increases, preload falls C. As afterload increases, stroke volume improves D. As muscle stretches, contraction strength initially increases - CORRECT ANSWER D. As muscle stretches, contraction strength initially increases Option A is a true statement, but reflect pulmonary shunt and not Starling's law, so eliminate A. Options B and C are not necessarily always true, and neither are they Starling's law, so can be eliminated as well. Option D describes Starling's law, or the "rubber band theory", which suggests that when the cardiac muscle is stretched, the strength of contraction increases. Choose D. Which of the following would normally cause a patient with chest pain to be transferred to the cardiac catheterization lab as quickly as possible? A. Lactate level of 1.8 B. Troponin I (cTnI) of < 1 C. ST-segment elevation in leads V1-V4 D. Right atrial pressure of 8 mmHg - CORRECT ANSWER C. ST-segment elevation in leads V1-V4 Acute ST elevation suggesting a STEMI is the primary criteria indicating a transfer to the cardiac catheterization lab as quickly as possible. The lactate level in option A is a normal finding, plus it is only a global indicator of tissue hypoxia and nonspecific with regard to MI, so eliminate A. A troponin I of < 1 may be present during a STEMI; however, this does not alone suggest prompt transfer for potential angioplasty, so eliminate B. A right atrial pressure of 8 mmHg, for the purposes of this exam, is a normal finding, thus eliminating D. Therefore, choose C. Which of the following is the most common reason for the left ventricular end-diastolic pressure (LVEDP) and the right atrial pressure (RAP) to increase? A. Left and right ventricular failure B. Excess blood volume C. RV failure D. Pulmonary hypertension - CORRECT ANSWER A. Left and right ventricular failure Options C and D only relate to right-sided cardiac failure and therefore can be eliminated quickly. Option A is more specific to the underlying cause of LVEDP (PAOP) and RAP (CVP) elevation (as opposed to option B, which is more generally stated); therefore, choose A. Reduction of myocardial oxygen consumption is best achieved through which of the following changes? A. Reducing afterload B. Reducing preload C. Increasing contractility D. Increasing preload - CORRECT ANSWER A. Reducing afterload Options C and D actually increase myocardial oxygen consumption (MvO2) and can be ruled out initially. Then when deciding between options A and B, consider what nitroglycerin does for ischemic chest pain -- It vasodilates and lowers the resistance to left ventricular ejection, thus making option A the best remaining answer. Which neurological structure or system has the strongest effect on regulating the heart rate? A. Sympathetic nervous system B. Parasympathetic nervous system C. Adrenergic system D. Cerebellum - CORRECT ANSWER B. Parasympathetic nervous system Options A and C essentially refer to the same, "fight or flight" component of the autonomic nervous system and can be eliminated quickly. The parasympathetic nervous system includes the vagus nerve, which is more closely associated with HR control. Consider how vagal maneuvers lower the HR or how atropine (a "parasympatho-lytic") blocks the parasympathetic (i.e., the "rest and digest") side of the nervous system so that sympathetic (i.e. "adrenergic") stimulation can take over and accelerate the HR. The cerebellum supports functions such as balance, so eliminate D also and choose B. Posterior hemiblock is seen when which conduction defect occurs? A. Obstruction of the left main bundle branch B. Obstruction of the right main bundle branch C. Blockage of the posterior portion of the right bundle D. Blockage of the posterior portion of the left bundle - CORRECT ANSWER D. Blockage of the posterior portion of the left bundle The left main is a coronary artery, but option A is not specific enough to address anterior or posterior blocks, so eliminate this option. Options B and C can also be eliminated because the right bundle branch only has one fascicle and the question refers to a hemiblock, so eliminate B and C as well. The left bundle branch involves two fascicles and could be responsible for a hemiblock. Posterior hemiblocks involve the posterior portion, so choose D. What is the preferred first treatment for ventricular fibrillation? A. Nifedipine B. Lidocaine 1 mg/kg C. Synchronized cardioversion, 50-100J D. Defibrillation, 200-300J monophasic or 120-180J biphasic - CORRECT ANSWER D. Defibrillation, 200-300J monophasic or 120-180J biphasic First-line therapy for ventricular fibrillation is defibrillation, so choose D. Since options A and B both refer to drug therapy, they can be ruled out as answers quickly. Option C refers to synchronized cardioversion, which is more appropriate for unstable tachydysrhythmias with a pulse present, such as SVT or atrial fibrillation, usually exceeding an HR rate of 160, so eliminate C as well. Which of the following leads are used un the diagnosis of an interior MI? A. V1, V2, V3, V4 B. I and aVL C. V5 and V6 D. II, III, aVF - CORRECT ANSWER D. II, III, aVF V1-V4 are anteroseptal leads, so eliminate option A. I and aVL are high lateral leads, so eliminate option B as well. Option C can also be ruled out because V5 and V6 are left lateral leads. The only inferior leads listed are II, III, and aVF, so choose D. Picture where the electrodes are placed to perform a 12 lead ECG in order to provide yourself with a "mental roadmap" to locate where these affected areas may be. Which of the following leads are used in the diagnosis of an anterior MI? A. V1, V2, V3, V4 B. I, aVL C. V5, V6 D. II, III, aVF - CORRECT ANSWER A. V1, V2, V3, V4 V1-V4 are anteroseptal leads so the best answer is option A. I and aVL are high lateral leads, so eliminate option B. Option C can also be ruled out because V5 and V6 are left lateral leads. II, III, and aVF are inferior leads, so eliminate D as well. Picture where the electrodes are placed to perform a 12 lead ECG in order to provide yourself with a "mental roadmap" to locate where these affected areas may be. Which of the following leads are used in the diagnosis of a lateral MI? A. V1, V2, V3, V4 B. I, aVL, V5, V6 C. V2R, V3R, V4R D. II, III, aVF - CORRECT ANSWER B. I, aVL, V5, V6 V1-V4 are anteroseptal leads, so eliminate option A. I and aVL are high lateral leads and V5 and V6 are left lateral leads, making option B the best answer. Option C refers to right-sided leads intended to specifically look for right ventricular and/or inferior ischemia or injury, so eliminate C. II, III, and aVF are inferior leads, so eliminate D as well. Which of the following leads are used in the diagnosis of an RV MI? A. V1, V2, V3, V4 B. I, aVL, V5, V6 C. aVR, aVL, aVF D. V1, V2, V4R, V6R - CORRECT ANSWER D. V1, V2, V4R, V6R V1-V4 are anteroseptal leads, so eliminate option A. I and aVL are high lateral leads and V5 and V6 are left lateral leads, so eliminate option B as well. Option C can be eliminated quickly, since the leads in option C are not contiguous leads (they are all limb leads) and aVR is an indeterminate lead. Option D is the only option that inlcudes right-sided leads to specifically look for right ventricular and/or inferior ischemia or injury, making option D the best answer. An atrial premature beat with aberrant conduction usually has which of the following characteristics? A. Left bundle branch block B. Left anterior hemiblock C. Right bundle branch block D. Posterior hemiblock - CORRECT ANSWER C. Right bundle branch block The rSR' in V1 is a common feature between the right bundle branch block and an atrial premature beat with aberrant conduction, making option C the best answer. A 12-lead ECG is often needed to differentiate between the two. APCs with aberrant conduction can be differentiated from PVCs by noting ECG changes. All of the following but one are associated with PVCs rather than APCs. Identify the one associated with APCs. A. Taller left peak (Rr') in V1 B. Right bundle branch block C. Marker left axis deviation D. rS pattern in V6 - CORRECT ANSWER B. Right bundle branch block Right bundle branch block patterns most closely resemble APCs with aberrant conduction of the options listed, making B the best answer. Option A can be eliminated since the taller left peak (Rr') in V1 is more closely associated with ventricular tachycardia or PVcs, as opposed to right bundle branch block pattern where the right peak ("rabbit ear") is taller. Options C and D can also be eliminated because they are both associated with ventricular and not supraventricular activity. Which of the following corresponds most closely to the definition of precordial concordancy? A. rsR' in V1 to V4 B. All QRS complexes have the same axis in V1 to V6 C. All T waves are inverted in V1 to V6 D. Left axis deviation in I and aVF - CORRECT ANSWER B. All QRS complexes have the same axis in V1 to V6 The precordial leads on the 12-lead ECG are V1 to V6, and precordial concordance can be very helpful in differentiating wide complex tachycardia. In these situations, if the precordial leads are either all positive or all negative, a high likelihood of ventricular tachycardia exists, making option B the best answer. Option A refers to a bundle branch block pattern, option C refers to potential ischemic changes, and option D refers to conditions such as LV hypertrophy. Inferior MIs produce conduction defects different from those seen in anterior MIs. Which type of dysrhythmia is more likely to occur in inferior as opposed to anterior MIs? A. Second-degree type I B. Second-degree type II C. Multiform PVCs D. Third-degree heart block - CORRECT ANSWER A. Second-degree type I Inferior MIs are associated with dysfunction of the SA node, making option A the best answer. Options B, C, and D all impact the conduction pathway farther down as compared to option A. Option A suggests a defect on the uppermost portion of the conduction pathway compared to the other options, so choose A. Anterior hemiblock is manifest by which of the following 12 lead ECG patterns? A. Left axis deviation greater than -30 degrees B. Right axis deviation greater than +90 degrees C. Q wave in V1 to V3 D. Large R wave in I and aVL - CORRECT ANSWER A. Left axis deviation greater than -30 degrees Anterior hemiblocks are a specific type of left bundle branch block associated with left axis deviation, making option A the best answer. Left bundle branch blocks are also associated with PVCs and LV hypertrophy. Right axis deviation would be associated with a right bundle branch block and/or a posterior hemiblock, eliminating option B. Q waves are simply dead tissue, ruling out option C as well. Option D is just a nonspecific referece to high lateral leads. Choose A. Posterior hemiblock is manifest by which of the following 12-lead ECG patterns? A. Left axis deviation greater than -30 degrees B. Right axis deviation greater than +90 degrees C. Q wave in V1 to V3 D. Large R wave in I and aVL - CORRECT ANSWER B. Right axis deviation greater than +90 degrees Posterior hemiblocks are a specific type of left bundle branch block associated with right axis deviation, making option B the best answer. Posterior hemiblocks are also associated with an RV hypertrophy pattern. Left axis deviation would be associated with an anterior hemiblock, eliminating option A. Q waves are simply dead tissue, ruling out option C as well. Option D is just a nonspecific reference to high lateral leads. Choose B. LV hypertrophy is manifest by which of the following ECG changes? A. Left anterior hemiblock patterns B. Left bundle branch patterns C. S wave in V1 and R wave in V5 totaling >35mm D. R wave in III and S wave in aVL totaling >30 mm - CORRECT ANSWER C. S wave in V1 and R wave in V5 totaling >35mm Option C is the best and most specific definition here. Options A and B may be seen with cardiomyopathy or LV hypertrophy physiology; however, these definitions are more vague. Large R waves may also be seen as mentioned in option D; however, the rest of option D is incorrect. Choose C. RV hypertrophy is manifest by which of the following ECG changes? A. Right anterior hemiblock patterns B. Right bundle branch block patterns C. S wave in V1 and R wave in V5 totaling >35 mm D. R:S ratio greater than 1:1 in V1 - CORRECT ANSWER D. R:S ratio greater than 1:1 in V1 Option D is the best and most specific definition here. Options A and B may be seen with RV hypertrophy physiology; however, these definitions are more vague. Option C describes criteria for diagnosing LV hypertrophy. Choose D. Which of the following is NOT an example of AV dissociation? A. Ventricular tachycardia B. Third-degree heart block C. First-degree heart block D. Atrial tachycardia with 2:1 block - CORRECT ANSWER C. First-degree heart block In this negatively stated question, it is asking, "AV dissociation is present in each of these options EXCEPT ..." Options B and D can be eliminated quickly because third-degree block is complete AV dissociation and atrial tachycardia with 2:1 block suggest AV block every other beat. Ventricular tachycardia can also be ruled out as P waves in VT are either not present or unable to assess, so eliminate A as well. Be careful not to be mislead by the name "first-degree block," even though it is a part of the heart block continuum, no AV dissociation exists with this rhythm. Choose C. What is the initial treatment of sinus tachycardia? A. Verapamil B. Initially carotid massage, then digoxin C. Esmolol or propranolol D. There is no primary treatment; the source of the tachycardia must be found - CORRECT ANSWER D. There is no primary treatment; the source of the tachycardia must be found Many different causes of sinus tachycardia exist and treatment should primarily be focused on addressing the underlying cause, making option D the best answer. Notice that options A, B, and C are all drug therapy, which helps enable the use of the "cluster technique" to eliminate them. The exam will generally not expect drug therapy to be chosen for a treatment unless necessary. Which of the physical treatments listed below is NOT a form of parasympathetic stimulation for atrial tachycardia? A. Carotid massage B. Pressure on the eyeballs C. Valsalva maneuver D. Hepatojugular reflux - CORRECT ANSWER D. Hepatojugular reflux This is another negatively stated question, asking in other words, "All of the following are physical parasympathetic stimulation treatments for atrial tachycardia EXCEPT..." Options A, B, and C would all be potential maneuvers to use. The hepatojugular reflux, however, is used to assess for right-sided heart failure. A 65-year-old man is admitted to your unit with chest pain. The chest pain developed 2 hr ago at his home. The pain went away while he rested but then returned. Currently, he has substernal chest pain radiating to the left arm and chin. The pain is the same regardless of position. No change in the pain occurs during inspiration. VS: BP 132/86, HR 96, RR 25. The 12-lead ECG shows depressed ST segments in the inferior leads. Small Q waves, less than one-third the height of the R wave, are present in the inferior leads. Which condition is likely to be developing? A. Angina B. Acute MI C. Pericarditis D. Pericardial tamponade - CORRECT ANSWER A. Angina Based on the case information, the patient in this question is likely suffering from unstable angina, option A. The absence of ST elevation is also often seen in pericarditis, ruling out option C as well. Pericarditis chest pain also tends to improve when sitting forward; however, the pain persists regardless of patient position in this case. Signs of pericardial tamponade are also absent, such as hypotension, tachycardia, and pulsus paradoxus, so eliminate D as well. A 65-year-old man is admitted to your unit with chest pain. The chest pain developed 2 hr ago at his home. The pain went away while he rested but then returned. Currently, he has substernal chest pain radiating to the left arm and chin. The pain is the same regardless of position. No change in the pain occurs during inspiration. VS: BP 132/86, HR 96, RR 25. The 12-lead ECG shows depressed ST segments in the inferior leads. Small Q waves, less than one-third the height of the R wave, are present in the inferior leads. What would be the most likely treatment for the condition? A. Nitrates and beta blockers B. Thrombolytic therapy C. Pericardiocentesis D. NSAIDs and consider steroids - CORRECT ANSWER A. Nitrates and beta blockers The patient is suffering from acute coronary syndrome, and central to the care of patients with ACS is the reduction of afterload and myocardial oxygen demand with nitrates and beta blockers, option A. Thrombolytic therapy would not be appropriate because this patient is not having an acute MI, so eliminate B. Pericardiocentesis would also not be appropriate since signs of pericardial tamponade are not present, so eliminate option C as well. Option D is more appropriate for pericarditis treatment. A 72-year-old man is admitted to your unit with the diagnosis of anterior MI. During your shift, you notice that he has developed a 2:1 heart block and a constant PR interval, with a ventricular response of 42. His BP is 84/50. Based on the preceding information and considering the type of MI, which type of heart block is likely? A. First degree B. Second-degree Type I C. Second-degree Type II D. Third degree - CORRECT ANSWER C. Second-degree Type II In this case, first degree block is not likely because first degree occurs in a 1:1 ratio of P waves to QRSs without any AV dissociation, so eliminate A. A constant PR interval is also described in the case, which is uncharacteristic for second-degree Type I and third-degree block, so eliminate B and D as well. A constant PR interval with 2:1 AV conduction is consistent with second-degree type II, so choose C. A 72-year-old man is admitted to your unit with the diagnosis of anterior MI. During your shift, you notice that he has developed a 2:1 heart block and a constant PR interval, with a ventricular response of 42. His BP is 84/50. Which treatment is likely to be most effective in stabilizing this rhythm? A. Pacemaker B. Nicardipine C. Dopamine IV drip D. Epinephrine IV drip - CORRECT ANSWER A. Pacemaker based on the available options, a pacemaker would be most appropriate to generate an increased ventricular rate. A calcium channel blocker such as nicardipine would risk further slowing the heart rate or exacerbating the AV block, so eliminate B. Options C and D may be considered due to their ability to increase HR; however, they are not considered first-line therapy. In addition, consider that dopamine and epinephrine are both catecholamines with many similarities, which may serve as a clue to "cluster" and eliminate them as possibilities. For what does the first letter in VVI stand? A. Ventricular paced B. Ventricular sensed C. Ventricular inhibited D. Ventricular programmed - CORRECT ANSWER A. Ventricular paced In the three letter pacemaker code, the first letter stands for the cardiac chamber paced, the second letter stands for the chamber sensed, and the last letter stands for the programed response to sensing. Therefore, option A is the correct answer. An easy way to remember the order of the first two letters is to remember that P (paced) comes before S (sensed) in the alphabet. For what does the second letter in VVI stand? A. Ventricular paced B. Ventricular sensed C. Ventricular inhibited D. Ventricular programmed - CORRECT ANSWER B. Ventricular sensed In the three letter pacemaker code, the first letter stands for the cardiac chamber paced, the second letter stands for the chamber sensed, and the last letter stands for the programed response to sensing. Therefore, option B is the correct answer. The sensed chamber is being monitored by the pacemaker for intrinsic cardiac activity. An easy way to remember the order of the first two letters is to remember that P (paced) comes before S (sensed) in the alphabet. Which of the following is an advantage of a transcutaneous pacemaker? A. It is easy to apply B. It requires lower electrical stimulation to capture the heart rate C. It requires peripheral intravenous access D. Electrical stimulation is not perceived by the patient - CORRECT ANSWER A. It is easy to apply The most significant advantage of a transcutaneous pacemaker is the ease of application of the pads, option A. The rest of the options are not true. Transcutaneous pacemakers require a higher electrical stimulation to capture the heart rate as compared to a transvenous pacemaker, eliminating option B. This higher stimulation is often required by the patient and analgesia is often required, eliminating option D as well. Peripheral intravenous access is technically not required, ruling out option C. A 45-year-old man is admitted to the unit with the diagnosis of inferior myocardial infarction (MI). Currently he has no chest pain or shortness of breath. Two hours after admission, he develops a bradycardia of 50 beats per minute with a blood pressure of 86/54. He also develops uniform PVCs at the rate of 10/min. Based on the diagnosis of inferior MI how long will the bradycardia last? A. It will usually be permanent and symptomatic B. It will usually be transient and possibly symptomatic C. Bradycardias are so uncommon with inferior MIs that the CHF will exist until the failure is resolved D. It will usually be permanent but asymptomatic - CORRECT ANSWER B. It will usually be transient and possibly symptomatic Since the right coronary artery is often the culprit in inferior MIs and also supplies the SA node, bradycardia are common in these cases, eliminating option C. However, the bradycardias are usually transient, are self-limiting, and resolve after reperfusion takes place, which also helps eliminate options A and D. A 45-year-old man is admitted to the unit with the diagnosis of inferior myocardial infarction (MI). Currently he has no chest pain or shortness of breath. Two hours after admission, he develops a bradycardia of 50 beats per minute with a blood pressure of 86/54. He also develops uniform PVCs at the rate of 10/min. Treatment for this dysrhythmia would most likely include which medication in the event of symptomatic bradycardia? A. Lidocaine B. Dopamine C. Atropine D. Diltiazem - CORRECT ANSWER C. Atropine Since the patient has an acute onset HR of 50 and a BP of 86/54, this question is asking for the first-line treatment for symptomatic bradycardia, which is atropine, option C. Dopamine, option B, may be considered as a second-line treatment, but is not the best answer. Both options A and D may cause further slowing of the HR, which helps eliminate them as well. In addition, the simple treatment of PVCs with lidocaine is no longer recommended. What is the inherent rate of the AV nodal area? A. 20-40 B. 40-60 C. 60-80 D. The AV nodal area has no inherent rate - CORRECT ANSWER B. 40-60 This a straight knowledge question. The inherent rate of the AV nodal area is 40-60, option B. 20-40 is the inherent rate of the His-Purkinje system, eliminating option A. 60-80 is within the normal sinus node range, eliminating option C. Option D is not true. Anterior MIs produce conduction defects different from those seen in inferior MIs. Which type of dysrhythmia is more likely to occur in anterior than inferior MIs? A. APCs with aberrancy B. Second degree type I C. Second degree type II D. Multiform premature ventricular contractions (PVCs) - CORRECT ANSWER C. Second degree type II In this questions option D can be ruled out quickly because PVCs are equally likely to occur with either type of MI. Next, consider that inferior MIs largely impact the SA node (creating bradydysrhythmias, etc.) whereas anterior MIs are more likely to impact the AV node (creating AV blocks, etc.). Option C identifies the location furthest down the conduction pathway of the remaining options. Option A and B may be more closely associated with SA node dysfunction, ruling them out. Passage of the electrical impulse through the AV node is represented by which ECG complex? A. PR interval B. QRS complex C. ST segment D. T wave - CORRECT ANSWER A. PR interval The QRS complex represents ventricular depolarization, the ST segment represents the end of ventricular depolarization, and the T wave represents ventricular repolarization, eliminating B, C, and D. The PR interval represents the impulse of atrial depolarization, through the AV node, and up to the ventricles. Atrial tachycardia is initially treated with which pharmacological agent? A. Atropine or isoproterenol B. Diltiazem or adenosine C. Digitalis or pronestyl D. Carvedilol or metoprolol - CORRECT ANSWER B. Diltiazem or adenosine In this question option A can be ruled out quickly because these drugs actually increase the HR. Option C can also be eliminated since pronestyl is not considered a first-line agent due to its poor side-effect profile. Carvedilol is considered a drug more appropriate for chronic HF treatment, helping to eliminate option D as well. Diltiazem and adenosine are short-acting agents that help further diagnose the rhythm and stabilize that patient quickly. A junctional rhythm has all of the following characteristics but one. Which of the following characteristics is NOT indicative of a junctional rhythm? A. Normal QRS complex B. Wide QRS complex C. Heart rate between 40 and 60 bpm D. Absent P wave - CORRECT ANSWER B. Wide QRS complex In this negatively stated question, it is stating that "all of the following options are true of junctional rhythms EXCEPT..." It is true that junction rhythms have normal QRS complexes, heart rates 40-60/min, and have absent P waves, which helps eliminate A, C, and D. Junctional rhythms do not have wide QRS complexes. Which lead is most likely to detect aberrantly conducted APCs? A. lead II B. lead III C. Lead aVF D. V1 lead - CORRECT ANSWER D. V1 lead If uncertain with this question, consider first that options A, B, and C are all inferior leads. This could serve as a clue to "cluster" and eliminate them (a much higher likelihood of success on the exam than guessing), V1 is the only precordial lead listed, and is a preferred lead for evaluating conduction defects, right and left bundle branch blocks, and differentiating PVCs from aberrantly conducted PACs. Which ECG change indicates an increased chance of sudden death following an MI? A. Left bundle branch block B. Right bundle branch block C. Sinus tachycardia D Second-degree type II heart block - CORRECT ANSWER A. Left bundle branch block New-onset left bundle branch block is considered a STEMI-equivalent finding in the setting of suspected acute MI. Right bundle branch blocks are not as serious in comparison, eliminating option B. Sinus tachycardia is too vague and nonspecific of a finding, eliminating option C. Second-degree type II heart block may require urgent attention; however, it is not as emergent as a STEMI-equivalent finding, which mandates PCI within 90 min unless proven otherwise. APCs with aberrant conduction can be differentiated from PVCs by noting ECG changes. All of the following findings but one are associated with APCs rather than PVCs. Identify the one associated with PVCs. A. Second R wave larger than the first in V1 B. RBBB C. Right axis deviation D. AV dissociation - CORRECT ANSWER D. AV dissociation If you are unsure with this question, notice that options A, B, and C are all associated with right-sided changes in order to be clustered together and eliminated. A second R wave larger than the first also suggests an RSR', second "rabbit ear" that is larger than the left R wave "rabbit ear", suggesting right bundle branch block. Which of the following isoenzymes is most diagnostic in identifying MI? A. Troponin I (cTnI) B. CPK-MB band C. Troponin K (cTnK) D. CPK-BB band - CORRECT ANSWER A. Troponin I (cTnI) The most cardio-specific isoenzyme listed above is option A, troponin I. Options B and D are less specific to the cardiac muscle, ruling these options out. Troponin K does not exist. A 51 year old man is admitted to your unit with the symptoms of crushing chest pain that is unrelieved by nitrates or rest. He has elevated ST segments elevated 3mm in V1 through V4 with ST segment depression in II, III, and aVF. His blood pressure is 94/64, pulse 110, and RR 32. Based on the preceding information, which type of MI would most likely be represented by the ECG changes? A. Anterior B. Inferior C. Lateral D. Posterior - CORRECT ANSWER A. Anterior ST elevation in V1-V4 suggests an anteroseptal MI, making option A the best answer. The inferior leads are II, III, and aVF, eliminating option B. The lateral leads are V5 and V6 and the high lateral leads are I and aVL, eliminating option C as well. For posterior MI to be visualized, leads V7 and V9 would need to be obtained via a right-sided 12 lead ECG. A 51 year old man is admitted to your unit with the symptoms of crushing chest pain that is unrelieved by nitrates or rest. He has elevated ST segments elevated 3mm in V1 through V4 with ST segment depression in II, III, and aVF. His blood pressure is 94/64, pulse 110, and RR 32. Is ECG confirmation of an MI with irreversible ischemia present in this patient? A. No, due to the absence of Q waves B. No, due to the ST-segment depression in the inferior leads C. Yes, due to ST-segment elevation in V1-V4 D. Yes, due to the absence of lateral ECG changes. - CORRECT ANSWER A. No, due to the absence of Q waves Q-waves suggest that dead myocardial tissue and irreversibility is present. Since Q waves are not present, option A is the best answer. ST depression in the inferior leads only reflects reciprocal changes in this example, so eliminate B. ST-segment elevation suggests active ischemic injury from compromised blood flow is occurring; however, this is still reversible, so eliminate option C as well. Option D is irrelevant. Which stage of HF poses a high risk of heart failure but is NOT associated with structural disease or symptoms? A. Stage A B. Stage B C. Stage C D. Stage D - CORRECT ANSWER A. Stage A This is a straight knowledge question. Stage A HF is an early class of HF common in hypertensives, diabetics, patients with substance abuse, or certain comorbid conditions that place a patient at increased risk for developing structural signs of HF. Stages B, C, and D indicate more advanced stages of HF, respectively (with Stage D representing end-stage HF). Choose A. When in doubt in a staged question such as this with options that indicate a continuum, consider using the "cluster technique" and eliminate the middle options (options B and C) initially to narrow it down. Unstable angina is characterized by all of the following features but one. Which feature does NOT characterize unstable angina? A. Increasing frequency of chest pain B. Chest pain at rest C Increasing severity of symptoms D. Q-wave formation - CORRECT ANSWER D. Q-wave formation The presence of pathological Q wave (deep and wide) indicates irreversible myocardial ischemia. All of the other symptoms listed are associated with unstable angina. Troponin I (cTnI) levels stay elevated for how long following an MI? A. Up to 8-10 days B. About 3 hrs C. Peaks immediately and stays elevated for 14 days D. About 3 days - CORRECT ANSWER A. Up to 8-10 days Troponin I stays elevated for up to 10 days post-MI in patients with normal renal function. It starts to rise in about 3 hrs after the onset of the MI. CK-MB rises within 4 hrs and resolves in 48-72 hrs. Sympathetic stimulants, such as dopamine, are not indicated in hypovolemia until the blood volume has been corrected. Which of the following is the best explanation for this approach? A. Massive sympathetic stimulation is already present and cannot reach effectiveness without adequate fluid volume. B. Sympathetic stimulation works only when vasodilation is the primary problem. C. Sympathetic stimulation cannot occur until vascular baroreceptors have been inactivated D. Dopamine is indicated in hypovolemia before fluid replacement. - CORRECT ANSWER A. Massive sympathetic stimulation is already present and cannot reach effectiveness without adequate fluid volume. Vasoactive agents are indicated in hemorrhagic shock only after intravascular volume is replaced and there is evidence of ongoing shock. Without adequate preload, stroke volume will continue to be low and heart rate will continue to increase in an attempt to maintain cardiac output. Additionally, dopamine itself isn't the best medication to give to tachycardic patients, since it acts on B1 receptors to increase heart rate. Which type of medication is common in the treatment of unstable angina? A. Diuretics B. Inotropic agents C. Beta blockers D. Sympathetic stimulants - CORRECT ANSWER C. Beta blockers Beta blockers are considered antianginal medications since they decrease heart rate thereby lowering myocardial oxygen demands. Option A is used to decrease preload in patients with heart failure, but does not affect angina. Options B and D are both sympathetic stimulants that would likely worsen the angina. Thrombolytic therapy is commonly associated with complications. Which of the following is NOT a complication of thrombolytic therapy? A. Intracranial hemorrhage B. Bleeding from venipuncture sites C. Ventricular ectopy due to reperfusion D. Extension of the MI due to embolic phenomena - CORRECT ANSWER D. Extension of the MI due to embolic phenomena All of the above with the exception of extending the MI due to an embolus are known complications of thrombolytic therapy Which of the following is an indication for angioplasty or stent placement? A. 80% proximal stenosis of a coronary artery B. 100% distal occlusion of a coronary artery C. 75% in three or more coronary arteries D. Vasospasm - CORRECT ANSWER A. 80% proximal stenosis of a coronary artery Percutaneous intervention (stenting) is only indicated in option A since the stenosis is >75% and involves a single vessel. Total (100%) occlusions of coronary arteries are not often stented due to the presence of extensive collateral circulation. Multivessel disease (option C) is incorrect as those patients are better served with CABG. Vasospasm is treated in the cath lab with either intracoronary verapamil or nitroglycerin. For long-term use, it is treated with oral calcium channel blockers. Which of the following are treatments for Prinzmetal's variant angina? A. Beta blockers, angiotensin-converting enzyme inhibitors B. Aspirin, nitrates C. Beta blockers, angiotensin receptor blockers D. Nitrates, calcium channel blockers - CORRECT ANSWER D. Nitrates, calcium channel blockers Vasospasm is treated in the cath lab with either intracoronary verapamil or nitroglycerin. For long-term use, it is treated with oral calcium channel blockers. Aspirin, ACE inhibitors, and angiotensin receptor blockers are not used to treat Prinzmetal's angina. Indications for thrombolytic therapy include the following except? A. New left bundle branch block B. Onset of pain less than 2 hrs prior to the initiation of therapy C. History of stroke within the previous 3 months D. ST-segment elevation in the anterior leads - CORRECT ANSWER C. History of stroke within the previous 3 months All of the above are indications except for a history of stroke within the previous 3 months due to the risk of iatrogenic stroke that may occur with thrombolytic administration. Dopamine is used with caution in patients with MI for which reason? A. Its potential for increasing myocardial oxygen consumption B. Because it has no inotropic component C. Because it may cause reflex bradycardia D. Due to decreasing the risk of atrial fibrillation development - CORRECT ANSWER A. Its potential for increasing myocardial oxygen consumption Whenever adding an inotrope or a positive chronotrope (dopamine is both), there is an increase in myocardial oxygen demand. Dopamine does not cause reflex bradycardia, eliminating options B and C. Dopamine can induce atrial fibrillation, eliminating option D. Pulsus paradoxus is utilized to identify which of the following conditions? A. Cardiac tamponade B. Myocardial infarction C. Respiratory failure D. Ruptured papillary muscle - CORRECT ANSWER A. Cardiac tamponade Pulsus paradoxus is defined as a decrease of >10 mmHg drop in BP upon inspiration. It is a classic sign of cardiac tamponade likely to be observed along with Beck's triad: low arterial BP, distended neck veins, and distant, muffled heart sounds. Nitroglycerin primarily affects which component of stroke volume? A. Preload B. Afterload C. Contractility D. Stroke volume variation - CORRECT ANSWER A. Preload Nitroglycerin is both an arterial dilator and a venodilator. However, it is primarily a venodilator. As a result, nitroglycerin infusions increase the likelihood of blood pooling in the abdominal and dependent venous circulation. By decreasing the amount of "relative" intravascular volume, nitroglycerin decreases preload (the amount of blood returned to the heart). Although decreasing preload can affect contractility and may affect stroke volume variation, those are not the primary effects, eliminating option C and D. What leads may be useful in establishing a diagnosis in a patient with a suspected right ventricular MI? A. V2, V3, V4 B. V5, V6 C. aVF, aVR D. V4R, V5R, V6R - CORRECT ANSWER D. V4R, V5R, V6R Ideally, a right-sided ECG is used to diagnose an RV infarct. The leads associated with an RV MI on a right-sided ECG are V4R, V5R, and V6R. Which of the following is NOT a symptom of pericarditis? A. Sudden, sharp pain and possible fever B. Increased pain in the left lateral position C. Pericardial friction rub D. Chest pain unchanged with deep breathing - CORRECT ANSWER D. Chest pain unchanged with deep breathing Pericarditis pain typically increased with respiration. It is also positional. It is worse when lying and improved when sitting forward. Fever is commonly present as a result of the inflammation involved in pericarditis. Pericardial friction rub is generally present in most cases, but it may not be present in all. A 59 year old man is admitted to your unit with the diagnosis "rule out myocardial infarction." He states that a work, 1 hr ago, he felt severe chest pain, became cool and clammy, and felt nauseated. He came immediately to the hospital. The ECG indicates ST segment elevation exists in I, aVL, V5, and V6. His VS are: BP 98/68, HR 107, RR 32. Which type of MI is represented by the ECG? A. Anterior B. Inferior C. Lateral D. Posterior - CORRECT ANSWER B. Inferior Inferior MIs have ST changes in II, III, aVF. The ST depression in lateral leads (I, aVL, V5, and V6) are reciprocal changes seen with inferior ST-segment elevation MIs. A 59 year old man is admitted to your unit with the diagnosis "rule out myocardial infarction." He states that a work, 1 hr ago, he felt severe chest pain, became cool and clammy, and felt nauseated. He came immediately to the hospital. The ECG indicates ST segment elevation exists in I, aVL, V5, and V6. His VS are: BP 98/68, HR 107, RR 32. Based on the preceding description, which initial treatment is indicated? A. Percutaneous coronary interventions (cardiac cath) for stent placement B. Thrombolytics therapy C. Coronary artery bypass grafting D. Supplemental O2 - CORRECT ANSWER A. Percutaneous coronary interventions (cardiac cath) for stent placement The patient is having a STEMI. This requires emergency intervention. The intervention of choice is percutaneous coronary intervention (cardiac cath) when available. Thrombolytic therapy is used in situations where percutaneous coronary intervention is not available and there is no contraindications. The use of furosemide (Lasix) in pulmonary edema due to acute systolic heart failure is designed to improve myocardial function by: A. Reducing preload and improving myocardial contractility B. Reducing afterload and decreasing myocardial oxygen consumption C. Increasing preload and improving contractility D. Improving contractility while increasing afterload - CORRECT ANSWER A. Reducing preload and improving myocardial contractility In systolic HF, the affected ventricle (in this scenario it is the left ventricle) is volume overloaded. This leads to "over-stretch" of the ventricular muscle fibers lowering contractility and stroke volume (Starling's law). Using furosemide to decrease the amount of circulating intravascular volume decreases the ventricular preload, leading to less ventricular muscle fiber stretch, thereby improving stroke volume and cardiac output. Ultimately, this will lower heart rate and therefore myocardial oxygen demand/consumption. Which of the following is NOT a positive inotrope? A. Epinephrine B. Dobutamine C. Milrinone D. Nitroglycerin - CORRECT ANSWER D. Nitroglycerin All of the agents except for nitroglycerin are positive inotropes. Nitroglycerin is a vasodilator that decreases afterload and lowers BP. A patient presents with acute shortness of breath. VS are T 102.3F, HR 126, RR 32, and SPO2 85% on room air. On exam, the patient is using accessory muscles to breath, there are crackles 2/3 of the way up bilaterally, and an IV/VI diastolic murmur at the right sternal border, second intercostal space. Based on these findings, the RNs suspects the patient has developed: A. Tricuspid insufficiency (regurgitation) due to endocarditis B. Mitral stenosis from rheumatic heart disease C. Aortic insufficiency (regurgitation) due to endocarditis D. Respiratory distress from pneumonia - CORRECT ANSWER C. Aortic insufficiency (regurgitation) due to endocarditis The patient has signs of an infection. The pulmonary symptoms and findings are consistent with left heart failure or an insufficient valve on the left side of the heart (mitral or aortic), excluding option A. We can exclude pneumonia since there is no mention of a cough or sputum production. The presence of the murmur points to endocarditis as the culprit. The murmur is at the right sternal border at the second intercostal space, which is where the aortic valve is auscultated. Aortic insufficiency (regurgitation) is a diastolic murmur. Which of the following is NOT a sign of right heart failure? A. Hypoxia B. Dependent edema C. Jugular venous distention D. Dependent edema - CORRECT ANSWER A. Hypoxia Hypoxia is associated with left heart failure. All of the other symptoms are seen in right heart failure. Pericarditis presents on the 12-lead ECG with which of the following changes? A. Q waves in precorial leads B. L axis deviation C. Generalized elevation of ST segments D. Depression of ST segments - CORRECT ANSWER C. Generalized elevation of ST segments Pericarditis typically presents with diffuse ST elevations and sloped PR intervals. Q waves are associated with dead myocardial tissue. Left axis deviation is more associated with left ventricular hypertrophy, and ST depressions are more reflective of ischemic changes. Which of the following are characteristics of PVA? A. Unprovoked chest pain with ST segment elevation B. Chest pain during exertion with ST segment depression C. Absence of chest pain with Q wave formation D. Abdominal pain with referred pain in left arm - CORRECT ANSWER A. Unprovoked chest pain with ST segment elevation Unprovoked chest pain with ST segment elevation is characteristic of Prinzmetal's variant angina (PVA), which can mimic unstable angina. PVA is also associated with exposure to cold temperatures. Chest pain during exertion is more associated with stable angina. Absence of chest pain with Q wave formation may be more associated with conditions such as diabetic neuropathy. Option D may be more associated with a gallbladder attack, but is a confusing option. Orthostatic hypotension results from which of the following conditions? A. LV failure B. Pulmonary hypertension C. Hypovolemia D. Portal hypertension - CORRECT ANSWER C. Hypovolemia Orthostatic hypotension is commonly seen in hypovolemia. LV failure, pulmonary hypertension, and portal hypertension are not common causes of orthostasis. Orthostatic hypotension is manifest by which of the following clinical symptoms following a change from lying down to sitting up? A. A fall in systolic BP of >25 and a decrease in diastolic BP of >10 B. Systolic BP is unchanged while a decrease in diastolic BP of >10 occurs C. A decrease in systolic BP while diastolic BP increases slightly D. An increase in systolic BP while diastolic BP falls - CORRECT ANSWER A. A fall in systolic BP of >25 and a decrease in diastolic BP of >10 In orthostatic hypotension, when changing position from supine to sitting, the heart rate increases by 10 bpm, SBP falls >25, and DBP falls > 10. Which of the following inflammatory markers is suggestive of coronary artery inflammation? A. Increased white blood cell count B. Decreased interleukin 6 (IL-6) C. Increased high-sensitivity C-reactive protein (CRP) D. Increased procalcitonin - CORRECT ANSWER C. Increased high-sensitivity C-reactive protein (CRP) High-sensitivity CRP is a marker of chronic, low-grade inflammation, which is a risk factor for atherosclerosis. CRP levels help stratify patients as low, intermediate, or high risk for future cardiovascular events. A high WBC count is seen more generally during times of acute inflammation or stress, eliminating option A. IL-6 is secreted by the immune system in response to trauma, eliminating option B. Procalcitonin is typically increased in bacterial infections, eliminating option D. Which medication has the strongest effect (assuming normovolemia) in elevating the blood pressure? A. Dobutamine (Dobutrex) B. Isoproterenol (Isuprel) C. Esmolol (Brevibloc) D. Dopamine (Intropin) - CORRECT ANSWER D. Dopamine (Intropin) Dopamine is an alpha agonist in addition to a positive chronotrope. At doses of 11-20 mcgs/kg/min it produces severe vasoconstriction. Dobutamine causes vasodilation, eliminating option A. Isoproterenol is a beta agonist used to increase HR in bradycardia and heart block, eliminating option B. Esmolol is a beta blocker, which decreased HR and BP, eliminating option C. In a patient admitted with the diagnosis of blunt cardiac injury, which physical sign would correlate best with this diagnosis? A. Distended neck veins B. Sinus tachycardia with premature atrial and ventricular contractions C. Shortness of breath D. Ecchymotic area over the entire sternum - CORRECT ANSWER B. Sinus tachycardia with premature atrial and ventricular contractions Sinus tachycardia is common in many trauma patients, including those with blunt cardiac injury. PACs and PVCs are associated with BCI. Some, but not all, patients with BCI may have sternal ecchymosis, eliminating option D. Distended neck veins would be present if the BCI leads to cardiac tamponade, eliminating option A. Shortness of breath is too nonspecific of an option so eliminate C as well. Furosemide (Lasix) is considered to affect primary which component of stroke volume? A. Preload B. Afterload C. Contractility D. Aortic distensibility - CORRECT ANSWER A. Preload Stroke volume primarily compromises of three main elements: preload, afterload, and contractility. Furosemide decreases circulating volume and preload, eliminating B and C. D is a more obscure option. A 69 year old woman with a history of coronary artery disease is admitted with substernal chest pain that is unrelieved by rest or sublingual nitroglycerin. The pain started at rest. While in the unit, her chest discomfort resolves. Two years earlier, she had a coronary angiogram that showed >75% narrowing of her left anterior descending artery. Medical treatment since then has been successful until this episode. Her 12 lead ECG shows SR segment depression in anterior leads. Her troponin I is 0.02. Based on this information, what is the likely diagnosis? A. Stable angina B. RV infarction C. Anterior MI D. Unstable angina - CORRECT ANSWER D. Unstable angina The patient is presenting with classic signs of unstable angina. Option C is incorrect because her troponin is negative at this point and no ST segment elevation is identified. Option A, stable angina, can be eliminated because it is unrelieved by rest. B can be eliminated because there are no Q waves, ST segment elevation, and no inferior injury described. The statin category of drugs exerts its beneficial effect by which of the following mechanisms? A. Inhibiting thrombin formation B. Increasing triglycerides C. Decreasing high-density lipoprotein levels D. Reducing LDL levels and anti-inflammatory properties - CORRECT ANSWER D. Reducing LDL levels and anti-inflammatory properties Statins decrease total cholesterol and LDL, while increasing HDL. They also have anti-inflammatory properties, which help decrease the risk of cardiovascular events. Physical signs associated with decompensated left ventricular failure include all of the following but one. Identify the one sign that is NOT associated with decompensated left ventricular failure. A. Dependent crackles in the lungs B. S3 heart sound C. Dependent edema and hepatomegaly D. Hypoxia - CORRECT ANSWER C. Dependent edema and hepatomegaly Options A, B, and D occur when the left ventricle fails and leads to pulmonary vascular congestion. The S3 heart sound is produced when blood is entering a volume overloaded ventricle. Option C is the correct choice since dependent edema and hepatomegaly are associated with right ventricular failure. A 75 year old woman is admitted to your unit from the emergency department with severe shortness of breath and orthopnea. She is very anxious and restless. She has a history of CHF and was fine until this morning, when the respiratory difficulties started and became progressively worse. Her ECG shows nonspecific ST segment changes. Breath sounds reveal crackles throughout her lungs. Her BP is 102/56, HR 118, and RR 38. Her pulse oximetry is 0.83 on a 50% high-humidity face mask. Based on these symptoms, which condition is probably developing? A. RV failure B. Pulmonary edema C. Myocardial infarction D. Pulmonary emboli - CORRECT ANSWER B. Pulmonary edema All of the signs point to pulmonary edema, which is likely the result of decompensated left ventricular CHF. RV failure and PE (both right sided issues) would not cause crackles throughout the lung fields, eliminating A and D. ECG findings are nonspecific and there is no mention of a positive troponin, eliminating option C. A 75 year old woman is admitted to your unit from the emergency department with severe shortness of breath and orthopnea. She is very anxious and restless. She has a history of CHF and was fine until this morning, when the respiratory difficulties started and became progressively worse. Her ECG shows nonspecific ST segment changes. Breath sounds reveal crackles throughout her lungs. Her BP is 102/56, HR 118, and RR 38. Her pulse oximetry is 0.83 on a 50% high-humidity face mask. Which of the following would probably NOT be used in the treatment of this patient? A. Morphine B. Nifedipine C. Dobutamine D. Furosemide - CORRECT ANSWER B. Nifedipine Although nifedipine causes vasodilation and decreases afterload, it is generally reserved for the treatment of hypertension. Dobutamine will increase contractility and decrease afterload. Furosemide and morphine will decrease preload, which is desirable in decompensated CHF. Which of the following would NOT be an expected treatment in decompensated congestive heart failure (CHF)? A. Inotrope (milrinone, dobutamine) B. Calcium channel blocker (diltiazem) C. Beta natriuretic peptide (nesiritide) D. Diuretic (furosemide) - CORRECT ANSWER B. Calcium channel blocker (diltiazem) Diltiazem is a non-dihydropyridine calcium channel blocker. Besides lowering BP, it lowers HR and can decrease myocardial contractility. Inotropes and diuretics (A and D) are the mainstay of treatment in decompensated CHF. Although its use is declining, nesiritide (Natrecor) (option c) is a synthetic b-type natriuretic peptide for the treatment of decompensated CHF. A patient with pneumonia is admitted to a rural hospital without a cardiac catheterization lab. On hospital day 1, the patient developed ST-segment elevation in leads II, III, and aVF, in addition to ST depression in leads I, aVL, V5, and V6. Which of the following is an absolute contraindication for administering a thrombolytic to this patient? A. BP 178/90 B. Ischemic stroke 2 months ago C. Recent CPR D. Ankle fracture 3 months ago - CORRECT ANSWER B. Ischemic stroke 2 months ago Out of all of these factors, only an ischemic stroke within the last 3 months is an absolute contraindication to administering a thrombolytic. Although high, the BP is still within parameters for thrombolytic administration, eliminating option A. Recent CPR and recent trauma are relative contraindications (eliminating C and D as the best answer). Thrombolytic administration is up to the discretion of the attending physician based on the risk-benefit to the patient. A patient is admitted with presyncope and chest pain. Which one of the symptoms below would make the RN suspect the patient may have aortic stenosis? A. Fatigue B. Palpitations C. Shortness of breath D. Unexpected weight loss - CORRECT ANSWER C. Shortness of breath The triad of symptoms in severe aortic stenosis is syncope or presyncope, chest pain (angina), and shortness of breath. Fatigue and palpitations can happen in a number of disease processes including aortic stenosis, but they are not major symptoms of aortic stenosis, eliminating options A and B. Unexplained weight loss is not typically seen in aortic stenosis (however, perhaps in TB or oncology), eliminating options D. The use of furosemide (Lasix) and morphine in pulmonary edema is designed to i