1.

Examination of a patient in a supine position reveals distended jugular veins from the base of the neck to the angle
of the jaw. This finding indicates:

 decreased venous return.

 increased central venous pressure.
 increased pulmonary artery capillary pressure.
 left-sided heart failure.

2. When caring for a patient who has intermittent claudication, the cardiac-vascular nurse advises the patient to:

 apply graduated compression stockings before getting out of bed.

 elevate the legs when sitting.
 refrain from exercise.
 walk as tolerated.

3. The cardiac-vascular nurse reviews recommended activities with a patient who sustained a myocardial infarction.
The patient states, "It doesn't really matter what I do or don't do. I will either get better or die." This statement reflects:

 acceptance of changed health status.

 an internal locus of control.
 feelings of loss of control.
 projection.

4. A patient who is in the 10th week of outpatient cardiac rehabilitation continues to exhibit symptoms of depression.
When developing a discharge plan, the cardiac-vascular nurse includes:

 a referral for counseling and possible medication.

 a trial of herbal remedies.
 alternative therapies, including yoga and massage.
 comprehensive information about the patient's cardiac status to help reduce his or her anxiety.

5. When reviewing a patient's four-week diet history, the cardiac-vascular nurse identifies a pattern of high calorie
intake on Monday, Wednesday, and Friday nights. The patient states that the patient's spouse recently started taking
a night class on those evenings at a local university. The patient's diet history indicates:

 a disabling family coping behavior.

 a lack of dietary instruction.
 a need for cooking classes.
 an individual coping behavior.
6. A patient who underwent a percutaneous, transluminal coronary angioplasty four weeks ago has a subsequent
ejection fraction of 30%. The patient returns for a follow-up visit. Examination reveals lungs that are clear to
auscultation and slight pedal edema. The patient's medications are digoxin (Lanoxin), furosemide (Lasix), enalapril
maleate (Vasotec), and aspirin. The patient reports a 5-lb (2.27-kg) weight gain over the past two days. The cardiac-
vascular nurse's initial action is to:

 document the weight and reassess the patient at the next session.
 inquire about the patient's medication compliance.
 notify the patient's physician.
 review the patient's most recent nuclear scan.

7. As the cardiac-vascular nurse prepares to administer an experimental cardiac drug to a patient who is participating
in a research study, the patient states that he or she no longer wants the medication. The nurse advises the patient
that:

 he or she has a right to refuse the medication and to withdraw from the study.
 participation in the study is critical to improving the quality of patient outcomes.
 the medication dose has been scheduled for administration.
 the primary investigator will speak with the patient about his or her decision.

8. Which is the primary consideration when preparing to administer thrombolytic therapy to a patient who is
experiencing an acute myocardial infarction (MI)?

 History of heart disease.

 Sensitivity to aspirin.
 Size and location of the MI.
 Time since onset of symptoms.

9. A 55-year-old patient who is diagnosed with an evolving myocardial infarction (MI) insists on going home. The
cardiac-vascular nurse encourages the patient to be admitted because the greatest risk within the first 24 hours of
sustaining an MI is:

 heart failure.
 pulmonary embolism.
 ventricular aneurysm.
 ventricular fibrillation.

10. A patient comes to the emergency department with reports of a swollen and painful leg but denies sustaining any
injury. Physical examination reveals a tense calf muscle, decreased sensation to the foot and leg, and absent pedal
pulses. The cardiac-vascular nurse asks the patient when the symptoms began because:
 a compartment syndrome develops days after an arterial occlusion.
 an arterial thrombosis is sudden and emergent, and an embolism develops gradually.
 irreversible anoxic injury to muscles and nerves can occur in as few as four hours.
 metabolic alkalosis from muscle swelling is cardiotoxic.

11. A primary prevention for reducing a female patient's risk of developing coronary heart disease is to:

 avoid excessive weight gain during pregnancy.

 enroll in a cardiac rehabilitation program.
 take 81 mg of aspirin daily.
 take nitroglycerin at the onset of chest pain.

12. Excessive alcohol use while on warfarin (Coumadin) therapy leads to:

 decreased anticoagulation effect.

 decreased international normalized ratio.
 increased anticoagulation effect.
 increased vitamin K absorption.

13. While the cardiac-vascular nurse preceptor is orienting a graduate nurse on the telemetry unit, a patient
experiences cardiac arrest. Which action by the preceptor, during the emergency cardiac care procedure, facilitates
the graduate nurse's competence and professional development?

 Asking the graduate nurse to review the policy and procedure for cardiac arrest.
 Assigning the graduate nurse to comfort the family during the arrest.
 Directing the graduate nurse to attempt IV access.
 Involving the graduate nurse in the resuscitation by assigning a basic task.

14. A patient is admitted to the hospital for a carotid angiogram with stent placement. The patient's spouse states, "I
don't want my spouse to find out there is a risk of a stroke connected with this procedure because he or she won't
sign the consent form." The cardiac-vascular nurse's most appropriate action is to:

 assess the patient's level of understanding of risks, benefits, and alternatives.

 assure the patient's spouse that the risk of stroke is minimal.
 offer the patient emotional support and reinforce the benefits of the procedure.
 perform a neurologic assessment to establish a baseline.

15. A patient who is recovering from a myocardial infarction may benefit from meditation because this technique:
 decreases sympathetic nervous system activity.
 decreases vasodilation.
 increases sympathetic nervous system activity.
 increases the release of catecholamines.

16. The cardiac-vascular nurse reviews risk factor reduction with a patient who is newly diagnosed with a myocardial
infarction. The patient states, "I don't know why you're making such a big deal about this stuff. I feel fine, and the
doctor said that my heart attack was small." The nurse's most effective action is to:

 assess the patient's perception of the event with open-ended questions.

 present research to support the need for risk factor reduction.
 reinforce patient education.
 review the laboratory values with the patient.

17. A 70-year-old patient with cardiovascular disease attends group classes on disease process, medications,
exercise, nutrition, and stress management. To promote optimal and effective learning, the cardiac-vascular nurse
uses which teaching strategy?

 Condensing the information to one session, so the patient need not return for a second day.
 Customizing teaching objectives based on the learner's interests.
 Preparing a PowerPoint presentation to enhance learning.
 Teaching the most important information at the end of the session, to maximize retention.

18. A patient who underwent coronary artery bypass surgery demonstrates effective understanding of discharge
teaching by:

 asking whether smoking one cigarette per day is acceptable.

 clarifying when cardiac rehabilitation will begin.
 describing plans to relax in a hot tub during recovery.
 planning to resume driving his or her spouse to work next week.

19. A patient with negative troponins and stress test results reports recurring chest pain that is similar to the patient's
pain on admission. According to the American Nurses Association's cardiovascular nursing scope and standards of
practice, the cardiac-vascular nurse's next action is to:

 activate the cardiac catheterization team.

 administer analgesics.
 obtain a 12-lead electrocardiogram.
 promote relaxation and monitor the response.
20. During a clinic appointment, a patient states, "I came in because my calcium score was positive on my computed
tomography scan last week." In which section of the patient assessment does the cardiac-vascular nurse document
this finding?

 Past medical history.

 Personal/social history.
 Presenting problem.
 Review of symptoms.

21. A patient with cardiogenic shock receives a nursing diagnosis of decreased cardiac output. With the appropriate
interventions, the anticipated outcome is for the patient to achieve:

 baseline activity level.

 baseline cardiac function.
 decreased afterload.
 reduced anxiety.

22. A patient has been receiving heparin IV for the last three days. The patient's most current platelet count is 65,000
× 103/uL; the platelet count on admission was 350,000 × 103/uL. The cardiac-vascular nurse contacts the physician to:

 report that the medication level is subtherapeutic.

 report that the patient is exhibiting signs of an adverse reaction.
 request an increase in the medication infusion rate.
 request an order for platelet transfusion.

23. A patient recently had a cardiac catheterization via right-radial approach. The patient has a compression device in
place. The patient complains of numbness and pain in the right hand. The cardiac-vascular nurse notes a diminished
pulse, with a cool and cyanotic hand. The nurse:

 calls the physician.

 performs an Allen's test.
 reduces the pressure on the puncture site.
 uses the Doppler to assess for pulse signals.

24. In an assessment for intermittent claudication, the cardiac-vascular nurse assesses for leg pain and cramping
with exertion, then asks the patient:

 "Does shortness of breath accompany the leg pain?"

 "Does this same type of pain occur without activity?"
 "Is the leg pain relieved by rest?"
 "Is the leg pain relieved with elevation?"

 Results

09/19/2022  06:02

Cardiac-Vascular Nursing

Information
First Name:
Last Name:

You have made the following errors

Question 1
The right answer was increased central venous pressure.

Question 2
The right answer was walk as tolerated.

Question 3
The right answer was feelings of loss of control.

Question 4
The right answer was a referral for counseling and possible medication.

Question 5
The right answer was an individual coping behavior.

Question 6
The right answer was inquire about the patient's medication compliance.

Question 7
The right answer was he or she has a right to refuse the medication and to withdraw from
the study.

Question 8
The right answer was Time since onset of symptoms.

Question 9
The right answer was ventricular fibrillation.

Question 10
The right answer was irreversible anoxic injury to muscles and nerves can occur in as few
as four hours.

Question 11
The right answer was avoid excessive weight gain during pregnancy.
Question 12
The right answer was increased anticoagulation effect.

Question 13
The right answer was Involving the graduate nurse in the resuscitation by assigning a basic
task.

Question 14
The right answer was assess the patient's level of understanding of risks, benefits, and
alternatives.

Question 15
The right answer was decreases sympathetic nervous system activity.

Question 16
The right answer was assess the patient's perception of the event with open-ended
questions.

Question 17
The right answer was Customizing teaching objectives based on the learner's interests.

Question 18
The right answer was clarifying when cardiac rehabilitation will begin.

Question 19
The right answer was obtain a 12-lead electrocardiogram.

Question 20
The right answer was Presenting problem.

Question 21
The right answer was baseline cardiac function.

Question 22
The right answer was report that the patient is exhibiting signs of an adverse reaction.

Question 23
The right answer was reduces the pressure on the puncture site.

Question 24
The right answer was "Is the leg pain relieved by rest?"

You have made 24 errors.

Total score: 0.

    
What is the JVP?

 The internal jugular vein (IJV) connects to the right atrium without any intervening
valves. The pulsation of the right atrium therefore causes the column of blood in the IJV
to rise and fall – this is called the the jugular venous pulse (JVP).
 The jugular venous pressure (also called the JVP and often used interchangeably with
the jugular venous pulse) is the height of this pulsation above the atrium.
 The jugular venous pulse therefore provides an estimate of the central venous pressure
(CVP) and hence the patient’s volume status and heart function.
 Although an important part of the cardiovascular examination, clinical assessment of
CVP using the JVP has poor sensitivity.
 The usual JVP waveform looks like this:

See below for descriptions of the waveform

Question 2.
How do you measure the JVP?

 To measure the JVP, position the patient at 45 degrees. Ask them to turn their head to
the left and extend their neck gently backwards. It may be helpful to adjust the patient’s
head into the correct position.
 First measure the height of the JVP’s highest point in centimetres. This is the vertical
height above the sternal angle at which a pulsation is observed in the internal jugular
vein.
 Look for the JVP along the course of the vein which travels from the earlobe, down the
neck and into the chest, between the two heads of sternocleidomastoid.

 A JVP of greater than 4cm above the sternal angle is said to be elevated.
Question 3.
What are the waves and descents of the JVP waveform?

 The JVP has a subtle double pulsation which follows the pattern below:

 The waves and descents of the JVP are:

 A wave: right Atrial contraction [presystolic]
 X descent: right atrial relaXation
 C wave (not seen Clinically): bulging of the tricuspid valve into the right atrium [beginning
of systole]
 V wave: maximum Venous return [late systole]
 Y descent: Right ventricular filling [diastole]

Question 4.
How can you differentiate the JVP from the carotid pulse?

 The JVP rises with pressure on the liver (hepatojugular reflux)

 The JVP is easily occludable
 The JVP is not strongly pulsatile
 The JVP has a double waveform, the carotid pulse is single

Question 5.
What is Kussmaul’s sign?

 Kussmaul’s sign is a paradoxical increase in the JVP with inspiration. It can occur in any
condition where right ventricular filling is restricted such as constrictive pericarditis or
cardiac tamponade

Question 6.
What is the usual position of the apex beat?

 The apex beat should be situated in the fifth intercostal space along the midclavicular
line.
 If the apex beat is impalpable here, move inferiorly and laterally.
 Displacement of the apex in this direction suggests cardiomegaly.

Question 7.
Why might the apex beat be impalpable?

 Hyperexpanded lungs: obstructive lung disease (e.g. COPD)

 Reduced impulse: tamponade or restrictive pericarditis
 Obesity
  Dextrocardia (try palpating on the right)

Question 8.
What can you to to emphasise the apex beat?

 If you are unable to feel the apex try rolling the patient further to the left to bring the heart
closer to the chest wall. If there is still no beat palpable, try feeling on the right for
dextrocardia.

Question 9.
What scars are common in a cardiac examination?

 Median sternotomy scar: Previous valve surgery or a coronary artery by-pass graft

(CABG)
o If you see a median sternotomy scar look at the lower limbs. If there are scars on
either calf this implies vein harvesting and therefore previous CABG as opposed
to  valve surgery.
o Note that a lack of scar on the calf does not definitely indicate that the patient
has not had a CABG: veins may be harvested from the internal mammary
arteries which are not visible.
 Lateral thoracotomy scar (in mid-axillary line): previous thoracic surgery.
 Inferior clavicle scar (and implant): cardiac pacemaker or defibrillator (usually on left)

Question 10.
How can you describe murmurs in a cardiovascular examination?

 Murmurs should be described in terms of timing, site of greatest intensity, character,

loudness, and radiation
 The intensity of a murmur does not necessarily help in assessing the severity of the
valve lesion, but a change in intensity can be important.

Question 11.
How is the loudness (intensity) of murmurs graded?

 Grade 1: Heard by an expert in optimum conditions

 Grade 2: Heard by a non-expert in optimum conditions
 Grade 3: Easily heard, no thrill
 Grade 4: Loud murmur, palpable thrill
 Grade 5: Very loud murmur, often heard over a wide area, palpable thrill
 Grade 6: Extremely loud, heard without a stethoscope

Question 12.
What is a third heart sound and what causes it?

 A third sound is caused by passive filling of ventricles in systole

  It happens in any condition where the artia are more full than they should be:
o Volume overload
o Mitral regurgitation
o Aortic regurgitation
 NB. An opening snap or myxoma polyp can be confused for a third sound

Question 13.
What is a fourth heart sound?

 The fourth heart sound is caused by atrial contraction against a stiff left ventricle.
Causes include:
o Fibrosis (e.g. post-MI)
o Hypertension
o Aortic stenosis
o HOCM

Question 14.
What does the splitting of heart sounds mean?

 The second heart sound (S2) is composed of aortic and pulmonary valve closure (A2
and P2)
 A2 usually occurs just before P2 as the aortic pressure is higher than pulmonary
pressure so the valve snaps closed quicker. This difference in timings is referred to as
splitting.
 S2 is therefore physiologically slightly split
 A2 gets closer to P2 during expiration
 The loudness of P2 is a measure of pulmonary vascular resistance

Question 15.
What is wide or pathological splitting of heart sounds

 Pathological splitting is when the physiological splitting (A2 before P2) is exaggerated. It
can happen either if A2 occurs early or if P2 occurs late.
 A2 earlier: (i.e. if blood leaves the left ventricle by other means, giving a very quick
reduction in LV pressure)
o Mitral regurgitation
o VSD
 P2 later: (i.e. high volume load or delay for mechanical reasons)
o RBBB
o Pulmonary stenosis
o ASD

Question 16.
What is reverse splitting of the heart sounds?
  Reverse splitting is when the aortic sound occurs AFTER the pulmonary sound. It can
happen either if A2 occurs late or if P2 occurs early:
o A2 later (delay LV contraction)
 Aortic stenosis
 HOCM
 LBBB
 RV pacing
o P2 early (occurs if blood leaves the right ventricle by other means, giving a very
quick reduction in RV pressure)
 TR
 PDA

Note that in modern medicine, splitting of heart sounds is rarely clinically relevant.
Sadly it still appears in exams.

Question 17.
What are the cardiac causes of clubbing?

 Congenital cyanotic heart disease

 Atrial myxoma
 Infective endocarditis

Question 18.
What are the risk factors for endocarditis?

 Previous cardiac valve surgery

 Previous infective endocarditis
 Mitral valve prolapse with valve leakage
 Abnormal valves (e.g. rheumatic fever and degenerative conditions)
 Congenital heart disease

Question 19.
What are the signs of endocarditis?

 Eyes: Roth spots

 Hands: Osler’s nodes, Janeway lesions
 Nails: splinter haemorrhages
 Kidneys: haematuria
 Abscess formation systemically from septic emboli

Question 20.
”What

 Observations
o Wide pulse pressure
 Palpation
 o Collapsing pulse
o Displaced apex beat that is forceful in character (volume-loaded)
 Auscultation
o High-pitched early-diastolic murmur at LLSE loudest with patient leant forward
o Commonly ejection systolic flow murmur due to large stroke volume
o Occasionally an Austin-Flint murmur
 Mid-diastolic murmur caused by regurgitant jet impinging on anterior
mitral cusp
 Eponymous signs of aortic regurgitation
o Quinke’s sign: nail bed capillary pulsation
o De Musset’s sign: Head nodding
o Corrigan’s sign: Visible carotid pulsation
o Duroziez’s sign: To-and-fro femoral artery bruit
o Traub’s sign: Pistol-shot femorals

Question 21.
What are the causes of mitral regurgitation?

 Chronic
o Structural
 Degenerative
 Rheumatic heart disease
 Congential: Marfans and Ehlers-Danloss
o Functional
 Dilated cardiomyapathy
 Secondary to aortic valve disease
o Mitral prolapse (mid-systolic click and late systolic murmur)
 Happens in 4% population. Click moves earlier with valsalva.
 Common in women, thyroid, E-D, Marfans, pseudoxanthoma elasticum.
 Endocarditis prophylaxis not indicated (PT 2012)
 Acute
o MI: papillary muscle or chordate tendineae rupture
o Endocarditis

Question 22.
What are the causes of aortic stenosis?

 Calcific valve disease

o Most common – inflammatory calcification of the valve in the elderly
 Congenital bicuspid valve
o 1-2% (familial 9% but sporadic). 1-2% of these need surgery
 Rheumatic fever
 Supravalvular aortic stenosis

Question 23.
How can you grade the severity of aortic stenosis?
  Clinical signs of severity of aortic stenosis:
o Small volume pulse
o Slow-rising pulse
o Narrow pulse pressure
o Prolonged murmur blocking out the second heart sound
 No other signs correlate with severity, in particular loudness of murmur is
NOT correlated with severity of AS
 Echocardiographic signs of severity of aortic stenosis are in the table below:

Degree of Mean Aortic

aortic gradient  – valve
stenosis from area
Gorlin (normal
formula 3-4
(mmHg) cm2)

Mild <25 >1.5

Moderat 25 – 50 1.0 –
e 1.5

Severe >50 < 1.0

Critical >70 < 0.6

Question 24.
When is a valve replacement indicated in aortic stenosis?

 Symptomatic patients with severe AS (gradient>50)

 Asymptomatic with:
o Need for CABG
o LV dysfunction (EF<40%)
o Abnormal BP in response to exercise
o VT
o Valve area <0.6cm

Question 25.
What are the indications for a pacemaker?

 Persisting symptomatic bradycardia

 Certain heart blocks:
o Complete AV block
o Mobitz type II AV block
o Persistent AV block post anterior myocardial infarction.
 Suppression of resistant tachyarrhythmias
  Improving synchronisation and therefore heart function in some cardiomyopathies
including HOCM

Question 26.
What are the different types of pacemaker?

 Unipolar pacemakers
o Permanent leads are either unipolar (where a single contact is made with the
heart) or bipolar.
o Unipolar systems (ventricular) are used in cases where AV conduction is likely to
return.
o When there is normal AV conduction and a sinoatrial (SA) disorder then the
pacing wire is situated in the right atrium.
 Dual-chamber pacemakers
o Electrodes are in both the right atrium and the right ventricle.
o Maintains a more physiological relationship between atrial and ventricular
contraction Allows the paced heart to follow the increase in sinus rate that occurs
during exercise.
 Dual-site atrial pacing
o Some pacing systems have two atrial leads, one in the right atrial appendage
and the other either at or in the coronary sinus
o The ventricular lead is in the right ventricle.
 Biventricular pacemakers
o Pacemaker leads are placed in the right atrium, right ventricle and left ventricle.
o Used in severe heart failure where there is abnormal intraventricular conduction
(most often evident as left bundle branch block) which causes deranged
ventricular contraction or dyssynchrony.
 Implantable cardioverter defibrillators
o Treat a cardiac tachyarrhythmia directly.
o The device senses a ventricular rate that exceeds the programmed cut-off rate
and the ICD can then either:
 Performs cardioversion/defibrillation, or…
 Pace rapidly for a number of pulses, usually around 10, to attempt pace-
termination of a ventricular tachycardia.

Question 27.
What do pacemaker letters and codes mean?

 Most pacemakers have three letter denominations only (e.g. “VVI”) though modern
pacemaker can have up to five letters:
 Letter 1: chamber that is PACED (A = atria, V = ventricles, D = dual-chamber).
 Letter 2: chamber that is SENSED (A = atria, V = ventricles, D = dual-chamber, 0 =
none).
 Letter 3: the pacemaker’s RESPONSE to a sensed event (T = triggered, I = inhibited, D
= dual – T and I, R = reverse).
 Letter 4: rate-responsive features; an activity sensor (eg, an accelerometer in the pulse
generator) in single or dual-chamber pacemakers detects bodily movement and
 increases the pacing rate according to a programmable algorithm (R = rate-responsive
pacemaker).
 Letter 5: anti-tachycardia facilities

Example: A pacemaker in VVI mode denotes that it paces and senses the ventricle and
is inhibited by a sensed ventricular event. The DDD mode denotes that both chambers
are capable of being sensed and paced.

Question 28.
What are the causes of heart failure

 Cardiac
o Preload issues
 Fluid overload
o Pump failure
 Muscle

Myocerdial infarction
Myoarditis
Cadiomyopathy
 Restriction
 Undilated cardiomyopathy (e.g. Hypertrophic)
 Constrictive pericarditis
 Cardiac tamponade
 Acute arrhythmia
 Valve lesion
 Congenital (e.g. ASD/VSD giving L-to-R shunt)
o Afterload issues
 Severe hypertension
 Pulmonary embolus
 Dissection
o High output
 Anaemia, thyrotoxicosis, haemochromatosis, Paget’s, septic shock
 Non-cardiac
o ARDS (essentially increased afterload)
o PE
o Pulmonary hypertension from any lung pathology (cor pulmonale)
o Renal failure and renal artery stenosis

Question 29.
How do you treat heart failure?

 Conservative
o Lose weight
o Restrict salt
o Fluid restrict
 o Bed rest for exacerbations (reduced demand on heart), but encourage low-level
endurance (20-30 mins waling or cycling) 3-5 times per week
 Medication
o To improve prognosis:
 ACE-1
 Beta-block
 Aspirin
 Statin
 Spironalactone (if severe)
o In addition
 Digoxin can help prevent hospitalisations but increases risk of arrhythmia
 Diuretics decrease oedema but have no effect on mortality

Question 30.
What medications improve prognosis in left ventricular failure?

 Ramipril
o Improves prognosis in LVF (as does enalipril – CONSENSUS trial)
o Reduces mortality by 20%
 NB ATII are the same as ACE-I
 And ATII (candesartan) prevents readmission in people with an LVEF of
>40% (CHARM study)
o Also improves morbidity and mortality in high risk patients with normal LV
function. (CAD, CVD, PVD, DM)
 Rise in creatinine of 20% is reasonable
 Bisoprolol or carvedilol
o Improves symptoms, exercise tolerance, time in hospital and reduces mortality in
heart failure of any cause
 MERIT and CIBIS 2 (used metoprolol, Bisoprolol and carvedilol)
 Basically no difference between them (BMJ 2013)
o Can give acutely
o Good especially in NYHA 1-2 failure, less in 3-4
 Spironolactone
o Reduces mortality in end-stage cardiac failure and prevents sudden cardiac
death (if NYHA II-IV) e.g. if EF<35%
o From RALES trial: RR reduction 0.7 (at 25mg)
 Aspirin
 Statin

Note that none of the other treatments (e.g. diuretics and digoxin) have been shown to
improve mortality.