Understanding The Essentials Of Critical Care Nursing By Perrin -Test Bank

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Understanding The Essentials Of Critical Care Nursing By Perrin -Test Bank

Chapter 6 Care of the Patient Experiencing Shock or Heart Failure

1) Which of the following should the nurse identify as symptoms of hypovolemic shock? (Select all that apply.)
1. A temperature of 97.6°F (36.4°C)
2. A decrease in blood pressure of 20 mm Hg when the patient sits up
3. Capillary refill time greater than 3 seconds
4. Restlessness
5. Sinus bradycardia of 55 beats per minute
Answer: 2, 3, 4
Explanation: 1. (Note: This requires multiple responses to be correct.)
Due to decreased blood flow to the brain and peripheral areas when blood is shunted to
maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the
blood to the brain by gravitational pull and will require increased peripheral resistance or
cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen
demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe
dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures
by peripheral shunting of blood away from the extremities and reducing the core metabolic
rate. If septic shock is present fever might be present, but it is not present in all patients with
hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is
to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids
that are not present in hypovolemic shock.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Physiological Integrity–Physiological Adaptations
2. (Note: This requires multiple responses to be correct.)
Due to decreased blood flow to the brain and peripheral areas when blood is shunted to
maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the
blood to the brain by gravitational pull and will require increased peripheral resistance or
cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen
demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe
dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures
by peripheral shunting of blood away from the extremities and reducing the core metabolic
rate. If septic shock is present fever might be present, but it is not present in all patients with
hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is
to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids
that are not present in hypovolemic shock.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Physiological Integrity–Physiological Adaptations
3. (Note: This requires multiple responses to be correct.)
Due to decreased blood flow to the brain and peripheral areas when blood is shunted to
maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the
blood to the brain by gravitational pull and will require increased peripheral resistance or
cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen
demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe
dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures
by peripheral shunting of blood away from the extremities and reducing the core metabolic
rate. If septic shock is present fever might be present, but it is not present in all patients with
hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is
to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids
that are not present in hypovolemic shock.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Physiological Integrity–Physiological Adaptations
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 137
4. (Note: This requires multiple responses to be correct.)
Due to decreased blood flow to the brain and peripheral areas when blood is shunted to
maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the
blood to the brain by gravitational pull and will require increased peripheral resistance or
cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen
demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe
dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures
by peripheral shunting of blood away from the extremities and reducing the core metabolic
rate. If septic shock is present fever might be present, but it is not present in all patients with
hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is
to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids
that are not present in hypovolemic shock.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Physiological Integrity–Physiological Adaptations
5. (Note: This requires multiple responses to be correct.)
Due to decreased blood flow to the brain and peripheral areas when blood is shunted to
maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the
blood to the brain by gravitational pull and will require increased peripheral resistance or
cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen
demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe
dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures
by peripheral shunting of blood away from the extremities and reducing the core metabolic
rate. If septic shock is present fever might be present, but it is not present in all patients with
hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is
to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids
that are not present in hypovolemic shock.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Physiological Integrity–Physiological Adaptations
Learning Outcome: 6-1: Recognize the manifestations of hypovolemia
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 138
2) Which of the following lab findings should cause the nurse to suspect that a patient was developing
hypovolemic shock?
1. Serum sodium of 130 mEq/L (130 mmol/L)
2. Metabolic alkalosis validated by arterial blood gases
3. Serum lactate of 5 mmol/L
4. SvO2 greater than 80%
Answer: 2
Explanation: 1. Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate
deficit from decreased tissue perfusion. #1 is incorrect. The sodium level in hypovolemic shock
is elevated above the normal values of 135 to 145 mEq/L, not depressed. The increased
concentration of sodium occurs when the circulating volume is decreased, concentrating the
elements. #3 is incorrect. Serum lactate is greater than 4 mmol/L as a result of tissue ischemia,
hypoxia, and breakdown from decreased blood flow with hypovolemic shock. Normal lactate
levels are 0.3 to 2.6 mmol/L. #4 is incorrect. SvO2 (mixed venous oxygen saturation) would be
less than 60% due to decreased circulating blood volume or decrease in cells to carry the
oxygen. Therefore, O2 is carried less efficiently and decreased, not increased. The normal
values for SvO2 are between 60% and 80%.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate
deficit from decreased tissue perfusion. #1 is incorrect. The sodium level in hypovolemic shock
is elevated above the normal values of 135 to 145 mEq/L, not depressed. The increased
concentration of sodium occurs when the circulating volume is decreased, concentrating the
elements. #3 is incorrect. Serum lactate is greater than 4 mmol/L as a result of tissue ischemia,
hypoxia, and breakdown from decreased blood flow with hypovolemic shock. Normal lactate
levels are 0.3 to 2.6 mmol/L. #4 is incorrect. SvO2 (mixed venous oxygen saturation) would be
less than 60% due to decreased circulating blood volume or decrease in cells to carry the
oxygen. Therefore, O2 is carried less efficiently and decreased, not increased. The normal
values for SvO2 are between 60% and 80%.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate
deficit from decreased tissue perfusion. #1 is incorrect. The sodium level in hypovolemic shock
is elevated above the normal values of 135 to 145 mEq/L, not depressed. The increased
concentration of sodium occurs when the circulating volume is decreased, concentrating the
elements. #3 is incorrect. Serum lactate is greater than 4 mmol/L as a result of tissue ischemia,
hypoxia, and breakdown from decreased blood flow with hypovolemic shock. Normal lactate
levels are 0.3 to 2.6 mmol/L. #4 is incorrect. SvO2 (mixed venous oxygen saturation) would be
less than 60% due to decreased circulating blood volume or decrease in cells to carry the
oxygen. Therefore, O2 is carried less efficiently and decreased, not increased. The normal
values for SvO2 are between 60% and 80%.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 139
4. Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate
deficit from decreased tissue perfusion. #1 is incorrect. The sodium level in hypovolemic shock
is elevated above the normal values of 135 to 145 mEq/L, not depressed. The increased
concentration of sodium occurs when the circulating volume is decreased, concentrating the
elements. #3 is incorrect. Serum lactate is greater than 4 mmol/L as a result of tissue ischemia,
hypoxia, and breakdown from decreased blood flow with hypovolemic shock. Normal lactate
levels are 0.3 to 2.6 mmol/L. #4 is incorrect. SvO2 (mixed venous oxygen saturation) would be
less than 60% due to decreased circulating blood volume or decrease in cells to carry the
oxygen. Therefore, O2 is carried less efficiently and decreased, not increased. The normal
values for SvO2 are between 60% and 80%.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 6-1: Recognize the manifestations of hypovolemia
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 140
3) The nurse should recognize that which of the following patients would be most likely to develop hypovolemic
shock? A patient with:
1. Decreased cardiac output.
2. Severe constipation, causing watery diarrhea.
3. Ascites.
4. Syndrome of inappropriate ADH (SIADH).
Answer: 3
Explanation: 1. Third spacing shifts move the fluids from the intravascular space into the interstitial space,
causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the
development of hypovolemic shock. #1 is incorrect. Although ECG changes reflect the
effectiveness of the heartʹs pumping when circulating the blood, it is not a risk factor for
hypovolemic shock that reflects a decreased circulating volume from either blood or fluid
losses within the intravascular system. #2 is incorrect. Severe constipation does not affect the
circulating blood volume. However, it may reflect a pattern of dehydration that might lead to a
decreased blood volume. But that is no direct risk for hypovolemic shock when oozing
diarrhea occurs with severe constipation. #4 is incorrect. Overhydration does not lead to
hypovolemic shock. It leads to fluid overload, which might cause cardiogenic shock,
congestive heart failure, and pulmonary edema.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptation
2. Third spacing shifts move the fluids from the intravascular space into the interstitial space,
causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the
development of hypovolemic shock. #1 is incorrect. Although ECG changes reflect the
effectiveness of the heartʹs pumping when circulating the blood, it is not a risk factor for
hypovolemic shock that reflects a decreased circulating volume from either blood or fluid
losses within the intravascular system. #2 is incorrect. Severe constipation does not affect the
circulating blood volume. However, it may reflect a pattern of dehydration that might lead to a
decreased blood volume. But that is no direct risk for hypovolemic shock when oozing
diarrhea occurs with severe constipation. #4 is incorrect. Overhydration does not lead to
hypovolemic shock. It leads to fluid overload, which might cause cardiogenic shock,
congestive heart failure, and pulmonary edema.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptation
3. Third spacing shifts move the fluids from the intravascular space into the interstitial space,
causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the
development of hypovolemic shock. #1 is incorrect. Although ECG changes reflect the
effectiveness of the heartʹs pumping when circulating the blood, it is not a risk factor for
hypovolemic shock that reflects a decreased circulating volume from either blood or fluid
losses within the intravascular system. #2 is incorrect. Severe constipation does not affect the
circulating blood volume. However, it may reflect a pattern of dehydration that might lead to a
decreased blood volume. But that is no direct risk for hypovolemic shock when oozing
diarrhea occurs with severe constipation. #4 is incorrect. Overhydration does not lead to
hypovolemic shock. It leads to fluid overload, which might cause cardiogenic shock,
congestive heart failure, and pulmonary edema.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptation
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 141
4. Third spacing shifts move the fluids from the intravascular space into the interstitial space,
causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the
development of hypovolemic shock. #1 is incorrect. Although ECG changes reflect the
effectiveness of the heartʹs pumping when circulating the blood, it is not a risk factor for
hypovolemic shock that reflects a decreased circulating volume from either blood or fluid
losses within the intravascular system. #2 is incorrect. Severe constipation does not affect the
circulating blood volume. However, it may reflect a pattern of dehydration that might lead to a
decreased blood volume. But that is no direct risk for hypovolemic shock when oozing
diarrhea occurs with severe constipation. #4 is incorrect. Overhydration does not lead to
hypovolemic shock. It leads to fluid overload, which might cause cardiogenic shock,
congestive heart failure, and pulmonary edema.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 6-1: Recognize the manifestations of hypovolemia
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 142
4) Which of the following findings would indicate that a patientʹs peripheral vascular resistance was increased?
1. Strong bounding pulse with deep red coloring
2. Pale, cool extremities with decreased pulses
3. Increased venous engorgement with strong pulses
4. Faster than normal capillary refill time
Answer: 2
Explanation: 1. With increased peripheral resistance the blood supply is decreased and results in decreased
blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would
decrease in intensity with a decreased blood supply. #1 is incorrect. An increased blood supply
would increase color and bounding pulses as seen with vasodilation (blood engorgement) and
not present with increased peripheral resistance and vasoconstriction. #3 is incorrect. Venous
engorgement would not result from vasoconstriction of the arteries. Strong pulses would not
be present with vasoconstriction from increased peripheral resistance. #4 is incorrect. Capillary
refill times are delayed or slowed due to decreased blood flow through the vessels caused by
the vasoconstriction from increased peripheral resistance.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
2. With increased peripheral resistance the blood supply is decreased and results in decreased
blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would
decrease in intensity with a decreased blood supply. #1 is incorrect. An increased blood supply
would increase color and bounding pulses as seen with vasodilation (blood engorgement) and
not present with increased peripheral resistance and vasoconstriction. #3 is incorrect. Venous
engorgement would not result from vasoconstriction of the arteries. Strong pulses would not
be present with vasoconstriction from increased peripheral resistance. #4 is incorrect. Capillary
refill times are delayed or slowed due to decreased blood flow through the vessels caused by
the vasoconstriction from increased peripheral resistance.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
3. With increased peripheral resistance the blood supply is decreased and results in decreased
blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would
decrease in intensity with a decreased blood supply. #1 is incorrect. An increased blood supply
would increase color and bounding pulses as seen with vasodilation (blood engorgement) and
not present with increased peripheral resistance and vasoconstriction. #3 is incorrect. Venous
engorgement would not result from vasoconstriction of the arteries. Strong pulses would not
be present with vasoconstriction from increased peripheral resistance. #4 is incorrect. Capillary
refill times are delayed or slowed due to decreased blood flow through the vessels caused by
the vasoconstriction from increased peripheral resistance.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
4. With increased peripheral resistance the blood supply is decreased and results in decreased
blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would
decrease in intensity with a decreased blood supply. #1 is incorrect. An increased blood supply
would increase color and bounding pulses as seen with vasodilation (blood engorgement) and
not present with increased peripheral resistance and vasoconstriction. #3 is incorrect. Venous
engorgement would not result from vasoconstriction of the arteries. Strong pulses would not
be present with vasoconstriction from increased peripheral resistance. #4 is incorrect. Capillary
refill times are delayed or slowed due to decreased blood flow through the vessels caused by
the vasoconstriction from increased peripheral resistance.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 143
Learning Outcome: 6-2: Describe hemodynamic findings indicative of hypovolemia
5) Which of the following solutions would be the most appropriate initial volume replacement for a patient with
severe GI bleeding?
1. 200 mL of normal saline (NS) per hour for 5 hours
2. A liter of Ringerʹs lactate (RL) over 15 minutes
3. Two liters of D5W over half an hour
4. 500 mL of 0.45% normal saline (1/2 NS) over half an hour
Answer: 2
Explanation: 1. The patient requires immediate infusion of an adequate amount of fluid. #1, #3, and #4 are
incorrect. 1/2NS is a hypotonic solution. It would not stay in the intravascular space long
enough to expand the circulating volume nor would it replace the lost cells needed to carry
oxygen. 200 mL is not an adequate amount of saline and D5W is not appropriate.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
2. The patient requires immediate infusion of an adequate amount of fluid. #1, #3, and #4 are
incorrect. 1/2NS is a hypotonic solution. It would not stay in the intravascular space long
enough to expand the circulating volume nor would it replace the lost cells needed to carry
oxygen. 200 mL is not an adequate amount of saline and D5W is not appropriate.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
3. The patient requires immediate infusion of an adequate amount of fluid. #1, #3, and #4 are
incorrect. 1/2NS is a hypotonic solution. It would not stay in the intravascular space long
enough to expand the circulating volume nor would it replace the lost cells needed to carry
oxygen. 200 mL is not an adequate amount of saline and D5W is not appropriate.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
4. The patient requires immediate infusion of an adequate amount of fluid. #1, #3, and #4 are
incorrect. 1/2NS is a hypotonic solution. It would not stay in the intravascular space long
enough to expand the circulating volume nor would it replace the lost cells needed to carry
oxygen. 200 mL is not an adequate amount of saline and D5W is not appropriate.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 6-2: Describe hemodynamic findings indicative of hypovolemia
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 144
6) Which life-threatening complications would the nurse anticipate might develop in the patient who is being
treated for hypovolemic shock? (Select all that apply.)
1. Renal insufficiency (RI)/renal failure (RF)
2. Cerebral ischemia
3. Irreversible shock
4. Gastric stress ulcer
Answer: 1, 2, 3
Explanation: 1. (Note: This requires multiple responses to be correct.)
Renal insufficiency (RI)/renal failure (RF), cerebral ischemia, and irreversible shock are correct
responses for complications that can occur from tissue hypoxia and decreased capillary
perfusion, which can result in neutrophil plugging or clot formation in smaller vessels from
decreased blood circulation caused by hypovolemic shock. #4 is incorrect. Although
physiological stress can increase the risk for the development of stress ulcers, it is not
considered one of the common or life-threatening complications of hypovolemic shock.
Nursing Process: Planning
Cognitive Level: Synthesis
Category of Need: Physiological Integrity–Physiological Adaptation
2. (Note: This requires multiple responses to be correct.)
Renal insufficiency (RI)/renal failure (RF), cerebral ischemia, and irreversible shock are correct
responses for complications that can occur from tissue hypoxia and decreased capillary
perfusion, which can result in neutrophil plugging or clot formation in smaller vessels from
decreased blood circulation caused by hypovolemic shock. #4 is incorrect. Although
physiological stress can increase the risk for the development of stress ulcers, it is not
considered one of the common or life-threatening complications of hypovolemic shock.
Nursing Process: Planning
Cognitive Level: Synthesis
Category of Need: Physiological Integrity–Physiological Adaptation
3. (Note: This requires multiple responses to be correct.)
Renal insufficiency (RI)/renal failure (RF), cerebral ischemia, and irreversible shock are correct
responses for complications that can occur from tissue hypoxia and decreased capillary
perfusion, which can result in neutrophil plugging or clot formation in smaller vessels from
decreased blood circulation caused by hypovolemic shock. #4 is incorrect. Although
physiological stress can increase the risk for the development of stress ulcers, it is not
considered one of the common or life-threatening complications of hypovolemic shock.
Nursing Process: Planning
Cognitive Level: Synthesis
Category of Need: Physiological Integrity–Physiological Adaptation
4. (Note: This requires multiple responses to be correct.)
Renal insufficiency (RI)/renal failure (RF), cerebral ischemia, and irreversible shock are correct
responses for complications that can occur from tissue hypoxia and decreased capillary
perfusion, which can result in neutrophil plugging or clot formation in smaller vessels from
decreased blood circulation caused by hypovolemic shock. #4 is incorrect. Although
physiological stress can increase the risk for the development of stress ulcers, it is not
considered one of the common or life-threatening complications of hypovolemic shock.
Nursing Process: Planning
Cognitive Level: Synthesis
Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 6-2: Describe hemodynamic findings indicative of hypovolemia
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 145
7) Which of the following reasons best explains why hypotonic solutions are not used in hypovolemic shock?
Hypotonic solutions:
1. Move quickly into the interstitial spaces and can cause third spacing.
2. Stay longer to expand the intravascular space but deplete intracellular fluid levels.
3. Do not stay in the intravascular space long enough to expand the circulating blood volume.
4. Need a smaller bore needle to run at a slower rate to keep the intravascular space low.
Answer: 3
Explanation: 1. Not staying in the intravascular space long enough to expand the circulating blood volume is
correct when describing the reason for not using hypotonic solutions to treat hypovolemic
shock. #1, #2, and #4 are incorrect. None of those concepts are correct when describing
hypotonic solutions. A hypertonic solution will pull fluids from the cells into the vascular bed.
Fluid overload or rapid infusion of solutions leads to third spacing. The bore size of the needle
does not affect the displacement or shifting of fluids.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Safe, Effective Care Environment–Management of Care
2. Not staying in the intravascular space long enough to expand the circulating blood volume is
correct when describing the reason for not using hypotonic solutions to treat hypovolemic
shock. #1, #2, and #4 are incorrect. None of those concepts are correct when describing
hypotonic solutions. A hypertonic solution will pull fluids from the cells into the vascular bed.
Fluid overload or rapid infusion of solutions leads to third spacing. The bore size of the needle
does not affect the displacement or shifting of fluids.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Safe, Effective Care Environment–Management of Care
3. Not staying in the intravascular space long enough to expand the circulating blood volume is
correct when describing the reason for not using hypotonic solutions to treat hypovolemic
shock. #1, #2, and #4 are incorrect. None of those concepts are correct when describing
hypotonic solutions. A hypertonic solution will pull fluids from the cells into the vascular bed.
Fluid overload or rapid infusion of solutions leads to third spacing. The bore size of the needle
does not affect the displacement or shifting of fluids.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Safe, Effective Care Environment–Management of Care
4. Not staying in the intravascular space long enough to expand the circulating blood volume is
correct when describing the reason for not using hypotonic solutions to treat hypovolemic
shock. #1, #2, and #4 are incorrect. None of those concepts are correct when describing
hypotonic solutions. A hypertonic solution will pull fluids from the cells into the vascular bed.
Fluid overload or rapid infusion of solutions leads to third spacing. The bore size of the needle
does not affect the displacement or shifting of fluids.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 6-3: Discuss volume replacement for the patient with hypovolemia
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 146
8) The nurse should warm intravenous fluids when a rapid infuser is being utilized in order to prevent which of
the following complications?
1. Hemorrhagic shock
2. Hypothermia
3. Sepsis
4. Cardiogenic shock
Answer: 2
Explanation: 1. Hypothermia (a decrease in body temperature) results from pushing room temperature fluids
at a faster pace than the body can warm them. #1 is incorrect. Hemorrhagic shock is caused by
a loss of cells or blood volume and not a result of running fluids too quickly. #3 is incorrect.
Bacterial contamination can be avoided by sterile technique, and sepsis is not caused by the
rate or temperature of the fluid is administered. #4 is incorrect. Cardiogenic shock (a low
cardiac output) results from poor ventricular functioning, not from the temperature of the IV
fluids being administered too rapidly.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
2. Hypothermia (a decrease in body temperature) results from pushing room temperature fluids
at a faster pace than the body can warm them. #1 is incorrect. Hemorrhagic shock is caused by
a loss of cells or blood volume and not a result of running fluids too quickly. #3 is incorrect.
Bacterial contamination can be avoided by sterile technique, and sepsis is not caused by the
rate or temperature of the fluid is administered. #4 is incorrect. Cardiogenic shock (a low
cardiac output) results from poor ventricular functioning, not from the temperature of the IV
fluids being administered too rapidly.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
3. Hypothermia (a decrease in body temperature) results from pushing room temperature fluids
at a faster pace than the body can warm them. #1 is incorrect. Hemorrhagic shock is caused by
a loss of cells or blood volume and not a result of running fluids too quickly. #3 is incorrect.
Bacterial contamination can be avoided by sterile technique, and sepsis is not caused by the
rate or temperature of the fluid is administered. #4 is incorrect. Cardiogenic shock (a low
cardiac output) results from poor ventricular functioning, not from the temperature of the IV
fluids being administered too rapidly.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
4. Hypothermia (a decrease in body temperature) results from pushing room temperature fluids
at a faster pace than the body can warm them. #1 is incorrect. Hemorrhagic shock is caused by
a loss of cells or blood volume and not a result of running fluids too quickly. #3 is incorrect.
Bacterial contamination can be avoided by sterile technique, and sepsis is not caused by the
rate or temperature of the fluid is administered. #4 is incorrect. Cardiogenic shock (a low
cardiac output) results from poor ventricular functioning, not from the temperature of the IV
fluids being administered too rapidly.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 6-3: Discuss volume replacement for the patient with hypovolemia
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 147
9) Which of the following findings would indicate that rehydration is complete and hypovolemic shock has been
successfully treated in a patient?
1. CVP = 7 mm Hg
2. MAP = 45 mm Hg
3. Urinary output of 0.1 mL/kg/hr
4. Hct = 54%
Answer: 1
Explanation: 1. A CVP reading of 7 mm Hg is within normal range and rehydration has been restored. Normal
range is 1 to 8 mm Hg. Central venous pressures measure the right ventricular function related
to the amount of circulating blood volume. #2 is incorrect. Mean arterial pressures (MAP) are
normally between 70 and 105 mm Hg. Therefore, 45 is too low and reflects inadequate
circulating blood volume. Additional fluids are needed. #3 is incorrect. Urinary output to
reflect adequate rehydration begins at 0.5 to 1 mL/kg/hr. Therefore, 0.1 mL is too small and
renal insufficiency may be present due to inadequate circulating blood volume. #4 is incorrect.
Hematocrit (Hct) is the percentage of the number of RBCs per fluid volume. The normal range
is 35% to 45% for an adult. The higher percentage represents a decreased fluid -to-cell ratio,
which implies a fluid deficit and rehydration is not complete. An Hct of 54% is critical and
increases the risk of clots, strokes, and other vessel obstruction from potential hemolysis and
sluggishness of cellular movements.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. A CVP reading of 7 mm Hg is within normal range and rehydration has been restored. Normal
range is 1 to 8 mm Hg. Central venous pressures measure the right ventricular function related
to the amount of circulating blood volume. #2 is incorrect. Mean arterial pressures (MAP) are
normally between 70 and 105 mm Hg. Therefore, 45 is too low and reflects inadequate
circulating blood volume. Additional fluids are needed. #3 is incorrect. Urinary output to
reflect adequate rehydration begins at 0.5 to 1 mL/kg/hr. Therefore, 0.1 mL is too small and
renal insufficiency may be present due to inadequate circulating blood volume. #4 is incorrect.
Hematocrit (Hct) is the percentage of the number of RBCs per fluid volume. The normal range
is 35% to 45% for an adult. The higher percentage represents a decreased fluid -to-cell ratio,
which implies a fluid deficit and rehydration is not complete. An Hct of 54% is critical and
increases the risk of clots, strokes, and other vessel obstruction from potential hemolysis and
sluggishness of cellular movements.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. A CVP reading of 7 mm Hg is within normal range and rehydration has been restored. Normal
range is 1 to 8 mm Hg. Central venous pressures measure the right ventricular function related
to the amount of circulating blood volume. #2 is incorrect. Mean arterial pressures (MAP) are
normally between 70 and 105 mm Hg. Therefore, 45 is too low and reflects inadequate
circulating blood volume. Additional fluids are needed. #3 is incorrect. Urinary output to
reflect adequate rehydration begins at 0.5 to 1 mL/kg/hr. Therefore, 0.1 mL is too small and
renal insufficiency may be present due to inadequate circulating blood volume. #4 is incorrect.
Hematocrit (Hct) is the percentage of the number of RBCs per fluid volume. The normal range
is 35% to 45% for an adult. The higher percentage represents a decreased fluid -to-cell ratio,
which implies a fluid deficit and rehydration is not complete. An Hct of 54% is critical and
increases the risk of clots, strokes, and other vessel obstruction from potential hemolysis and
sluggishness of cellular movements.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 148
4. A CVP reading of 7 mm Hg is within normal range and rehydration has been restored. Normal
range is 1 to 8 mm Hg. Central venous pressures measure the right ventricular function related
to the amount of circulating blood volume. #2 is incorrect. Mean arterial pressures (MAP) are
normally between 70 and 105 mm Hg. Therefore, 45 is too low and reflects inadequate
circulating blood volume. Additional fluids are needed. #3 is incorrect. Urinary output to
reflect adequate rehydration begins at 0.5 to 1 mL/kg/hr. Therefore, 0.1 mL is too small and
renal insufficiency may be present due to inadequate circulating blood volume. #4 is incorrect.
Hematocrit (Hct) is the percentage of the number of RBCs per fluid volume. The normal range
is 35% to 45% for an adult. The higher percentage represents a decreased fluid -to-cell ratio,
which implies a fluid deficit and rehydration is not complete. An Hct of 54% is critical and
increases the risk of clots, strokes, and other vessel obstruction from potential hemolysis and
sluggishness of cellular movements.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 6-3: Discuss volume replacement for the patient with hypovolemia
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 149
10) When teaching a patient with heart failure about ventricular remodeling, the nurse should recognize that the
patient needs additional teaching if the patient made which of the following statements? ʺRemodeling:
1. Leads to progressive worsening of heart function.ʺ
2. Can be described as an enlargement of the pumping chamber.ʺ
3. Occurs with an increase in blood pressure and results in weight gain.ʺ
4. Develops primarily because the heart is pumping harder.ʺ
Answer: 4
Explanation: 1. This response is not true and additional teaching is needed to clarify that the contractility or
elasticity of the ventricle is decreased or stiffer in nature. It is not caused by ongoing
hypotension but by prolonged stress or injury to the myocardium such as hypertension, not
hypotension. #1, #2, and #3 are correct statements about remodeling and no additional teaching
is required.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
2. This response is not true and additional teaching is needed to clarify that the contractility or
elasticity of the ventricle is decreased or stiffer in nature. It is not caused by ongoing
hypotension but by prolonged stress or injury to the myocardium such as hypertension, not
hypotension. #1, #2, and #3 are correct statements about remodeling and no additional teaching
is required.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
3. This response is not true and additional teaching is needed to clarify that the contractility or
elasticity of the ventricle is decreased or stiffer in nature. It is not caused by ongoing
hypotension but by prolonged stress or injury to the myocardium such as hypertension, not
hypotension. #1, #2, and #3 are correct statements about remodeling and no additional teaching
is required.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
4. This response is not true and additional teaching is needed to clarify that the contractility or
elasticity of the ventricle is decreased or stiffer in nature. It is not caused by ongoing
hypotension but by prolonged stress or injury to the myocardium such as hypertension, not
hypotension. #1, #2, and #3 are correct statements about remodeling and no additional teaching
is required.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
Learning Outcome: 6-4: Explain the pathophysiologic and neurohormonal mechanisms of heart failure
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 150
11) The nurse is reviewing a patientʹs medical history. Which of the following factors in the history are most likely
to have contributed to the patientʹs development of heart failure? (Select all that apply.)
1. Hypertension
2. Diabetes mellitus
3. Drinking one or two alcoholic drinks daily
4. Being overweight
5. Persistent atrial fibrillation
Answer: 1, 5
Explanation: 1. (Note: This requires multiple responses to be correct.)
Hypertension and persistent atrial fibrillation are correct responses as sources of risks for heart
disease. Chronic hypertension, valve disease, dysrhythmias, and so on cause the damage to the
myocardium that creates the risk for heart failure. #2, #3, and #4 are incorrect. Diabetes and
drinking moderately are not known causes of heart failure. Being overweight is not a direct
contributing factor, although it does increase the risk of coronary artery disease (CAD) based
on the types of food that are eaten.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
2. (Note: This requires multiple responses to be correct.)
Hypertension and persistent atrial fibrillation are correct responses as sources of risks for heart
disease. Chronic hypertension, valve disease, dysrhythmias, and so on cause the damage to the
myocardium that creates the risk for heart failure. #2, #3, and #4 are incorrect. Diabetes and
drinking moderately are not known causes of heart failure. Being overweight is not a direct
contributing factor, although it does increase the risk of coronary artery disease (CAD) based
on the types of food that are eaten.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
3. (Note: This requires multiple responses to be correct.)
Hypertension and persistent atrial fibrillation are correct responses as sources of risks for heart
disease. Chronic hypertension, valve disease, dysrhythmias, and so on cause the damage to the
myocardium that creates the risk for heart failure. #2, #3, and #4 are incorrect. Diabetes and
drinking moderately are not known causes of heart failure. Being overweight is not a direct
contributing factor, although it does increase the risk of coronary artery disease (CAD) based
on the types of food that are eaten.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
4. (Note: This requires multiple responses to be correct.)
Hypertension and persistent atrial fibrillation are correct responses as sources of risks for heart
disease. Chronic hypertension, valve disease, dysrhythmias, and so on cause the damage to the
myocardium that creates the risk for heart failure. #2, #3, and #4 are incorrect. Diabetes and
drinking moderately are not known causes of heart failure. Being overweight is not a direct
contributing factor, although it does increase the risk of coronary artery disease (CAD) based
on the types of food that are eaten.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 151
5. (Note: This requires multiple responses to be correct.)
Hypertension and persistent atrial fibrillation are correct responses as sources of risks for heart
disease. Chronic hypertension, valve disease, dysrhythmias, and so on cause the damage to the
myocardium that creates the risk for heart failure. #2, #3, and #4 are incorrect. Diabetes and
drinking moderately are not known causes of heart failure. Being overweight is not a direct
contributing factor, although it does increase the risk of coronary artery disease (CAD) based
on the types of food that are eaten.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
Learning Outcome: 6-4: Explain the pathophysiologic and neurohormonal mechanisms of heart failure
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 152
12) The nurse is assessing a patient for heart failure (HF). Which early findings would reflect a decreased cardiac
output and a potential for fluid overload from heart failure?
1. Orthopnea, peripheral edema, crackles
2. Dizziness, syncope, palpitations
3. Pallor and/or cyanosis of extremities
4. PAWP of 12 and CVP of 6
Answer: 1
Explanation: 1. These symptoms reflect decreasing perfusion and accumulation of fluid in the pulmonary
system, which is not being effectively circulated by a failing heart. #2 is incorrect. Dizziness,
syncope, and palpitations are symptoms of end-organ hypoperfusion, not fluid overload.
These symptoms represent later symptoms of hypoxia from less blood being carried to distal
organs, especially the brain and the heart. The pulmonary backup of fluid occurs before the
hypoxia. #3 is incorrect. Pallor and/or cyanosis are seen in end-organ hypoperfusion, not a
fluid overload situation. Distal areas do not receive adequate arterial blood flow and the tissue
becomes hypoxic quickly, which causes the pallor or cyanosis (from venous stasis). #4 is
incorrect. PAWP/CVP pressures will increase with fluid overload because the pressure of
additional fluids must be overcome to circulate the blood.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
2. These symptoms reflect decreasing perfusion and accumulation of fluid in the pulmonary
system, which is not being effectively circulated by a failing heart. #2 is incorrect. Dizziness,
syncope, and palpitations are symptoms of end-organ hypoperfusion, not fluid overload.
These symptoms represent later symptoms of hypoxia from less blood being carried to distal
organs, especially the brain and the heart. The pulmonary backup of fluid occurs before the
hypoxia. #3 is incorrect. Pallor and/or cyanosis are seen in end-organ hypoperfusion, not a
fluid overload situation. Distal areas do not receive adequate arterial blood flow and the tissue
becomes hypoxic quickly, which causes the pallor or cyanosis (from venous stasis). #4 is
incorrect. PAWP/CVP pressures will increase with fluid overload because the pressure of
additional fluids must be overcome to circulate the blood.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
3. These symptoms reflect decreasing perfusion and accumulation of fluid in the pulmonary
system, which is not being effectively circulated by a failing heart. #2 is incorrect. Dizziness,
syncope, and palpitations are symptoms of end-organ hypoperfusion, not fluid overload.
These symptoms represent later symptoms of hypoxia from less blood being carried to distal
organs, especially the brain and the heart. The pulmonary backup of fluid occurs before the
hypoxia. #3 is incorrect. Pallor and/or cyanosis are seen in end-organ hypoperfusion, not a
fluid overload situation. Distal areas do not receive adequate arterial blood flow and the tissue
becomes hypoxic quickly, which causes the pallor or cyanosis (from venous stasis). #4 is
incorrect. PAWP/CVP pressures will increase with fluid overload because the pressure of
additional fluids must be overcome to circulate the blood.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 153
4. These symptoms reflect decreasing perfusion and accumulation of fluid in the pulmonary
system, which is not being effectively circulated by a failing heart. #2 is incorrect. Dizziness,
syncope, and palpitations are symptoms of end-organ hypoperfusion, not fluid overload.
These symptoms represent later symptoms of hypoxia from less blood being carried to distal
organs, especially the brain and the heart. The pulmonary backup of fluid occurs before the
hypoxia. #3 is incorrect. Pallor and/or cyanosis are seen in end-organ hypoperfusion, not a
fluid overload situation. Distal areas do not receive adequate arterial blood flow and the tissue
becomes hypoxic quickly, which causes the pallor or cyanosis (from venous stasis). #4 is
incorrect. PAWP/CVP pressures will increase with fluid overload because the pressure of
additional fluids must be overcome to circulate the blood.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
Learning Outcome: 6-6: Recognize the manifestations of heart failure
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 154
13) Which of the following findings would indicate that a patientʹs heart failure (HF) was worsening?
1. An increase in O2 saturation to greater than 90%
2. A decrease in heart rate to 66 bpm
3. The onset of atrial fibrillation
4. Louder S1 and S2 heart sounds
Answer: 3
Explanation: 1. As HF continues to progress, less oxygenation occurs all over the body, especially the
myocardium, which is sensitive to the hypoxia and will result in dysrhythmias of both the
atrium and ventricles. #1 is incorrect. Oxygenation saturations will decline to less than 90%
(not increase to more than 90%). Declining O2 saturation levels reflect deteriorating pulmonary
status from a buildup of fluids with pulmonary edema. #2 is incorrect. Tachycardia increases to
compensate for the decreasing O2 levels by trying to circulate what cells are present, but at the
same time increases the O2 demand by increased cardiac functioning. #4 is incorrect. The S1
and S2 sounds remain the same but extra sounds (S3 and S4) are noted with increased
demands on the heart resulting in less synchronization.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
2. As HF continues to progress, less oxygenation occurs all over the body, especially the
myocardium, which is sensitive to the hypoxia and will result in dysrhythmias of both the
atrium and ventricles. #1 is incorrect. Oxygenation saturations will decline to less than 90%
(not increase to more than 90%). Declining O2 saturation levels reflect deteriorating pulmonary
status from a buildup of fluids with pulmonary edema. #2 is incorrect. Tachycardia increases to
compensate for the decreasing O2 levels by trying to circulate what cells are present, but at the
same time increases the O2 demand by increased cardiac functioning. #4 is incorrect. The S1
and S2 sounds remain the same but extra sounds (S3 and S4) are noted with increased
demands on the heart resulting in less synchronization.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
3. As HF continues to progress, less oxygenation occurs all over the body, especially the
myocardium, which is sensitive to the hypoxia and will result in dysrhythmias of both the
atrium and ventricles. #1 is incorrect. Oxygenation saturations will decline to less than 90%
(not increase to more than 90%). Declining O2 saturation levels reflect deteriorating pulmonary
status from a buildup of fluids with pulmonary edema. #2 is incorrect. Tachycardia increases to
compensate for the decreasing O2 levels by trying to circulate what cells are present, but at the
same time increases the O2 demand by increased cardiac functioning. #4 is incorrect. The S1
and S2 sounds remain the same but extra sounds (S3 and S4) are noted with increased
demands on the heart resulting in less synchronization.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 155
4. As HF continues to progress, less oxygenation occurs all over the body, especially the
myocardium, which is sensitive to the hypoxia and will result in dysrhythmias of both the
atrium and ventricles. #1 is incorrect. Oxygenation saturations will decline to less than 90%
(not increase to more than 90%). Declining O2 saturation levels reflect deteriorating pulmonary
status from a buildup of fluids with pulmonary edema. #2 is incorrect. Tachycardia increases to
compensate for the decreasing O2 levels by trying to circulate what cells are present, but at the
same time increases the O2 demand by increased cardiac functioning. #4 is incorrect. The S1
and S2 sounds remain the same but extra sounds (S3 and S4) are noted with increased
demands on the heart resulting in less synchronization.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
Learning Outcome: 6-7: Describe the hemodynamic findings indicative of heart failure
14) A patient is very short of breath. Which of the following findings should cause the nurse to be concerned that
the shortness of breath might be due to heart failure?
1. An echocardiogram that reflected increased right ventricular wall thickening
2. A B-type natriuretic peptide (BNP) of 300 pg/mL
3. A left ventricular ejection fraction (VEF) of 50%
4. A serum sodium of 135
Answer: 2
Explanation: 1. A BNP greater than 500 is indicative of heart failure. #1 is incorrect. Echocardiogram would
reflect left ventricular hypertrophy, not right ventricular enlargement. #3 is incorrect. The left
VEF will decline to less than 40%. #4 is incorrect. Heart failure is usually associated with
dilutional hyponatremia.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. A BNP greater than 500 is indicative of heart failure. #1 is incorrect. Echocardiogram would
reflect left ventricular hypertrophy, not right ventricular enlargement. #3 is incorrect. The left
VEF will decline to less than 40%. #4 is incorrect. Heart failure is usually associated with
dilutional hyponatremia.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. A BNP greater than 500 is indicative of heart failure. #1 is incorrect. Echocardiogram would
reflect left ventricular hypertrophy, not right ventricular enlargement. #3 is incorrect. The left
VEF will decline to less than 40%. #4 is incorrect. Heart failure is usually associated with
dilutional hyponatremia.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. A BNP greater than 500 is indicative of heart failure. #1 is incorrect. Echocardiogram would
reflect left ventricular hypertrophy, not right ventricular enlargement. #3 is incorrect. The left
VEF will decline to less than 40%. #4 is incorrect. Heart failure is usually associated with
dilutional hyponatremia.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 6-7: Describe the hemodynamic findings indicative of heart failure
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 156
15) Which of the following findings would support the diagnosis of heart failure (HF)?
1. CVP/RA of 8 mm Hg
2. PAWP of 20 mm Hg
3. Cardiac index of 3
4. Peripheral vasodilation reflected by normalizing capillary refill times
Answer: 2
Explanation: 1. With HF the backup of fluid from inadequate pumping results in increased PAWP because the
heart has to pump harder to push through the rising capillary pressures on the venous side
from peripheral edema and ascites. #1 is incorrect. The CVP/RA are increased with rising
pressures to push through the inadequate pumping that occurs with HF from systemic venous
pressure elevations from ascites and peripheral edema. #3 is incorrect. Cardiac output is
decreased with HF because the preload volume continues to rise with a less efficient pump to
remove the blood. #4 is incorrect. Peripheral vasoconstriction occurs still and capillary refills
are sluggish and delayed.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. With HF the backup of fluid from inadequate pumping results in increased PAWP because the
heart has to pump harder to push through the rising capillary pressures on the venous side
from peripheral edema and ascites. #1 is incorrect. The CVP/RA are increased with rising
pressures to push through the inadequate pumping that occurs with HF from systemic venous
pressure elevations from ascites and peripheral edema. #3 is incorrect. Cardiac output is
decreased with HF because the preload volume continues to rise with a less efficient pump to
remove the blood. #4 is incorrect. Peripheral vasoconstriction occurs still and capillary refills
are sluggish and delayed.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. With HF the backup of fluid from inadequate pumping results in increased PAWP because the
heart has to pump harder to push through the rising capillary pressures on the venous side
from peripheral edema and ascites. #1 is incorrect. The CVP/RA are increased with rising
pressures to push through the inadequate pumping that occurs with HF from systemic venous
pressure elevations from ascites and peripheral edema. #3 is incorrect. Cardiac output is
decreased with HF because the preload volume continues to rise with a less efficient pump to
remove the blood. #4 is incorrect. Peripheral vasoconstriction occurs still and capillary refills
are sluggish and delayed.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. With HF the backup of fluid from inadequate pumping results in increased PAWP because the
heart has to pump harder to push through the rising capillary pressures on the venous side
from peripheral edema and ascites. #1 is incorrect. The CVP/RA are increased with rising
pressures to push through the inadequate pumping that occurs with HF from systemic venous
pressure elevations from ascites and peripheral edema. #3 is incorrect. Cardiac output is
decreased with HF because the preload volume continues to rise with a less efficient pump to
remove the blood. #4 is incorrect. Peripheral vasoconstriction occurs still and capillary refills
are sluggish and delayed.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 6-8: Defferentiate between the hemodynamic findings of hypovolemia and heart failure
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 157
16) After teaching a patient in heart failure about beta blocking agents, the nurse would understand that the
patient required additional teaching if he said, ʺWhile taking the medication, I will:
1. Weigh myself every day.ʺ
2. Check my blood sugar regularly.ʺ
3. Notify my health care provider if I become increasingly short of breath.ʺ
4. Monitor myself daily for an increased heart rate and blood pressure.ʺ
Answer: 4
Explanation: 1. Beta blocking agents will decrease the heart rate and blood pressure. #1, #2, and #3 are correct
statements that do not require additional instruction.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity; Physiological Integrity–Pharmacological and
Parenteral Therapies
2. Beta blocking agents will decrease the heart rate and blood pressure. #1, #2, and #3 are correct
statements that do not require additional instruction.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity; Physiological Integrity–Pharmacological and
Parenteral Therapies
3. Beta blocking agents will decrease the heart rate and blood pressure. #1, #2, and #3 are correct
statements that do not require additional instruction.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity; Physiological Integrity–Pharmacological and
Parenteral Therapies
4. Beta blocking agents will decrease the heart rate and blood pressure. #1, #2, and #3 are correct
statements that do not require additional instruction.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity; Physiological Integrity–Pharmacological and
Parenteral Therapies
Learning Outcome: 6-9: Explain collaborative management of the patient with heart failure
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 158
17) The nurse should explain to a patient in heart failure that an aldactone antagonist works by:
1. Reducing sodium and water retention.
2. Filtering potassium out with the water in the renal tubules.
3. Promoting the excretion of the urinary waste products urea and creatinine.
4. Retaining calcium to improve the condition of blood vessels in the glomeruli.
Answer: 1
Explanation: 1. Aldactone antagonist is a diuretic that removes water through the excretion of sodium and
water through the renal tubules. #2, #3, and #4 are incorrect definitions of how the drug works.
Nursing Process: Planning
Cognitive Level: Comprehension
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
2. Aldactone antagonist is a diuretic that removes water through the excretion of sodium and
water through the renal tubules. #2, #3, and #4 are incorrect definitions of how the drug works.
Nursing Process: Planning
Cognitive Level: Comprehension
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
3. Aldactone antagonist is a diuretic that removes water through the excretion of sodium and
water through the renal tubules. #2, #3, and #4 are incorrect definitions of how the drug works.
Nursing Process: Planning
Cognitive Level: Comprehension
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
4. Aldactone antagonist is a diuretic that removes water through the excretion of sodium and
water through the renal tubules. #2, #3, and #4 are incorrect definitions of how the drug works.
Nursing Process: Planning
Cognitive Level: Comprehension
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 6-9: Explain collaborative management of the patient with heart failure
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 159
18) Which of the following would the nurse not expect to find in a patient who was experiencing acute
decompensated heart failure with pulmonary edema?
1. Dyspnea at rest, peripheral edema
2. Hypertension, bradycardia
3. Increased coughing, crackles
4. Decreased O2 saturation, increased PAWP
Answer: 2
Explanation: 1. (Note: This question is asking which is ʺnotʺ a symptom)
Hypertension, bradycardia is not a symptom of pulmonary edema. Hypotension and
tachycardia are present in cardiogenic shock. #1, #3, and #4 are incorrect responses because
they are symptoms of cardiogenic shock. As fluids back up in the pulmonary system, ascites
and peripheral edema occur. Fluid can be heard on chest auscultation and coughing will
increase when attempting to try to clear the passageways of the backed-up fluid. Due to fluid
in the capillary beds, less perfusion and ventilation occur, which lead to hypoxia and increased
pressures in the pulmonary artery.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
2. (Note: This question is asking which is ʺnotʺ a symptom)
Hypertension, bradycardia is not a symptom of pulmonary edema. Hypotension and
tachycardia are present in cardiogenic shock. #1, #3, and #4 are incorrect responses because
they are symptoms of cardiogenic shock. As fluids back up in the pulmonary system, ascites
and peripheral edema occur. Fluid can be heard on chest auscultation and coughing will
increase when attempting to try to clear the passageways of the backed-up fluid. Due to fluid
in the capillary beds, less perfusion and ventilation occur, which lead to hypoxia and increased
pressures in the pulmonary artery.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
3. (Note: This question is asking which is ʺnotʺ a symptom)
Hypertension, bradycardia is not a symptom of pulmonary edema. Hypotension and
tachycardia are present in cardiogenic shock. #1, #3, and #4 are incorrect responses because
they are symptoms of cardiogenic shock. As fluids back up in the pulmonary system, ascites
and peripheral edema occur. Fluid can be heard on chest auscultation and coughing will
increase when attempting to try to clear the passageways of the backed-up fluid. Due to fluid
in the capillary beds, less perfusion and ventilation occur, which lead to hypoxia and increased
pressures in the pulmonary artery.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
4. (Note: This question is asking which is ʺnotʺ a symptom)
Hypertension, bradycardia is not a symptom of pulmonary edema. Hypotension and
tachycardia are present in cardiogenic shock. #1, #3, and #4 are incorrect responses because
they are symptoms of cardiogenic shock. As fluids back up in the pulmonary system, ascites
and peripheral edema occur. Fluid can be heard on chest auscultation and coughing will
increase when attempting to try to clear the passageways of the backed-up fluid. Due to fluid
in the capillary beds, less perfusion and ventilation occur, which lead to hypoxia and increased
pressures in the pulmonary artery.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
Learning Outcome: 6-10: Recognize the patient with acutely decompensated heart failure
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 160
19) A patient in heart failure is to be started on an infusion of dobutamine (Dobutrex). Which of the following is
most important for the nurse to assess before starting the infusion? The patientʹs:
1. Blood pressure.
2. Level of consciousness.
3. Breath sounds.
4. Urine output.
Answer: 1
Explanation: 1. Prior to initiation, before each titration, and at the peak action of dobutamine, the nurse must
assess blood pressure, heart rate, respiratory rate, and oxygen saturation. Frequent assessment
of these parameters should continue throughout the infusion period.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
2. Prior to initiation, before each titration, and at the peak action of dobutamine, the nurse must
assess blood pressure, heart rate, respiratory rate, and oxygen saturation. Frequent assessment
of these parameters should continue throughout the infusion period.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
3. Prior to initiation, before each titration, and at the peak action of dobutamine, the nurse must
assess blood pressure, heart rate, respiratory rate, and oxygen saturation. Frequent assessment
of these parameters should continue throughout the infusion period.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
4. Prior to initiation, before each titration, and at the peak action of dobutamine, the nurse must
assess blood pressure, heart rate, respiratory rate, and oxygen saturation. Frequent assessment
of these parameters should continue throughout the infusion period.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 6-9: Explain collaborative management of the patient with heart failure
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 161
20) A patient in heart failure is being given a first dose of lisinopril 10 mg PO. Which of the following findings
would cause the nurse to question the administration of the first dose?
1. Blood pressure 100/72
2. Heart rate 92 beats per minute
3. Potassium 5.7 mEq/dL
4. Urine output 35 mL/hr
Answer: 3
Explanation: 1. Ace inhibitors increase the serum potassium and a further increase from 5.7 could be
problematic so the nurse should question the administration. The other findings are all in
range for administration of the medication.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
2. Ace inhibitors increase the serum potassium and a further increase from 5.7 could be
problematic so the nurse should question the administration. The other findings are all in
range for administration of the medication.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
3. Ace inhibitors increase the serum potassium and a further increase from 5.7 could be
problematic so the nurse should question the administration. The other findings are all in
range for administration of the medication.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
4. Ace inhibitors increase the serum potassium and a further increase from 5.7 could be
problematic so the nurse should question the administration. The other findings are all in
range for administration of the medication.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 6-9: Explain collaborative management of the patient with heart failure
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 162
21) An 82-year-old man is readmitted for heart failure (HF) 1 week after being discharged for the same diagnosis.
Which of the following is likely to have contributed to his readmission? (Select all that apply.) He may:
1. Be depressed.
2. Not have been prescribed appropriate medications, including ACE inhibitors and beta blockers.
3. Not have filled his prescribed medications.
4. Not have known how or when to take his medications.
5. Not have weighed himself since discharge.
Answer: 1, 2, 3, 4, 5
Explanation: 1. (Note: This requires multiple responses to be correct.)
There is evidence that a significant number of older adults with HF do not receive
evidence-based, AHA-recommended care including angiotensin-converting enzymes (ACE)
inhibitors and beta blockers. Some studies indicate that older patients with HF have poor
knowledge of appropriate diet and medication management. Pharmacy records indicate that
prescriptions are not promptly refilled. Patient records indicate that daily weights are not
consistently obtained. The development of HF is associated with significant cognitive
impairment in the older adult and mental performance may be at least partly related to ejection
fraction. Older patients with HF are more likely to be depressed and the presence of
depression worsens patient outcomes.
Cognitive Level: Knowledge
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. (Note: This requires multiple responses to be correct.)
There is evidence that a significant number of older adults with HF do not receive
evidence-based, AHA-recommended care including angiotensin-converting enzymes (ACE)
inhibitors and beta blockers. Some studies indicate that older patients with HF have poor
knowledge of appropriate diet and medication management. Pharmacy records indicate that
prescriptions are not promptly refilled. Patient records indicate that daily weights are not
consistently obtained. The development of HF is associated with significant cognitive
impairment in the older adult and mental performance may be at least partly related to ejection
fraction. Older patients with HF are more likely to be depressed and the presence of
depression worsens patient outcomes.
Cognitive Level: Knowledge
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. (Note: This requires multiple responses to be correct.)
There is evidence that a significant number of older adults with HF do not receive
evidence-based, AHA-recommended care including angiotensin-converting enzymes (ACE)
inhibitors and beta blockers. Some studies indicate that older patients with HF have poor
knowledge of appropriate diet and medication management. Pharmacy records indicate that
prescriptions are not promptly refilled. Patient records indicate that daily weights are not
consistently obtained. The development of HF is associated with significant cognitive
impairment in the older adult and mental performance may be at least partly related to ejection
fraction. Older patients with HF are more likely to be depressed and the presence of
depression worsens patient outcomes.
Cognitive Level: Knowledge
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 163
4. (Note: This requires multiple responses to be correct.)
There is evidence that a significant number of older adults with HF do not receive
evidence-based, AHA-recommended care including angiotensin-converting enzymes (ACE)
inhibitors and beta blockers. Some studies indicate that older patients with HF have poor
knowledge of appropriate diet and medication management. Pharmacy records indicate that
prescriptions are not promptly refilled. Patient records indicate that daily weights are not
consistently obtained. The development of HF is associated with significant cognitive
impairment in the older adult and mental performance may be at least partly related to ejection
fraction. Older patients with HF are more likely to be depressed and the presence of
depression worsens patient outcomes.
Cognitive Level: Knowledge
Category of Need: Physiological Integrity–Reduction of Risk Potential
5. (Note: This requires multiple responses to be correct.)
There is evidence that a significant number of older adults with HF do not receive
evidence-based, AHA-recommended care including angiotensin-converting enzymes (ACE)
inhibitors and beta blockers. Some studies indicate that older patients with HF have poor
knowledge of appropriate diet and medication management. Pharmacy records indicate that
prescriptions are not promptly refilled. Patient records indicate that daily weights are not
consistently obtained. The development of HF is associated with significant cognitive
impairment in the older adult and mental performance may be at least partly related to ejection
fraction. Older patients with HF are more likely to be depressed and the presence of
depression worsens patient outcomes.
Cognitive Level: Knowledge
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 6-9: Explain collaborative management of the patient with heart failure
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 164
22) The nurse is caring for a patient with acute decompensated heart failure (HF) receiving BiPaP. While caring for
this patient, the nurse should:
1. Assess the patient for the development of gastric distention, nausea, and vomiting.
2. Ensure that the mask does not fit too tightly on the patientʹs face to prevent skin breakdown.
3. Monitor the expiratory time to be sure that it always exceeds the inspiratory time.
4. Prepare for endotracheal intubation because BiPap is used primarily to buy time for intubation.
Answer: 1
Explanation: 1. BiPAP provides a positive pressure when it senses an inspiratory effort. In addition BiPAP also
provides end-expiratory pressure, further decreasing the work of breathing. During this
therapy the nurse must closely monitor the heart rate, respiratory rate, blood pressure, and
oxygen saturation. The high airway pressures of CPAP and BiPAP are commonly delivered
through a tight-fitting mask.
The nurse must assess the patient for complications resulting from this delivery method:
 Air leak around the mask
 Facial skin breakdown
 Gastric distention
 Vomiting and aspiration
 Claustrophobia
If noninvasive ventilation fails, endotracheal intubation and mechanical ventilation may be
necessary to improve gas exchange in the patient with HF.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. BiPAP provides a positive pressure when it senses an inspiratory effort. In addition BiPAP also
provides end-expiratory pressure, further decreasing the work of breathing. During this
therapy the nurse must closely monitor the heart rate, respiratory rate, blood pressure, and
oxygen saturation. The high airway pressures of CPAP and BiPAP are commonly delivered
through a tight-fitting mask.
The nurse must assess the patient for complications resulting from this delivery method:
 Air leak around the mask
 Facial skin breakdown
 Gastric distention
 Vomiting and aspiration
 Claustrophobia
If noninvasive ventilation fails, endotracheal intubation and mechanical ventilation may be
necessary to improve gas exchange in the patient with HF.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 165
3. BiPAP provides a positive pressure when it senses an inspiratory effort. In addition BiPAP also
provides end-expiratory pressure, further decreasing the work of breathing. During this
therapy the nurse must closely monitor the heart rate, respiratory rate, blood pressure, and
oxygen saturation. The high airway pressures of CPAP and BiPAP are commonly delivered
through a tight-fitting mask.
The nurse must assess the patient for complications resulting from this delivery method:
 Air leak around the mask
 Facial skin breakdown
 Gastric distention
 Vomiting and aspiration
 Claustrophobia
If noninvasive ventilation fails, endotracheal intubation and mechanical ventilation may be
necessary to improve gas exchange in the patient with HF.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. BiPAP provides a positive pressure when it senses an inspiratory effort. In addition BiPAP also
provides end-expiratory pressure, further decreasing the work of breathing. During this
therapy the nurse must closely monitor the heart rate, respiratory rate, blood pressure, and
oxygen saturation. The high airway pressures of CPAP and BiPAP are commonly delivered
through a tight-fitting mask.
The nurse must assess the patient for complications resulting from this delivery method:
 Air leak around the mask
 Facial skin breakdown
 Gastric distention
 Vomiting and aspiration
 Claustrophobia
If noninvasive ventilation fails, endotracheal intubation and mechanical ventilation may be
necessary to improve gas exchange in the patient with HF.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 6-11: Describe collaborative management strategies appropriate for the patient with acutely
decompensated heart failure
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 166
23) What is the most appropriate position for a patient in pulmonary edema with a blood pressure of 194/92?
1. Dorsal recumbent
2. Head of the bed elevated 60 degrees
3. Sitting upright with legs dependent
4. Torso flat, feet elevated
Answer: 3
Explanation: 1. A patient with a blood pressure of 194/92 is able to sit upright. Sitting upright with legs
dependent allows the patient to breathe more comfortably and prevents fluid from
accumulating as easily in the lungs.
Nursing Process: Intervention
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. A patient with a blood pressure of 194/92 is able to sit upright. Sitting upright with legs
dependent allows the patient to breathe more comfortably and prevents fluid from
accumulating as easily in the lungs.
Nursing Process: Intervention
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. A patient with a blood pressure of 194/92 is able to sit upright. Sitting upright with legs
dependent allows the patient to breathe more comfortably and prevents fluid from
accumulating as easily in the lungs.
Nursing Process: Intervention
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. A patient with a blood pressure of 194/92 is able to sit upright. Sitting upright with legs
dependent allows the patient to breathe more comfortably and prevents fluid from
accumulating as easily in the lungs.
Nursing Process: Intervention
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 6-11: Describe collaborative management strategies appropriate for the patient with acutely
decompensated heart failure
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 167
24) The nurse notes that the QRS duration of a patient with a biventricular pacemaker is widening? What does this
most likely indicate?
1. Battery failure
2. Loss of ventricular capture
3. Loss of ventricular synchronization
4. Worsening of the patientʹs underlying cardiomyopathy
Answer: 3
Explanation: 1. Widening of the QRS duration from the baseline may indicate a loss of ventricular
synchronization.
Nursing Process: Assessment
Cognitive Level: Knowledge
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. Widening of the QRS duration from the baseline may indicate a loss of ventricular
synchronization.
Nursing Process: Assessment
Cognitive Level: Knowledge
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. Widening of the QRS duration from the baseline may indicate a loss of ventricular
synchronization.
Nursing Process: Assessment
Cognitive Level: Knowledge
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. Widening of the QRS duration from the baseline may indicate a loss of ventricular
synchronization.
Nursing Process: Assessment
Cognitive Level: Knowledge
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 6-9: Explain collaborative management of the patient with heart failure
Understanding

Chapter 7 Care of the Patient with Acute Coronary Syndrome
1) A patient says to his nurse, ʺIʹve never heard of an acute coronary syndrome. Please explain what happened to
me.ʺ The nurse should respond, ʺAcute coronary syndrome is:
1. Another name for a myocardial infarction (MI) or heart attack.ʺ
2. A group of disorders that result in insufficient oxygen supply to the heart.ʺ
3. The second leading cause of death in the United States.ʺ
4. A type of abnormal heart rhythm.ʺ
Answer: 2
Explanation: 1. This is the definition and/or criteria that guide a diagnosis of ACS. #1 is incorrect. An MI/heart
attack is only one of the disorders that falls under this group of disorders. An MI includes
tissue necrosis from arterial obstruction. #3 is incorrect. ACS is the number 1 leading cause of
death in United States. #4 is incorrect. A cardiac arrest does not always occur when ACS is
present. Cardiac arrest is a possibility but it does not occur in every patient.
Nursing Process: Evaluation
Cognitive Level: Comprehension
Category of Need: Psychosocial Integrity
2. This is the definition and/or criteria that guide a diagnosis of ACS. #1 is incorrect. An MI/heart
attack is only one of the disorders that falls under this group of disorders. An MI includes
tissue necrosis from arterial obstruction. #3 is incorrect. ACS is the number 1 leading cause of
death in United States. #4 is incorrect. A cardiac arrest does not always occur when ACS is
present. Cardiac arrest is a possibility but it does not occur in every patient.
Nursing Process: Evaluation
Cognitive Level: Comprehension
Category of Need: Psychosocial Integrity
3. This is the definition and/or criteria that guide a diagnosis of ACS. #1 is incorrect. An MI/heart
attack is only one of the disorders that falls under this group of disorders. An MI includes
tissue necrosis from arterial obstruction. #3 is incorrect. ACS is the number 1 leading cause of
death in United States. #4 is incorrect. A cardiac arrest does not always occur when ACS is
present. Cardiac arrest is a possibility but it does not occur in every patient.
Nursing Process: Evaluation
Cognitive Level: Comprehension
Category of Need: Psychosocial Integrity
4. This is the definition and/or criteria that guide a diagnosis of ACS. #1 is incorrect. An MI/heart
attack is only one of the disorders that falls under this group of disorders. An MI includes
tissue necrosis from arterial obstruction. #3 is incorrect. ACS is the number 1 leading cause of
death in United States. #4 is incorrect. A cardiac arrest does not always occur when ACS is
present. Cardiac arrest is a possibility but it does not occur in every patient.
Nursing Process: Evaluation
Cognitive Level: Comprehension
Category of Need: Psychosocial Integrity
Learning Outcome: 7-1: Explain acute coronary syndrome
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 169
2) Which of the following is an accurate description of the progression of events in an acute coronary syndrome
(ACS)?
1. A thin fibrin layer stabilizes the ruptured plaque and prevents the occlusion of coronary vessels when
stable angina is present in ACS.
2. When complete platelet occlusion occurs in a vessel, the ECG changes include nonspecific ST elevation
without necrosis occurring in ACS.
3. The growth of platelet-rich thrombi in the smaller vessels creates a blockage and is the cause for unstable
angina symptoms in ACS.
4. Sudden plaque buildup in a narrow vessel immediately leads to an acute myocardial infarction when
stable angina is present in ACS.
Answer: 3
Explanation: 1. Unstable angina occurs when a blockage from platelet-rich thrombi in smaller vessels occurs,
causing myocardial ischemia. Because ischemic pattern of pain varies, it is unpredictable and
can occur with exertion and rest. Eventually, the patient will limit activity to minimize the
symptoms. #1 is incorrect. The formation of fibrin along the area of ruptured plaque will
stabilize the thrombi and fully occlude the coronary vessel. Therefore, with full occlusion an
STEMI occurs. #2 is incorrect. When occlusion occurs, ST elevation occurs; necrosis and
ischemia are a result of the decreased blood flow. Ischemic and necrotic tissue has decreased
contractility, causing decreased cardiac output. #4 is incorrect. The buildup of plaque takes a
longer period and will not give immediate symptoms of an MI. Stable angina occurs in a
predictable manner, because there is gradual reduction of the vessel lumen size and other
vessels may compensate for this minor hypoxia until the vessel is completely occluded.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
2. Unstable angina occurs when a blockage from platelet-rich thrombi in smaller vessels occurs,
causing myocardial ischemia. Because ischemic pattern of pain varies, it is unpredictable and
can occur with exertion and rest. Eventually, the patient will limit activity to minimize the
symptoms. #1 is incorrect. The formation of fibrin along the area of ruptured plaque will
stabilize the thrombi and fully occlude the coronary vessel. Therefore, with full occlusion an
STEMI occurs. #2 is incorrect. When occlusion occurs, ST elevation occurs; necrosis and
ischemia are a result of the decreased blood flow. Ischemic and necrotic tissue has decreased
contractility, causing decreased cardiac output. #4 is incorrect. The buildup of plaque takes a
longer period and will not give immediate symptoms of an MI. Stable angina occurs in a
predictable manner, because there is gradual reduction of the vessel lumen size and other
vessels may compensate for this minor hypoxia until the vessel is completely occluded.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
3. Unstable angina occurs when a blockage from platelet-rich thrombi in smaller vessels occurs,
causing myocardial ischemia. Because ischemic pattern of pain varies, it is unpredictable and
can occur with exertion and rest. Eventually, the patient will limit activity to minimize the
symptoms. #1 is incorrect. The formation of fibrin along the area of ruptured plaque will
stabilize the thrombi and fully occlude the coronary vessel. Therefore, with full occlusion an
STEMI occurs. #2 is incorrect. When occlusion occurs, ST elevation occurs; necrosis and
ischemia are a result of the decreased blood flow. Ischemic and necrotic tissue has decreased
contractility, causing decreased cardiac output. #4 is incorrect. The buildup of plaque takes a
longer period and will not give immediate symptoms of an MI. Stable angina occurs in a
predictable manner, because there is gradual reduction of the vessel lumen size and other
vessels may compensate for this minor hypoxia until the vessel is completely occluded.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 170
4. Unstable angina occurs when a blockage from platelet-rich thrombi in smaller vessels occurs,
causing myocardial ischemia. Because ischemic pattern of pain varies, it is unpredictable and
can occur with exertion and rest. Eventually, the patient will limit activity to minimize the
symptoms. #1 is incorrect. The formation of fibrin along the area of ruptured plaque will
stabilize the thrombi and fully occlude the coronary vessel. Therefore, with full occlusion an
STEMI occurs. #2 is incorrect. When occlusion occurs, ST elevation occurs; necrosis and
ischemia are a result of the decreased blood flow. Ischemic and necrotic tissue has decreased
contractility, causing decreased cardiac output. #4 is incorrect. The buildup of plaque takes a
longer period and will not give immediate symptoms of an MI. Stable angina occurs in a
predictable manner, because there is gradual reduction of the vessel lumen size and other
vessels may compensate for this minor hypoxia until the vessel is completely occluded.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
Learning Outcome: 7-1: Explain acute coronary syndrome
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 171
3) A nurse is discussing management of hypertension with a patient. Which of the following statements by the
patient would indicate that the patient needs additional teaching about the relationship between hypertension
and acute coronary syndrome (ACS)?
1. ʺMy high blood pressure has no relationship to the severity of heart disease or its outcomes.ʺ
2. ʺBecause Iʹm over 80, even a 20 mm Hg drop in my blood pressure can reduce my risk.ʺ
3. ʺHigh blood pressure will increase my bodyʹs need for oxygen and increase my heartʹs workload.ʺ
4. ʺControlling my blood pressure will decrease my risk of having a heart attack to some degree.ʺ
Answer: 1
Explanation: 1. (Note: The question is asking what statement needs more teaching because it is incorrect)
The higher the hypertension rates, the greater the severity of ACS. Therefore, there is a direct
correlation between the two. #2, #3, and #4 are incorrect answers to this question. These
statements are correct information. Minimal reduction and management of blood pressure will
decrease the severity and risk for ACS.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
2. (Note: The question is asking what statement needs more teaching because it is incorrect)
The higher the hypertension rates, the greater the severity of ACS. Therefore, there is a direct
correlation between the two. #2, #3, and #4 are incorrect answers to this question. These
statements are correct information. Minimal reduction and management of blood pressure will
decrease the severity and risk for ACS.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
3. (Note: The question is asking what statement needs more teaching because it is incorrect)
The higher the hypertension rates, the greater the severity of ACS. Therefore, there is a direct
correlation between the two. #2, #3, and #4 are incorrect answers to this question. These
statements are correct information. Minimal reduction and management of blood pressure will
decrease the severity and risk for ACS.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
4. (Note: The question is asking what statement needs more teaching because it is incorrect)
The higher the hypertension rates, the greater the severity of ACS. Therefore, there is a direct
correlation between the two. #2, #3, and #4 are incorrect answers to this question. These
statements are correct information. Minimal reduction and management of blood pressure will
decrease the severity and risk for ACS.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
Learning Outcome: 7-1: Explain acute coronary syndrome
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 172
4) Which of the following explanations of the relationship of being overweight to acute coronary syndrome (ACS)
should the nurse include when presenting a healthy heart program to a community group?
1. Excessive weight will result in a decrease in low-density lipoproteins (LDL) that is linked to ACS.
2. Extra weight can lead to diabetes insipidus that will increase the risk for ACS.
3. Losing as little as 5% of oneʹs body weight will significantly lower the risk for ACS.
4. Obesity, a BMI of greater than 30, increases the risk for ACS at a greater rate than just being overweight.
Answer: 4
Explanation: 1. #3 is incorrect information that needs additional teaching or clarification. A 10% loss, not a 5%
loss, has been shown to improve risk for ACS. #1 and #2 are incorrect responses for this
question because they are correct statements. Increased weight increases the risk for diabetes
mellitus and decreased HDL, which are both risk factors for ACS.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
2. #3 is incorrect information that needs additional teaching or clarification. A 10% loss, not a 5%
loss, has been shown to improve risk for ACS. #1 and #2 are incorrect responses for this
question because they are correct statements. Increased weight increases the risk for diabetes
mellitus and decreased HDL, which are both risk factors for ACS.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
3. #3 is incorrect information that needs additional teaching or clarification. A 10% loss, not a 5%
loss, has been shown to improve risk for ACS. #1 and #2 are incorrect responses for this
question because they are correct statements. Increased weight increases the risk for diabetes
mellitus and decreased HDL, which are both risk factors for ACS.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
4. #3 is incorrect information that needs additional teaching or clarification. A 10% loss, not a 5%
loss, has been shown to improve risk for ACS. #1 and #2 are incorrect responses for this
question because they are correct statements. Increased weight increases the risk for diabetes
mellitus and decreased HDL, which are both risk factors for ACS.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
Learning Outcome: 7-1: Explain acute coronary syndrome
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 173
5) When a patient says, ʺThe chest pain occurs each time I play basketball; it does not occur when I am sleeping;
and it improves when I take those pills under my tongue,ʺ the pain will most likely be classified as:
1. Variant or Prinzmetalʹs angina.
2. Undifferentiated angina.
3. Unstable angina.
4. Stable angina.
Answer: 4
Explanation: 1. Stable angina occurs in a predictable manner, not when resting, and improves with NTG under
the tongue. #1 is incorrect. Variant or Prinzmetal angina occurs in an unpredictable pattern that
is caused by vasospasm and cause transient ST-segment elevation. These are best treated with
calcium channel blockers. #2 is incorrect. There is no such term used to describe angina. #3 is
incorrect. Unstable angina does not respond well to nitroglycerin (NTG) and has no set
pattern. The pain can occur at rest and with minimal exertion.
Nursing Process: Evaluation
Cognitive Level: Application
Category of Need: Physiological Integrity–Physiological Adaptations
2. Stable angina occurs in a predictable manner, not when resting, and improves with NTG under
the tongue. #1 is incorrect. Variant or Prinzmetal angina occurs in an unpredictable pattern that
is caused by vasospasm and cause transient ST-segment elevation. These are best treated with
calcium channel blockers. #2 is incorrect. There is no such term used to describe angina. #3 is
incorrect. Unstable angina does not respond well to nitroglycerin (NTG) and has no set
pattern. The pain can occur at rest and with minimal exertion.
Nursing Process: Evaluation
Cognitive Level: Application
Category of Need: Physiological Integrity–Physiological Adaptations
3. Stable angina occurs in a predictable manner, not when resting, and improves with NTG under
the tongue. #1 is incorrect. Variant or Prinzmetal angina occurs in an unpredictable pattern that
is caused by vasospasm and cause transient ST-segment elevation. These are best treated with
calcium channel blockers. #2 is incorrect. There is no such term used to describe angina. #3 is
incorrect. Unstable angina does not respond well to nitroglycerin (NTG) and has no set
pattern. The pain can occur at rest and with minimal exertion.
Nursing Process: Evaluation
Cognitive Level: Application
Category of Need: Physiological Integrity–Physiological Adaptations
4. Stable angina occurs in a predictable manner, not when resting, and improves with NTG under
the tongue. #1 is incorrect. Variant or Prinzmetal angina occurs in an unpredictable pattern that
is caused by vasospasm and cause transient ST-segment elevation. These are best treated with
calcium channel blockers. #2 is incorrect. There is no such term used to describe angina. #3 is
incorrect. Unstable angina does not respond well to nitroglycerin (NTG) and has no set
pattern. The pain can occur at rest and with minimal exertion.
Nursing Process: Evaluation
Cognitive Level: Application
Category of Need: Physiological Integrity–Physiological Adaptations
Learning Outcome: 7-2: Defferentiate among different types of acute coronary syndrome
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 174
6) A patient tells a nurse, ʺMy chest pain starts when I am resting and when I had a cardiac catheterization, the
doctor said I was having vasospasms.ʺ Which of the following types of medications would the nurse anticipate
would be utilized to treat the patientʹs angina?
1. A vasodilator such as nitroglycerin (NTG)
2. A calcium channel blocking agent
3. An antidysrhythmic such as lidocaine
4. A beta adrenergic blocking agent
Answer: 2
Explanation: 1. Calcium channel blocking agents would be the drug of choice to stop the spasms of the
coronary arteries that are causing the hypoxic pain in the myocardium from Prinzmetal
angina. #1 is incorrect. NTG is used with stable angina, not Prinzmetalʹs angina. #3 is incorrect.
Lidocaine IV push will treat cardiac dysrhythmias but not hypoxic pain or coronary
vasospasm. #4 is incorrect. Beta adrenergic blocking agents are used to treat stable angina.
Nursing Process: Planning
Cognitive Level: Synthesis
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
2. Calcium channel blocking agents would be the drug of choice to stop the spasms of the
coronary arteries that are causing the hypoxic pain in the myocardium from Prinzmetal
angina. #1 is incorrect. NTG is used with stable angina, not Prinzmetalʹs angina. #3 is incorrect.
Lidocaine IV push will treat cardiac dysrhythmias but not hypoxic pain or coronary
vasospasm. #4 is incorrect. Beta adrenergic blocking agents are used to treat stable angina.
Nursing Process: Planning
Cognitive Level: Synthesis
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
3. Calcium channel blocking agents would be the drug of choice to stop the spasms of the
coronary arteries that are causing the hypoxic pain in the myocardium from Prinzmetal
angina. #1 is incorrect. NTG is used with stable angina, not Prinzmetalʹs angina. #3 is incorrect.
Lidocaine IV push will treat cardiac dysrhythmias but not hypoxic pain or coronary
vasospasm. #4 is incorrect. Beta adrenergic blocking agents are used to treat stable angina.
Nursing Process: Planning
Cognitive Level: Synthesis
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
4. Calcium channel blocking agents would be the drug of choice to stop the spasms of the
coronary arteries that are causing the hypoxic pain in the myocardium from Prinzmetal
angina. #1 is incorrect. NTG is used with stable angina, not Prinzmetalʹs angina. #3 is incorrect.
Lidocaine IV push will treat cardiac dysrhythmias but not hypoxic pain or coronary
vasospasm. #4 is incorrect. Beta adrenergic blocking agents are used to treat stable angina.
Nursing Process: Planning
Cognitive Level: Synthesis
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 7-2: Defferentiate among different types of acute coronary syndrome
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 175
7) A nurse is evaluating a patientʹs understanding after he was diagnosed with a myocardial infarction. Which of
the following would indicate that the patient did not understand important information and needs additional
teaching?
1. A heart attack is the same as a myocardial infarction (MI).
2. A heart attack causes tissue death and that part of the heart may not pump as well.
3. A heart attack in the anterior wall of the heart can be very serious because a large portion of the heart
may not pump as well.
4. Angina always leads first to decreased blood flow to the heart muscle and then to tissue death.
Answer: 4
Explanation: 1. (Note: This question is asking which information is incorrect)
Angina pectoris is the pain from ischemia, but necrosis of myocardial tissue does not occur
with each episode of pain. The pain is from tissue hypoxia; ischemia areas may improve or
deteriorate into necrosis due to collateral circulation from other vessels. #1, #2, and #3 are
incorrect responses because all of these statements are correct information. No clarification is
needed by the nurse.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
2. (Note: This question is asking which information is incorrect)
Angina pectoris is the pain from ischemia, but necrosis of myocardial tissue does not occur
with each episode of pain. The pain is from tissue hypoxia; ischemia areas may improve or
deteriorate into necrosis due to collateral circulation from other vessels. #1, #2, and #3 are
incorrect responses because all of these statements are correct information. No clarification is
needed by the nurse.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
3. (Note: This question is asking which information is incorrect)
Angina pectoris is the pain from ischemia, but necrosis of myocardial tissue does not occur
with each episode of pain. The pain is from tissue hypoxia; ischemia areas may improve or
deteriorate into necrosis due to collateral circulation from other vessels. #1, #2, and #3 are
incorrect responses because all of these statements are correct information. No clarification is
needed by the nurse.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
4. (Note: This question is asking which information is incorrect)
Angina pectoris is the pain from ischemia, but necrosis of myocardial tissue does not occur
with each episode of pain. The pain is from tissue hypoxia; ischemia areas may improve or
deteriorate into necrosis due to collateral circulation from other vessels. #1, #2, and #3 are
incorrect responses because all of these statements are correct information. No clarification is
needed by the nurse.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
Learning Outcome: 7-2: Defferentiate among different types of acute coronary syndrome
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 176
8) Which of the following would be most helpful to the nurse in determining whether the chest pain of a patient
who has just entered the emergency department is cardiac in origin?
1. Gathering a complete medical history
2. Performing a 12-lead ECG
3. Administering NTG to see if the pain goes away
4. Asking the patient if performing a Valsalva maneuver reduces the pain
Answer: 2
Explanation: 1. A 12-lead ECG is performed immediately if the symptoms are suggestive of pain that is
cardiac in origin. #1 is incorrect. Reviewing a complete history will waste time in what might
be an emergent situation. #3 is incorrect. Just experimenting with a drug such as NTG should
not be the first choice for differentiating the source of the chest pain. Also it is unethical to give
a drug without a specific reason or cause. #4 is incorrect. Performing the Valsalva maneuver
will increase abdominal and thoracic pressures and can cause vagal stimulation that will result
in decreased heart rate. It should not be suggested unless tachycardia is present and
emergency equipment is available in case of cardiac arrest. This is not a method of
differentiating the types of chest pain.
Nursing Process: Assessment
Cognitive Level: Application
2. A 12-lead ECG is performed immediately if the symptoms are suggestive of pain that is
cardiac in origin. #1 is incorrect. Reviewing a complete history will waste time in what might
be an emergent situation. #3 is incorrect. Just experimenting with a drug such as NTG should
not be the first choice for differentiating the source of the chest pain. Also it is unethical to give
a drug without a specific reason or cause. #4 is incorrect. Performing the Valsalva maneuver
will increase abdominal and thoracic pressures and can cause vagal stimulation that will result
in decreased heart rate. It should not be suggested unless tachycardia is present and
emergency equipment is available in case of cardiac arrest. This is not a method of
differentiating the types of chest pain.
Nursing Process: Assessment
Cognitive Level: Application
3. A 12-lead ECG is performed immediately if the symptoms are suggestive of pain that is
cardiac in origin. #1 is incorrect. Reviewing a complete history will waste time in what might
be an emergent situation. #3 is incorrect. Just experimenting with a drug such as NTG should
not be the first choice for differentiating the source of the chest pain. Also it is unethical to give
a drug without a specific reason or cause. #4 is incorrect. Performing the Valsalva maneuver
will increase abdominal and thoracic pressures and can cause vagal stimulation that will result
in decreased heart rate. It should not be suggested unless tachycardia is present and
emergency equipment is available in case of cardiac arrest. This is not a method of
differentiating the types of chest pain.
Nursing Process: Assessment
Cognitive Level: Application
4. A 12-lead ECG is performed immediately if the symptoms are suggestive of pain that is
cardiac in origin. #1 is incorrect. Reviewing a complete history will waste time in what might
be an emergent situation. #3 is incorrect. Just experimenting with a drug such as NTG should
not be the first choice for differentiating the source of the chest pain. Also it is unethical to give
a drug without a specific reason or cause. #4 is incorrect. Performing the Valsalva maneuver
will increase abdominal and thoracic pressures and can cause vagal stimulation that will result
in decreased heart rate. It should not be suggested unless tachycardia is present and
emergency equipment is available in case of cardiac arrest. This is not a method of
differentiating the types of chest pain.
Nursing Process: Assessment
Cognitive Level: Application
Learning Outcome: 7-3: Describe emergent assessment and collaborative management of the person with chest discomfort
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 177
9) An 80-year-old woman has arrived in the ED. The ED physician is questioning whether she has had an MI
although she is not displaying the classic chest pain. Which of the following symptoms might cause him to
suspect that she was experiencing an MI?
1. Jaw and/or tooth pain
2. Confusion accompanied by hypotension
3. Generalized fatigue accompanied by dyspnea and diaphoresis
4. Dyspnea accompanied by crackles in all lobes
Answer: 3
Explanation: 1. Coronary symptoms in women include fatigue, diaphoresis, and nonspecific pain that is
different than that identified by men. #1 is incorrect. This is a symptom of cardiac disease and
can occur in men and women, so it is not a differential for women. #2 is incorrect. Centralized
chest pain is more likely to occur in men than in women. #4 is incorrect. Rales are evidence of
fluid backup in the pulmonary system as seen in congestive heart failure. Both genders can
have dyspnea and, therefore, it is not a differential factor.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
2. Coronary symptoms in women include fatigue, diaphoresis, and nonspecific pain that is
different than that identified by men. #1 is incorrect. This is a symptom of cardiac disease and
can occur in men and women, so it is not a differential for women. #2 is incorrect. Centralized
chest pain is more likely to occur in men than in women. #4 is incorrect. Rales are evidence of
fluid backup in the pulmonary system as seen in congestive heart failure. Both genders can
have dyspnea and, therefore, it is not a differential factor.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
3. Coronary symptoms in women include fatigue, diaphoresis, and nonspecific pain that is
different than that identified by men. #1 is incorrect. This is a symptom of cardiac disease and
can occur in men and women, so it is not a differential for women. #2 is incorrect. Centralized
chest pain is more likely to occur in men than in women. #4 is incorrect. Rales are evidence of
fluid backup in the pulmonary system as seen in congestive heart failure. Both genders can
have dyspnea and, therefore, it is not a differential factor.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
4. Coronary symptoms in women include fatigue, diaphoresis, and nonspecific pain that is
different than that identified by men. #1 is incorrect. This is a symptom of cardiac disease and
can occur in men and women, so it is not a differential for women. #2 is incorrect. Centralized
chest pain is more likely to occur in men than in women. #4 is incorrect. Rales are evidence of
fluid backup in the pulmonary system as seen in congestive heart failure. Both genders can
have dyspnea and, therefore, it is not a differential factor.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
Learning Outcome: 7-3: Describe emergent assessment and collaborative management of the person with chest discomfort
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 178
10) Which of the following lab findings would the nurse review to validate a diagnosis of a myocardial infarction
(MI) that was suspected of occurring approximately 3 hours earlier?
1. CK
2. Troponin T assay
3. Myoglobin
4. PTT
Answer: 3
Explanation: 1. Myoglobin will peak between 1 and 4 hours after the hypoxic/necrotic event and return to
normal in 24 hours. Therefore, it is the first to rise when tissue damage has occurred. #1 is
incorrect. Creatinine phosphokinase (CK) serum levels peak between 12 and 14 hours and
return to normal after 72 to 96 hours. Therefore, it would not help during the first few hours to
validate an MI. #2 is incorrect. Troponin T assay is the most sensitive for cardiac damage but
does not appear in the bloodstream until 4 to 12 hours after the damage occurs. It returns to
normal after 4 to 10 days. #4 is incorrect. PTT does not measure tissue damage; it measures
serum clotting times for anticoagulant therapy. Therefore, it would not validate when or if an
MI occurred.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. Myoglobin will peak between 1 and 4 hours after the hypoxic/necrotic event and return to
normal in 24 hours. Therefore, it is the first to rise when tissue damage has occurred. #1 is
incorrect. Creatinine phosphokinase (CK) serum levels peak between 12 and 14 hours and
return to normal after 72 to 96 hours. Therefore, it would not help during the first few hours to
validate an MI. #2 is incorrect. Troponin T assay is the most sensitive for cardiac damage but
does not appear in the bloodstream until 4 to 12 hours after the damage occurs. It returns to
normal after 4 to 10 days. #4 is incorrect. PTT does not measure tissue damage; it measures
serum clotting times for anticoagulant therapy. Therefore, it would not validate when or if an
MI occurred.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. Myoglobin will peak between 1 and 4 hours after the hypoxic/necrotic event and return to
normal in 24 hours. Therefore, it is the first to rise when tissue damage has occurred. #1 is
incorrect. Creatinine phosphokinase (CK) serum levels peak between 12 and 14 hours and
return to normal after 72 to 96 hours. Therefore, it would not help during the first few hours to
validate an MI. #2 is incorrect. Troponin T assay is the most sensitive for cardiac damage but
does not appear in the bloodstream until 4 to 12 hours after the damage occurs. It returns to
normal after 4 to 10 days. #4 is incorrect. PTT does not measure tissue damage; it measures
serum clotting times for anticoagulant therapy. Therefore, it would not validate when or if an
MI occurred.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 179
4. Myoglobin will peak between 1 and 4 hours after the hypoxic/necrotic event and return to
normal in 24 hours. Therefore, it is the first to rise when tissue damage has occurred. #1 is
incorrect. Creatinine phosphokinase (CK) serum levels peak between 12 and 14 hours and
return to normal after 72 to 96 hours. Therefore, it would not help during the first few hours to
validate an MI. #2 is incorrect. Troponin T assay is the most sensitive for cardiac damage but
does not appear in the bloodstream until 4 to 12 hours after the damage occurs. It returns to
normal after 4 to 10 days. #4 is incorrect. PTT does not measure tissue damage; it measures
serum clotting times for anticoagulant therapy. Therefore, it would not validate when or if an
MI occurred.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 7-4: Evaluate various laboratory tests used to determine if a person is experiencing an acute coronary
event
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 180
11) The multidisciplinary team would identify which of the following goals for initial collaborative management of
a patient with an acute coronary event (ACS)? (Select all that apply.)
1. Maximize coronary artery blood flow.
2. Limit the size of infarction by decreasing oxygen demands.
3. Strengthen the heart by increasing activity as soon as possible.
4. Balance oxygen demand with supply.
5. Prevent dysrhythmias with prophylactic antidysrhythmic medications.
Answer: 1, 2, 4
Explanation: 1. (Note: This requires multiple responses to be correct.)
The symptoms are caused by decreased oxygen or increased demand for oxygen in the
myocardium. If the nurse increases the oxygen supply and decreases the level of activity
(decreasing metabolic rates) to decrease the demands, ischemic tissue can recover or limit
additional tissue death. Prolonged continually, hypoxia will eventually cause tissue necrosis
(death). #3 and #4 are incorrect. Ambulation will increase demand for O2 and is not
recommended until the patient is stable. Preventing dysrhythmias prophylactically is not
appropriate because the nurse may not know which type of irregularity will occur until it does
occur. Early treatment should be used once the irregularity has been identified but it is not
recommended to give medications before symptoms have developed. Dysrhythmias occur due
to hypoxia, electrolyte imbalance, necrosis, or fluid shifts in the myocardium once the vessel
has ruptured or occluded in ACS.
Nursing Process: Planning
Cognitive Level: Synthesis
Category of Need: Safe, Effective Care Environment–Management of Care
2. (Note: This requires multiple responses to be correct.)
The symptoms are caused by decreased oxygen or increased demand for oxygen in the
myocardium. If the nurse increases the oxygen supply and decreases the level of activity
(decreasing metabolic rates) to decrease the demands, ischemic tissue can recover or limit
additional tissue death. Prolonged continually, hypoxia will eventually cause tissue necrosis
(death). #3 and #4 are incorrect. Ambulation will increase demand for O2 and is not
recommended until the patient is stable. Preventing dysrhythmias prophylactically is not
appropriate because the nurse may not know which type of irregularity will occur until it does
occur. Early treatment should be used once the irregularity has been identified but it is not
recommended to give medications before symptoms have developed. Dysrhythmias occur due
to hypoxia, electrolyte imbalance, necrosis, or fluid shifts in the myocardium once the vessel
has ruptured or occluded in ACS.
Nursing Process: Planning
Cognitive Level: Synthesis
Category of Need: Safe, Effective Care Environment–Management of Care
3. (Note: This requires multiple responses to be correct.)
The symptoms are caused by decreased oxygen or increased demand for oxygen in the
myocardium. If the nurse increases the oxygen supply and decreases the level of activity
(decreasing metabolic rates) to decrease the demands, ischemic tissue can recover or limit
additional tissue death. Prolonged continually, hypoxia will eventually cause tissue necrosis
(death). #3 and #4 are incorrect. Ambulation will increase demand for O2 and is not
recommended until the patient is stable. Preventing dysrhythmias prophylactically is not
appropriate because the nurse may not know which type of irregularity will occur until it does
occur. Early treatment should be used once the irregularity has been identified but it is not
recommended to give medications before symptoms have developed. Dysrhythmias occur due
to hypoxia, electrolyte imbalance, necrosis, or fluid shifts in the myocardium once the vessel
has ruptured or occluded in ACS.
Nursing Process: Planning
Cognitive Level: Synthesis
Category of Need: Safe, Effective Care Environment–Management of Care
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 181
4. (Note: This requires multiple responses to be correct.)
The symptoms are caused by decreased oxygen or increased demand for oxygen in the
myocardium. If the nurse increases the oxygen supply and decreases the level of activity
(decreasing metabolic rates) to decrease the demands, ischemic tissue can recover or limit
additional tissue death. Prolonged continually, hypoxia will eventually cause tissue necrosis
(death). #3 and #4 are incorrect. Ambulation will increase demand for O2 and is not
recommended until the patient is stable. Preventing dysrhythmias prophylactically is not
appropriate because the nurse may not know which type of irregularity will occur until it does
occur. Early treatment should be used once the irregularity has been identified but it is not
recommended to give medications before symptoms have developed. Dysrhythmias occur due
to hypoxia, electrolyte imbalance, necrosis, or fluid shifts in the myocardium once the vessel
has ruptured or occluded in ACS.
Nursing Process: Planning
Cognitive Level: Synthesis
Category of Need: Safe, Effective Care Environment–Management of Care
5. (Note: This requires multiple responses to be correct.)
The symptoms are caused by decreased oxygen or increased demand for oxygen in the
myocardium. If the nurse increases the oxygen supply and decreases the level of activity
(decreasing metabolic rates) to decrease the demands, ischemic tissue can recover or limit
additional tissue death. Prolonged continually, hypoxia will eventually cause tissue necrosis
(death). #3 and #4 are incorrect. Ambulation will increase demand for O2 and is not
recommended until the patient is stable. Preventing dysrhythmias prophylactically is not
appropriate because the nurse may not know which type of irregularity will occur until it does
occur. Early treatment should be used once the irregularity has been identified but it is not
recommended to give medications before symptoms have developed. Dysrhythmias occur due
to hypoxia, electrolyte imbalance, necrosis, or fluid shifts in the myocardium once the vessel
has ruptured or occluded in ACS.
Nursing Process: Planning
Cognitive Level: Synthesis
Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 7-4: Evaluate various laboratory tests used to determine if a person is experiencing an acute coronary
event
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 182
12) A patient is admitted with chest discomfort and a possible UA/NSTEMI. Which of the following would be a
contraindication to administration of GP-IIb-IIIA inhibitors to the patient? The patient had:
1. A platelet count greater than 150,000 mm3.
2. Major surgery in the last 6 months.
3. A stroke within the past month.
4. A creatinine level of 1.4 mg/dL.
Answer: 3
Explanation: 1. The purpose of this drug is to prevent platelet aggregation by keeping fibrinogen from binding
to the GP IIb-IIIA receptors on the platelet surfaces. This condition is a contraindication for
giving this drug group because increased bleeding episodes might follow its administration.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
2. The purpose of this drug is to prevent platelet aggregation by keeping fibrinogen from binding
to the GP IIb-IIIA receptors on the platelet surfaces. This condition is a contraindication for
giving this drug group because increased bleeding episodes might follow its administration.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
3. The purpose of this drug is to prevent platelet aggregation by keeping fibrinogen from binding
to the GP IIb-IIIA receptors on the platelet surfaces. This condition is a contraindication for
giving this drug group because increased bleeding episodes might follow its administration.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
4. The purpose of this drug is to prevent platelet aggregation by keeping fibrinogen from binding
to the GP IIb-IIIA receptors on the platelet surfaces. This condition is a contraindication for
giving this drug group because increased bleeding episodes might follow its administration.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 7-5: Compare and contrast fibrinolysis and angioplasty for emergent reperfusion of the cardiac patient
13) The ECG of a patient receiving tPA for a myocardial infarction shows that the ST segment has returned to
baseline. How should the nurse interpret this finding?
1. The myocardial injury is evolving.
2. The blocked artery has been reperfused.
3. The patient has become more relaxed.
4. The spasm in the coronary artery has resolved.
Answer: 2
Explanation: 1. Early reperfusion can resolve coronary ischemia.
Cognitive Level: Application
Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
2. Early reperfusion can resolve coronary ischemia.
Cognitive Level: Application
Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
3. Early reperfusion can resolve coronary ischemia.
Cognitive Level: Application
Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
4. Early reperfusion can resolve coronary ischemia.
Cognitive Level: Application
Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 7-3: Describe emergent assessment and collaborative management of the person with chest discomfort
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 183
14) A nurse is preparing to administer the first 5-mg dose of metoprolol to a patient who is 12 hours post MI. For
which of the following findings should the nurse withhold administration of the medication?
1. Blood pressure of 110/65
2. PR interval 0.12 second
3. Serum potassium 3.9 mEq/L
4. Sinus bradycardia 52 beats per minute
Answer: 4
Explanation: 1. Beta blocker therapy is contraindicated when the patient has a heart rate less than 60 beats per
minute, systolic blood pressure less than 100 mm Hg, moderate or severe left ventricular
failure, shock, PR interval on the electrocardiogram greater than 0.24 second, second- and
third-degree heart block, and active asthma and/or reactive airway disease.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
2. Beta blocker therapy is contraindicated when the patient has a heart rate less than 60 beats per
minute, systolic blood pressure less than 100 mm Hg, moderate or severe left ventricular
failure, shock, PR interval on the electrocardiogram greater than 0.24 second, second- and
third-degree heart block, and active asthma and/or reactive airway disease.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
3. Beta blocker therapy is contraindicated when the patient has a heart rate less than 60 beats per
minute, systolic blood pressure less than 100 mm Hg, moderate or severe left ventricular
failure, shock, PR interval on the electrocardiogram greater than 0.24 second, second- and
third-degree heart block, and active asthma and/or reactive airway disease.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
4. Beta blocker therapy is contraindicated when the patient has a heart rate less than 60 beats per
minute, systolic blood pressure less than 100 mm Hg, moderate or severe left ventricular
failure, shock, PR interval on the electrocardiogram greater than 0.24 second, second- and
third-degree heart block, and active asthma and/or reactive airway disease.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 7-3: Describe emergent assessment and collaborative management of the person with chest discomfort
Understanding the