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Chapter 11: Cardiovascular Clinical Assessment and Diagnostic Procedures
Test Bank
MULTIPLE CHOICE
1. Which of the following conditions is usually associated with clubbing?

a. Central cyanosis
b. Peripheral cyanosis
c. Carbon monoxide poisoning
d. Acute hypoxemia
ANS: A
Clubbing in the nail bed is a sign associated with longstanding central cyanotic heart disease
or pulmonary disease with hypoxemia. Peripheral cyanosis, a bluish discoloration of the nail
bed, is seen more commonly. Peripheral cyanosis results from a reduction in the quantity of
oxygen in the peripheral extremities from arterial disease or decreased cardiac output. Central
cyanosis is a bluish discoloration of the tongue and sublingual area. Multiracial studies
indicate that the tongue is the most sensitive site for observation of central cyanosis.
2. The abdominojugular reflux test determines the presence of

a. right ventricular failure.
b. hypoxemia.
c. liver failure.
d. pitting edema.
ANS: A
The abdominojugular reflux sign can assist with the diagnosis of right ventricular failure. A
positive abdominojugular reflux sign is an increase in the jugular venous pressure (CVP
equivalent) of greater than 3 cm sustained for at least 15 seconds.
3. The purpose of the Allen test is to

a. assess adequate blood flow through the ulnar artery.
b. occlude the brachial artery and evaluate hypoxemia to the hand.
c. test the patency of an internal graft.
d. determine the size of needle to be used for puncture.
ANS: A
The Allen test assesses the adequacy of blood flow to the hand through the ulnar artery.
4. Evaluation of arterial circulation to an extremity is accomplished by assessing which of the

following?
a. Homans sign
b. Skin turgor
c. Peripheral edema
d. Capillary refill
ANS: D
Capillary refill assessment is a maneuver that uses the patient’s nail beds to evaluate both
arterial circulation to the extremity and overall perfusion. The severity of arterial insufficiency
is directly proportional to the amount of time necessary to re-establish flow and color.
5. When checking the patient’s back, the nurse pushes her thumb into the patient’s sacrum. An
indentation remains. The nurse charts that the patient has
a. sacral compromise.
b. delayed skin turgor.
c. pitting edema.
d. dehydration.
ANS: C
Pitting edema occurs when an impression is left in the tissue when the thumb is removed. The
dependent tissues within the legs and sacrum are particularly susceptible. Edema may be
dependent, unilateral, or bilateral and pitting or nonpitting.
6. An assessment finding of pulsus alternans may indicate evidence of

a. left-sided heart failure.
b. jugular venous distention.
c. pulmonary embolism.
d. myocardial ischemia.
ANS: A
Pulsus alternans describes a regular pattern of pulse amplitude changes that alternate between
stronger and weaker beats. This finding is suggestive of end-stage left ventricular heart
failure.
7. The presence of a carotid or femoral bruit may be evidence of

a. left-sided heart failure.
b. blood flow through a partially occluded vessel.
c. the early onset of pulmonary embolism.
d. myocardial rupture.
ANS: B
A bruit is an extracardiac vascular sound that results from blood flow through a tortuous or
partially occluded vessel.
8. A 68-year-old patient is admitted to the critical care unit with reports of midchest pressure
radiating into the jaw and shortness of breath when walking up stairs. The patient is admitted
with a diagnosis of “rule out myocardial infarction.” The history portion of the assessment
should be guided by
a. medical history.
b. history of prior surgeries.
c. presenting symptoms.
d. a review of systems.
ANS: C
For a patient in acute distress, the history taking is shortened to just a few questions about the
patient’s chief complaint, precipitating events, and current medications. For a patient who is
not in obvious distress, the history focuses on the following four areas: review of the patient’s
present illness; overview of the patient’s general cardiovascular status; review of the patient’s
general health status, including family history of coronary artery disease (CAD),
hypertension, diabetes, peripheral arterial disease, or stroke; and survey of the patient’s
lifestyle, including risk factors for CAD.
9. A 68-year-old patient is admitted to the critical care unit with reports of midchest pressure
radiating into the jaw and shortness of breath when walking up stairs. The patient is admitted
with a diagnosis of “rule out myocardial infarction.” When inspecting the patient, the nurse
notes that the patient needs to sit in a high Fowler position to breathe. This may indicate
a. pericarditis.
b. anxiety.
c. heart failure.
d. angina.
ANS: C
Sitting upright to breathe may be necessary for the patient with acute heart failure, and leaning
forward may be the least painful position for a patient with pericarditis.
10. An 82-year-old patient is admitted into the critical care unit with a diagnosis of left-sided
heart failure related to mitral stenosis. Physical assessment findings reveal tachycardia with
an S3 and a 3/6 systolic murmur. The nurse knows that the presence of an S3 heart sound is
a. normal for a person this age.
b. a ventricular gallop.
c. a systolic sound.
d. heard best with the diaphragm of the stethoscope.
ANS: B
The abnormal heart sounds are labeled the third heart sound (S3) and the fourth heart sound
(S4) and are referred to as gallops when auscultated during an episode of tachycardia. Not
unexpectedly, the development of an S3 heart sound is strongly associated with elevated
levels of brain natriuretic peptide.
an S3 and a 3/6 systolic murmur. The grading of a murmur as a 3/6 refers to which of the
following characteristics of murmurs?
a. Intensity
b. Quality
c. Timing
d. Pitch
ANS: A
Intensity, or the “loudness,” is graded on a scale of 1 to 6; the higher the number, the louder
the murmur.
an S3 and a 3/6 systolic murmur. Which of the following descriptions best describes the
murmur heard with mitral stenosis?
a. High-pitched systolic sound
b. Medium-pitched systolic sound
c. High-pitched diastolic sound
d. Low-pitched diastolic sound
ANS: D
Mitral stenosis describes a narrowing of the mitral valve orifice. This produces a low-pitched
murmur, which varies in intensity and harshness depending on the degree of valvular stenosis.
It occurs during diastole, is auscultated at the mitral area (fifth ICS, midclavicular line), and
does not radiate.
13. _____ are created by the turbulence of blood flow through a vessel caused by constriction of
the blood pressure cuff.
a. Korotkoff sounds
b. Pulse pressures
c. Murmurs
d. Gallops
ANS: A
Korotkoff sounds are the sounds created by turbulence of blood flow within a vessel caused by
constriction of the blood pressure cuff. Pulse pressure describes the difference between
systolic and diastolic values. The normal pulse pressure is 40 mm Hg. Abnormal heart sounds
are known as the third heart sound (S3) and the fourth heart sound (S4); they are referred to as
gallops when auscultated during an episode of tachycardia. Murmurs are produced by
turbulent blood flow through the chambers of the heart, from forward flow through narrowed
or irregular valve openings, or backward regurgitate flow through an incompetent valve.
14. Abnormal heart sounds are labeled S3 and S4 and are referred to as __________ when
auscultated during a tachycardic episode.
a. Korotkoff sounds
b. pulse pressure
c. murmurs
d. gallops
ANS: D
Abnormal heart sounds are known as the third heart sound (S3) and the fourth heart sound
(S4); they are referred to as gallops when auscultated during an episode of tachycardia.
Murmurs are produced by turbulent flood flow through the chambers of the heart, from
forward flow through narrowed or irregular valve openings, or backward regurgitate flow
through an incompetent valve. Korotkoff sounds are the sounds created by turbulence of blood
flow within a vessel caused by constriction of the blood pressure cuff. Pulse pressure
describes the difference between systolic and diastolic values. A normal pulse pressure is 40
mm Hg.
15. A heart murmur is described as blowing, grating, or harsh. This description would fall under
which criteria?
a. Intensity
b. Quality
c. Timing
d. Pitch
ANS: B
Quality is whether the murmur is blowing, grating, or harsh. Intensity is the loudness graded
on a scale of 1 through 6; the higher the number, the louder is the murmur. Timing is the place
in the cardiac cycle (systole/diastole). Pitch is whether the tone is high or low.
16. The nurse assesses the dorsalis pedis and posterior tibial pulses as weak and thready. Indicate
the correct documentation for the pulse volume that the nurse would use.
a. 0
b. 1+
c. 2+
d. 3+
ANS: B
Pulse volumes are 0, not palpable; 1+, faintly palpable (weak and thready); 2+, palpable
(normal pulse); and 3+, bounding (hyperdynamic pulse).
17. A nurse palpates the descending aorta and feels a strong, bounding pulse. The nurse reports
the findings to the physician because the results suggest
a. decreased cardiac output.
b. increased cardiac output.
c. an aneurysm.
d. aortic insufficiency.
ANS: C
When the patient is in the supine position, the abdominal aortic pulsation is located in the
epigastric area and can be felt as a forward movement when firm fingertip pressure is applied
above the umbilicus. An abnormally strong or bounding pulse suggests the presence of an
aneurysm or an occlusion distal to the examination site. If it is prominent or diffuse, the
pulsation may indicate an abdominal aneurysm. A diminished or absent pulse may indicate
low CO, arterial stenosis, or occlusion proximal to the site of the examination.
18. A nurse from the ICU receives report from the ED nurse on a patient that includes a diagnosis
of syncope unknown etiology. Orthostatic VS lying: 110/80 mm/Hg; sitting: 100/74 mm/Hg;
standing: 92/40 mm/Hg. Based on this information, the nurse should monitor the patient’s
a. breathing.
b. dietary intake.
c. peripheral pulses.
d. activity.
ANS: D
Postural (orthostatic) hypotension occurs when the systolic blood pressure drops by 10 to 20
mm Hg or the diastolic blood pressure drops by 5 mm Hg after a change from the supine
posture to the upright posture. This is usually accompanied by dizziness, lightheadedness, or
syncope. If a patient experiences these symptoms, it is important to complete a full set of
postural vital signs before increasing the patient’s activity level.
19. A patient’s blood pressure is 90/72 mm Hg. What is the patient’s pulse pressure?
a. 40 mm Hg
b. 25 mm Hg
c. 18 mm Hg
d. 12 mm Hg
ANS: C
Pulse pressure describes the difference between systolic and diastolic values. The normal
pulse pressure is 40 mm Hg (i.e., the difference between an SBP of 120 mm Hg and a DBP of
80 mm Hg). A patient with a blood pressure of 90/72 mm Hg has a pulse pressure of 18 mm
Hg.
20. A sudden increase in left atrial pressure, acute pulmonary edema, and low cardiac output,
caused by the ventricle contracting during systole, are all characteristics of
a. acute mitral regurgitation.
b. aortic insufficiency.
c. chronic mitral regurgitation.
d. pericardial friction rub.
ANS: A
Acute mitral regurgitation occurs when the ventricle contracts during systole and a jet of
blood is sent in a retrograde manner to the left atrium, causing a sudden increase in left atrial
pressure, acute pulmonary edema, and low CO and leading to cardiogenic shock. Chronic
mitral regurgitation is auscultated in the mitral area and occurs during systole. It is high
pitched and blowing, although the pitch and intensity vary, depending on the degree of
regurgitation. As mitral regurgitation progresses, the murmur radiates more widely. Aortic
insufficiency is an incompetent aortic valve. If the valve cusps do not maintain this seal, the
sound of blood flowing back into the left ventricle during diastole is heard as a decrescendo,
high-pitched, blowing murmur. A pericardial friction rub is a sound that can occur within 2 to
7 days after a myocardial infarction. The friction rub results from pericardial inflammation
(pericarditis). Classically, a pericardial friction rub is a grating or scratching sound that is
both systolic and diastolic, corresponding to cardiac motion within the pericardial sac.
21. A patient was admitted to the ICU 3 days ago with a diagnosis of myocardial infarction. The
patient is complaining of increased chest pain when coughing, swallowing, and changing
positions. The nurse hears a systolic scratching sound upon auscultation of the apical pulse.
The nurse notifies the physician. Based on the symptoms, the physician suspects a(n)
ANS: D
A pericardial friction rub is a sound that can occur within 2 to 7 days after a myocardial
infarction. The friction rub results from pericardial inflammation (pericarditis). Classically, a
pericardial friction rub is a grating or scratching sound that is both systolic and diastolic,
corresponding to cardiac motion within the pericardial sac. Acute mitral regurgitation occurs
when the ventricle contracts during systole and a jet of blood is sent in a retrograde manner to
the left atrium, causing a sudden increase in left atrial pressure, acute pulmonary edema, and
low CO and leading to cardiogenic shock. Chronic mitral regurgitation is auscultated in the
mitral area and occurs during systole. It is high pitched and blowing, although the pitch and
intensity vary, depending on the degree of regurgitation. As mitral regurgitation progresses,
the murmur radiates more widely. Aortic insufficiency is an incompetent aortic valve. If the
valve cusps do not maintain this seal, the sound of blood flowing back into the left ventricle
during diastole is heard as a decrescendo, high-pitched, blowing murmur.
22. During a history examination, a patient tells the nurse, “The cardiologist says I have a leaking
valve.” The nurse documents that the patient has a history of
ANS: B
Aortic insufficiency is an incompetent aortic valve. If the valve cusps do not maintain this seal,
the sound of blood flowing back into the left ventricle during diastole is heard as a
decrescendo, high-pitched, blowing murmur. A pericardial friction rub is a sound that can
occur within 2 to 7 days after a myocardial infarction. The friction rub results from pericardial
inflammation (pericarditis). Classically, a pericardial friction rub is a grating or scratching
sound that is both systolic and diastolic, corresponding to cardiac motion within the
pericardial sac. Acute mitral regurgitation occurs when the ventricle contracts during systole
and a jet of blood is sent in a retrograde manner to the left atrium, causing a sudden increase
in left atrial pressure, acute pulmonary edema, and low CO and leading to cardiogenic shock.
Chronic mitral regurgitation is auscultated in the mitral area and occurs during systole. It is
high pitched and blowing, although the pitch and intensity vary, depending on the degree of
regurgitation. As mitral regurgitation progresses, the murmur radiates more widely.
23. A patient was admitted on the night shift with a diagnosis of acute myocardial infarction.
Upon auscultation, the nurse hears a harsh, holosystolic murmur along the left sternal border.
The nurse notifies the physician immediately because the symptoms are indicate the patient
has developed
a. papillary muscle rupture.
b. tricuspid stenosis.
c. ventricular septal rupture.
ANS: C
Ventricular septal rupture is a new opening in the septum between the two ventricles. It
creates a harsh, holosystolic murmur that is loudest (by auscultation) along the left sternal
border. Papillary muscle rupture is auscultation of a new, high-pitched, holosystolic, blowing
murmur at the cardiac apex. Tricuspid stenosis is a quiet murmur that becomes louder with
inspiration and is located in the epigastrium area. A pericardial friction rub is a sound that can
occur within 2 to 7 days after a myocardial infarction. The friction rub results from pericardial
inflammation (pericarditis). Classically, a pericardial friction rub is a grating or scratching
sound that is both systolic and diastolic, corresponding to cardiac motion within the
pericardial sac.
24. A patient with a serum potassium level of 6.8 mEq/L may exhibit electrocardiographic
changes of
a. a prominent U wave.
b. tall, peaked T waves.
c. a narrowed QRS.
d. sudden ventricular dysrhythmias.
ANS: B
Normal serum potassium levels are 3.5 to 4.5 mEq/L. Tall, narrow peaked T waves are
usually, although not uniquely, associated with early hyperkalemia and are followed by
prolongation of the PR interval, loss of the P wave, widening of the QRS complex, heart
block, and asystole. Severely elevated serum potassium (greater than 8 mEq/L) causes a wide
QRS tachycardia.
25. A patient with heart failure may be at risk for hypomagnesemia as a result of
a. pump failure.
b. diuretic use.
c. fluid overload.
d. hemodilution.
ANS: B
Hypomagnesemia can be caused by diuresis. Diuretic use with heart failure often contributes
to low serum magnesium levels.
26. Which of the following diagnostic tests is most effective for measuring overall heart size?
a. Twelve-lead electrocardiography
b. Echocardiography
c. Chest radiography
d. Vectorcardiography
ANS: C
Chest radiography is the oldest noninvasive method for visualizing images of the heart, and it
remains a frequently used and valuable diagnostic tool. Information about cardiac anatomy
and physiology can be obtained with ease and safety at a relatively low cost. Radiographs of
the chest are used to estimate the cardiothoracic ratio and measure overall heart size.
27. ST segment monitoring for ischemia has gained increasing importance with the advent of
thrombolytic therapy. The most accurate method for monitoring the existence of true ischemic
changes is
a. T-wave inversion in leads overlying the ischemia.
b. ST segment depression in leads overlying the ischemia.
c. adjusting the gain control on bedside monitoring for best visualization.
d. 12-lead ECG for confirmation.
ANS: D
Cardiac biomarkers are proteins that are released from damaged myocardial cells. The initial
elevation of cTnI, cTnT, and CK-MB occurs 3 to 6 hours after the acute myocardial damage.
This means that if an individual comes to the emergency department as soon as chest pain is
experienced, the biomarkers will not have risen. For this reason, it is clinical practice to
diagnose an acute myocardial infarction by 12-lead electrocardiography and clinical
symptoms without waiting for elevation of cardiac biomarkers.
28. Which of the following criteria are representative of the patient in normal sinus rhythm?
a. Heart rate, 64 beats/min; rhythm regular; PR interval, 0.10 second; QRS, 0.04
second
b. Heart rate, 88 beats/min; rhythm regular; PR interval, 0.18 second; QRS, 0.06
second
c. Heart rate, 54 beats/min; rhythm regular; PR interval, 0.16 second; QRS, 0.08
second
d. Heart rate, 92 beats/min; rhythm irregular; PR interval, 0.16 second; QRS, 0.04
second
ANS: B
The parameters for normal sinus rhythm are heart rate, 60 to 100 beats/min; rhythm, regular;
PR interval, 0.12 to 0.20 second; and QRS, 0.06 to 0.10 second.
29. The major key to the clinical significance of atrial flutter is the
a. atrial rate.
b. ventricular response rate.
c. PR interval.
d. QRS duration.
ANS: B
The major factor underlying atrial flutter symptoms is the ventricular response rate. If the
atrial rate is 300 and the atrioventricular (AV) conduction ratio is 4:1, the ventricular response
rate is 75 beats/min and should be well tolerated. If, on the other hand, the atrial rate is 300
beats/min but the AV conduction ratio is 2:1, the corresponding ventricular rate of 150
beats/min may cause angina, acute heart failure, or other signs of cardiac decompensation.
30. A characteristic event in junctional dysrhythmias is

a. irregular rhythm.
b. rapid depolarization to the ventricles.
c. the spread of the impulse in two directions at once.
d. a widened QRS.
ANS: C
After an ectopic impulse arises in the junction, it spreads in two directions at once. One wave
of depolarization spreads upward into the atria and depolarizes them, causing the recording of
a P wave on the electrocardiogram. At the same time, another wave of depolarization spreads
downward into the ventricles through the normal conduction pathway, producing a normal
QRS complex.
31. When assessing a patient with PVCs, the nurse knows that the ectopic beat is multifocal
because it appears
a. in various shapes in the same lead.
b. with increasing frequency.
c. to widen the QRS width.
d. in a specific pattern in the same lead.
ANS: A
If the ventricular ectopic beats are of various shapes in the same lead, they are multifocal.
Multifocal ventricular ectopics are more serious than unifocal ventricular ectopics because
they indicate a greater area of irritable myocardial tissue and are more likely to deteriorate
into ventricular tachycardia or fibrillation.
32. A patient with ventricular fibrillation (VF) is

a. hypertensive.
b. bradypneic.
c. diaphoretic.
d. pulseless.
ANS: D
In VF, the patient does not have a pulse, no blood is being pumped forward, and defibrillation
is the only definitive therapy. No forward flow of blood or palpable pulse is present in VF.
33. Which portion of the ECG is most valuable in diagnosing atrioventricular (AV) conduction
disturbances?
a. P wave
b. PR interval
c. QRS complex
d. QT interval
ANS: B
The PR interval is an indicator of atrioventricular nodal function. The P wave represents atrial
depolarization. The QRS complex represents ventricular depolarization, corresponding to
phase 0 of the ventricular action potential. The QT interval is measured from the beginning of
the QRS complex to the end of the T wave and indicates the total time interval from the onset
of depolarization to the completion of repolarization.
34. The rationale for giving the patient additional fluids after a cardiac catheterization is that
a. fluids help keep the femoral vein from clotting at the puncture site.
b. the patient had a nothing-by-mouth order before the procedure.
c. the radiopaque contrast acts as an osmotic diuretic.
d. fluids increase cardiac output.
ANS: C
Fluid is given for rehydration because the radiopaque contrast acts as an osmotic diuretic.
Fluid is also used to prevent contrast-induced nephropathy or damage to the kidney from the
contrast dye used to visualize the heart structures.
35. Pulsus paradoxus may be seen on intra-arterial blood pressure monitoring when
a. there is a decrease of more than 10 mm Hg in the arterial waveform before
inhalation.
b. there is a single, nonperfused beat.
c. the waveform demonstrates tall, tented T waves.
d. the pulse pressure is greater than 20 mm Hg on exhalation.
ANS: A
Pulsus paradoxus is a decrease of more than 10 mm Hg in the arterial waveform that occurs
during inhalation. It is caused by a fall in CO as a result of increased negative intrathoracic
pressure during inhalation.
36. When assessing the pulmonary arterial waveform, the nurse notices dampening. After
tightening the stopcocks and flushing the line, the nurse decides to calibrate the transducer.
What are two essential components included in calibration?
a. Obtaining a baseline blood pressure and closing the transducer to air
b. Leveling the air–fluid interface to the phlebostatic axis and opening the transducer
to air
c. Having the patient lay flat and closing the transducer to air
d. Obtaining blood return on line and closing all stopcocks
ANS: B
Ensuring accuracy of waveform calibration of the system includes opening the transducer to
air and leveling the air–fluid interface of the transducer to the phlebostatic axis.
37. The mean arterial pressure (MAP) is calculated by

a. averaging three of the patient’s blood pressure readings over a 6-hour period.
b. dividing the systolic pressure by the diastolic pressure.
c. adding the systolic pressure and two diastolic pressures and then dividing by 3.
d. dividing the diastolic pressure by the pulse pressure.
ANS: C
The mean arterial pressure is one-third systole and two-thirds diastole.
38. The physiologic effect of left ventricular afterload reduction is

a. decreased left atrial tension.
b. decreased systemic vascular resistance.
c. increased filling pressures.
d. decreased cardiac output.
ANS: B
Afterload is defined as the pressure the ventricle generates to overcome the resistance to
ejection created by the arteries and arterioles. After a decrease in afterload, wall tension is
lowered. The technical name for afterload is systemic vascular resistance (SVR). Resistance to
ejection from the right side of the heart is estimated by calculating the pulmonary vascular
resistance (PVR). The PVR value is normally one-sixth of the SVR.
39. Contractility of the left side of the heart is measured by

a. pulmonary artery wedge pressure.
b. left atrial pressure.
c. systemic vascular resistance.
d. left ventricular stroke work index.
ANS: D
Contractility of the left side of the heart is measured by the left ventricular stroke work index.
40. Which of the following interventions should be strictly followed to ensure accurate cardiac
output readings?
a. Use 5 mL of iced injectate only.
b. Inject the fluid into the pulmonary artery port only.
c. Ensure a difference of at least 5° C between injectate temperature and the patient’s
body temperature.
d. Administer the injectate within 4 seconds.
ANS: D
To ensure accurate readings, the difference between injectate temperature and body
temperature must be at least 10° C, and the injectate must be delivered within 4 seconds, with
minimal handling of the syringe to prevent warming of the solution. This is particularly
important when iced injectate is used.
41. The value of SVO2 monitoring is to determine

a. oxygen saturation at the capillary level.
b. an imbalance between oxygen supply and metabolic tissue demand.
c. the diffusion of gases at the alveolar capillary membrane.
d. the predicted cardiac output for acute pulmonary edema.
ANS: B
Three of these factors (CO, Hgb, and SaO2) contribute to the supply of oxygen to the tissues.
Tissue metabolism (VO2) determines oxygen consumption or the quantity of oxygen extracted
at tissue level that creates the demand for oxygen.
42. A 52-year-old patient presents to the emergency department with reports of substernal chest
pain. A history is taken; serum creatine kinase (CK) and lactate dehydrogenase (LDH)
isoenzymes and serum lipid studies are ordered, as is a 12-lead ECG. Which of the following
results is most significant in diagnosing an MI during the first 12 hours of chest pain?
a. ECG—inverted T waves
b. Serum enzymes—elevated LDH4
c. Serum enzymes—elevated CK-MB
d. Patient history—substernal chest pain
ANS: C
The creatine kinase (CK) muscle/brain (MB) biomarker (CK-MB) is released as a result of
myocardial damage, and serum levels rise 4 to 8 hours after myocardial infarction (MI), peak
at 15 to 24 hours, and remain elevated for 2 to 3 days. Serial samples are drawn routinely at 6-
or 8-hour intervals, and three samples are usually sufficient to support or rule out the
diagnosis of MI.
43. Which serum lipid value is a significant predictor of future acute MI in persons with
established coronary artery atherosclerosis?
a. High-density lipoprotein (HDL)
b. Low-density lipoprotein (LDL)
c. Triglycerides
d. Very-low-density lipoprotein
ANS: B
Both the LDL-C and total serum cholesterol levels are directly correlated with risk for
coronary artery disease, and high levels of each are significant predictors of future acute
myocardial infarction in persons with established coronary artery atherosclerosis. LDL-C is
the major atherogenic lipoprotein and thus is the primary target for cholesterol-lowering
efforts.
44. Which of the ECG findings would be positive for an inferior wall MI?
a. ST segment depression in leads I, aVL, and V2 to V4
b. Q waves in leads V1 to V2
c. Q waves in leads II, III, and aVF
d. T-wave inversion in leads V4 to V6, I, and aVL
ANS: C
Abnormal Q waves develop in leads overlying the affected area. An inferior wall infarction is
seen with changes in leads II, III, and aVF. Leads I and aVF are selected to detect a sudden
change in ventricular axis. If ST segment monitoring is required, the lead is selected
according to the area of ischemia. If the ischemic area is not known, leads V3 and III are
recommended to detect ST segment ischemia.
45. A patient’s bedside ECG strips show the following changes: increased PR interval; increased
QRS width; and tall, peaked T waves. Vital signs are T 98.2° F; HR 118 beats/min; BP 146/90
mm Hg; and RR 18 breaths/min. The patient is receiving the following medications: digoxin
0.125 mg PO every day; D51/2 normal saline with 40 mEq potassium chloride at 125 mL/hr;
Cardizem at 30 mg PO q8h; and aldosterone at 300 mg PO q12h. The physician is notified of
the ECG changes. What orders should the nurse expect to receive?
a. Change IV fluid to D51/2 normal saline and draw blood chemistry.
b. Give normal saline with 40 mEq of potassium chloride over a 6-hour period.
c. Hold digoxin and draw serum digoxin level.
d. Hold Cardizem and give 500 mL normal saline fluid challenge over a 2-hour
period.
ANS: A
The electrocardiographic (ECG) changes are most consistent with hyperkalemia. Removing
the potassium from the intravenous line and drawing laboratory values to check the potassium
level is the best choice with the least chance of further harm. Digoxin toxicity can be
suspected related to the prolonged PR interval, but hyperkalemia explains all the ECG
changes. The patient is not hypotensive or bradycardic, so holding the Cardizem is not
indicated.
46. A patient with a potassium level of 2.8 mEq/L is given 60 mEq over a 12-hour period, and a
repeat potassium level is obtained after the bolus. The current potassium level is 2.9 mEq/L.
Which of the following should now be considered?
a. Stopping the patient’s Aldactone
b. Drawing a serum magnesium level
c. Rechecking the potassium level
d. Monitoring the patient’s urinary output
ANS: B
A total serum magnesium concentration below 1.5 mEq/L defines hypomagnesemia. It is
commonly associated with other electrolyte imbalances, most notably alterations in
potassium, calcium, and phosphorus. Low serum magnesium levels can result from many
causes.
47. Which of the following cardiac enzymes is a highly specific biomarker for myocardial
damage?
a. CK-MB
b. Troponin I
c. Troponin T
d. LDH
ANS: B
Because cTnI is found only in cardiac muscle, it is a highly specific biomarker for myocardial
damage, considerably more specific than CK-MB. As a consequence, patients with a positive
cTnI result and a negative CK-MB result usually rule in an acute myocardial infarction (MI).
A negative cTnI result that remains negative many hours after an episode of chest pain is a
strong indicator that the patient is not experiencing an acute MI. Even with a negative cTnI
result, symptoms of chest pain still indicate that the patient should have a comprehensive
cardiac evaluation to determine if there is underlying CAD present that may later lead to
complications.
48. The physician anticipates the CVC dwelling time to be 10 to 20 days. The nurse anticipates
that the CVC will be placed in the
a. SC vein.
b. IJ vein.
c. EJ vein.
d. femoral vein.
ANS: A
If the anticipated central venous catheter (CVC) dwelling time is prolonged more than 5 days,
the subcutaneous (SC) site is preferred. The SC position has the lowest infection rate and
produces the least patient discomfort from the catheter. The internal jugular (IJ) vein is the
most frequently used access site for CVC insertion. Compared with the other thoracic veins, it
is the easiest to canalize. If the IJ vein is not available, the external jugular (EJ) vein may be
accessed, although blood flow is significantly higher in the IJ vein, making it the preferred
site. This may be the reason why catheter-related infections are higher in the IJ than the SC
position for indwelling catheters left in place for more than 4 days. The femoral vein is
considered the easiest cannulation site because there are no curves in the insertion route.
Because there is a higher rate of nosocomial infection with femoral catheters, this site is not
recommended.
49. The most common complication of a central venous catheter (CVC) is

a. air embolus.
b. infection.
c. thrombus formation.
d. pneumothorax.
ANS: B
Infection related to the use of CVCs is a major problem. The incidence of infection strongly
correlates with the length of time the CVC has been inserted, with longer insertion times
leading to a higher infection rate. The risk of air embolus, although uncommon, is always
present for a patient with a central venous line in place. Air can enter during insertion through
a disconnected or broken catheter by means of an open stopcock, or air can enter along the
path of a removed CVC. Unfortunately, clot formation (thrombus) at the CVC site is common.
Thrombus formation is not uniform; it may involve development of a fibrin sleeve around the
catheter, or the thrombus may be attached directly to the vessel wall. Pneumothorax has a
higher occurrence during placement of a CVC than during removal.
50. A physician orders removal of the central venous catheter (CVC) line. The patient has a
diagnosis of heart failure with chronic obstructive pulmonary disease. The nurse would place
the patient in what position for this procedure?
a. Supine in bed
b. Supine in a chair
c. Flat in bed
d. Reverse Trendelenburg position
ANS: A
Recommended techniques to avoid air embolus during CVC removal include removing the
catheter when the patient is supine in bed (not in a chair) and placing the patient flat or in the
reverse Trendelenburg position if the patient’s clinical condition permits this maneuver.
Patients with heart failure, pulmonary disease, and neurologic conditions with raised
intracranial pressure should not be placed flat.
51. The P wave represents which of the following?
a. Atrial contraction
b. Atrial depolarization
c. Sinus node discharge
d. Ventricular contraction
ANS: B
The P wave is an electrical event and represents atrial depolarization. Atrial contraction
should accompany the P wave but does not always. The sinus node discharge is too faint to be
recorded on the surface electrocardiogram. Ventricular contraction usually accompanies the
QRS complex.
52. Why is the measurement of the QT interval important?

a. It represents ventricular depolarization.
b. It represents ventricular contraction.
c. An increasing QT interval increases the risk of torsades de pointes.
d. A decreasing QT interval increases the risk of torsades de pointes.
ANS: C
A prolonged QT interval is significant because it can predispose the patient to the
development of polymorphic ventricular tachycardia, known also as torsades de pointes. A
long QT interval can be congenital, as a result of genetic inheritance, or it can be acquired
from an electrolyte imbalance or medications.
53. Which lead is best to monitor a patient?

a. Varies based on the patient’s clinical condition and recent clinical history
b. Lead MCL1
c. Lead V1
d. Lead II
ANS: A
The selection of an electrocardiographic monitoring lead is not a decision to be made casually
or according to habit. The monitoring lead should be chosen with consideration of the
patient’s clinical condition and recent clinical history. If the monitored heart has a normal
electrical axis, lead II displays a waveform that is predominantly upright, with a positive P
wave and positive QRS waveform. P waves are usually easy to identify in lead II, and it is
recommended for monitoring of atrial dysrhythmias. However, it is difficult to identify right
bundle branch block (RBBB) and left bundle branch block (LBBB). Lead V1 is the optimal
lead to select if the critical care nurse needs to analyze ventricular ectopy. V1 provides
information to facilitate differentiation between RBBB versus LBBB pattern or distinguish
between ventricular tachycardia and supraventricular tachycardia with aberrant conduction,
determine whether premature ventricular contractions originate in the right or left ventricle,
and clarify when ST segment changes are caused by the RBBB and when they are the result of
ischemia. Lead V1 is excellent for this purpose. MCL1 is an uncommon lead choice today. It
is used only if monitoring with a three-lead system such as on a transport monitor.
54. When performing a 12-lead ECG, how many wires are connected to the patient?
a. 3
b. 5
c. 10
d. 12
ANS: C
The standard 12-lead electrocardiogram provides a picture of electrical activity in the heart
using 10 different electrode positions to create 12 unique views of electrical activity occurring
within the heart. Fours wires are applied to the extremities to produce leads I, II, III, aVR,
aVL, and aVF. Six wires are attached to the V1 to V6 chest lead positions.
55. A patient returns from the cardiac catheterization laboratory after angioplasty and stent
placement (ECG changes had indicated an inferior wall myocardial infarction in progress).
Which lead would best monitor this patient?
a. Varies based on the patient’s clinical condition and recent clinical history
b. Lead MCL1
c. Lead V1
d. Lead II
ANS: B
If the monitored heart has a normal electrical axis, lead II displays a waveform that is
predominantly upright, with a positive P wave and positive QRS waveform. P waves are
usually easy to identify in lead II, and it is recommended for monitoring of atrial
dysrhythmias. However, it is difficult to identify right bundle branch block (RBBB) and left
bundle branch block (LBBB). The selection of an electrocardiographic monitoring lead is not
a decision to be made casually or according to habit. The monitoring lead should be chosen
with consideration of the patient’s clinical condition and recent clinical history. Lead V1 is the
optimal lead to select if the critical care nurse needs to analyze ventricular ectopy. V1
provides information to facilitate differentiation between RBBB versus LBBB pattern or
distinguish between ventricular tachycardia and supraventricular tachycardia with aberrant
conduction; determine whether premature ventricular contractions originate in the right or left
ventricle, and clarify when ST segment changes are caused by the RBBB and when they are
the result of ischemia. Lead V1 is excellent for this purpose. MCL1 is an uncommon lead
choice today. It is used only if monitoring with a three-lead system such as on a transport
monitor.
56. The patient’s admitting 12-lead ECG shows peaked P waves. Which of the following
admitting diagnoses could be responsible for this finding?
a. Mitral stenosis
b. Pulmonary edema
c. Ischemia
d. Pericarditis
ANS: B
Tall, peaked P waves occur in right atrial hypertrophy and are referred to as P pulmonale
because this condition is often the result of chronic pulmonary disease. Ischemia occurs when
the delivery of oxygen to the tissues is insufficient to meet metabolic demand. Cardiac
ischemia in an unstable form occurs because of a sudden decrease in supply, such as when the
artery is blocked by a thrombus or when coronary artery spasm occurs. If the pulmonary
edema is caused by heart failure, sometimes described as hydrostatic pulmonary edema, the
fluid may be in a “bat-wing” distribution, with the white areas concentrated in the hilar region
(origin of the major pulmonary vessels). However, as the heart failure progresses, the quantity
of fluid in the alveolar spaces increases, and the white, fluffy appearance is seen throughout
the lung. Pericarditis is inflammation of the sac around the heart.
57. A nurse is obtaining the history of a patient who reveals that he had an MI 5 years ago. When
the admission 12-lead ECG is reviewed, Q waves are noted in leads V3 and V4 only. Which of
the following conclusions is most consistent with this situation?
a. The patient may have had a posterior wall MI.
b. The patient must have had a right ventricular MI.
c. The admission 12-lead ECG was done incorrectly.
d. The patient may have had an anterior MI.
ANS: D
Not every acute myocardial infarction (MI) results in a pathologic Q wave on the 12-lead
electrocardiogram (ECG). When the typical ECG changes are not present, the diagnosis
depends on symptomatic clinical presentation, specific cardiac biomarkers (e.g., cTnI, cTnT,
CK-MB), and non-ECG diagnostic tests such as cardiac catheterization. Anterior and posterior
wall MIs have ST changes, not Q wave changes.
58. A new-onset MI can be recognized by which of the following ECG changes?

a. Q waves
b. Smaller R waves
c. Widened QRS
d. ST segment elevation
ANS: D
Any change from baseline is expressed in millimeters and may indicate myocardial ischemia
(one small box equals 1 mm). ST segment elevation of 1 to 2 mm is associated with acute
myocardial injury, preinfarction, and pericarditis. ST segment depression (decrease from
baseline more of 1 to 2 mm) is associated with myocardial ischemia. Widened QRS complexes
are indicative of ventricular depolarization abnormalities such as bundle branch blocks and
ventricular dysrhythmias. Q waves and smaller R waves are indications usually present 24
hours to 1 week after the myocardial infarction is completely evolved; they represent necrosis.
59. To accurately measure the heart rate of a patient in normal sinus rhythm, which technique
would be the most accurate?
a. The number of R waves in a 6-second strip
b. The number of large boxes in a 6-second strip
c. The number of small boxes between QRS complexes divided into 1500
d. The number of large boxes between consecutive R waves divided into 300
ANS: C
Calculation of heart rate if the rhythm is regular may be done using the following methods.
Method 1: number of RR intervals in 6 seconds multiplied by 10 (e.g., 8  10 = 80/min).
Method 2: number of large boxes between QRS complexes divided into 300 (e.g., 300 ÷ 4 =
75/min). Method 3: number of small boxes between QRS complexes divided into 1500 (e.g.,
1500 ÷ 18 = 84/min).
60. What is the initial intervention in a patient with sinus tachycardia with the following vital
signs: HR, 136 beats/min; BP, 102/60 mm Hg; RR, 24 breaths/min; T, 99.2° F; SpO2, 94% on
oxygen 2 L/min by nasal cannula?
a. Stat adenosine to decrease heart rate
b. Identification and correction of the cause of the increased heart rate
c. Sublingual nitroglycerine 0.4 mg
d. Lidocaine 75 mg IV push
ANS: B
Sinus tachycardia can be caused by a wide variety of factors, such as exercise, emotion, pain,
fever, hemorrhage, shock, heart failure, and thyrotoxicosis. Illegal stimulant drugs such as
cocaine, “ecstasy,” and amphetamines can raise the resting heart rate significantly. Many
medications used in critical care can also cause sinus tachycardia; common culprits are
aminophylline, dopamine, hydralazine, atropine, and catecholamines such as epinephrine.
This patient has a stable heart rate and SpO2; therefore, there is time to identify the cause of
the sinus tachycardia. Lidocaine is indicated for ventricular dysrhythmias. Nitroglycerine is
not indicated because the patient is not having chest pain at this time. Adenosine is usually not
indicated unless the heart rate is greater than 150 beats/min.
61. A patient presents with atrial flutter with an atrial rate of 280 beats/min and a ventricular rate
of 70 beats/min. Which of the following best explains this discrepancy in rates?
a. The ventricles are too tired to respond to all the atrial signals.
b. The AV node does not conduct all the atrial signals to the ventricles.
c. Some of the atrial beats are blocked before reaching the AV node.
d. The ventricles are responding to a ventricular ectopic pacemaker.
ANS: B
The atrioventricular (AV) node does not allow conduction of all these impulses to the
ventricles. In this case, the rhythm would be described as atrial flutter with a 4:1 AV block,
indicating that only one of every four atrial signals is conducted to the ventricles.
62. New-onset atrial fibrillation can be serious for which of the following reasons?
a. It increases the risk of stroke and pulmonary embolism from atrial clots.
b. It increases the patient’s risk of deep venous thrombosis.
c. It may increase cardiac output to dangerous levels.
d. It indicates that the patient is about to have an MI.
ANS: A
In atrial fibrillation the atria do not contract normally; they quiver. This increases the chance
of the blood clotting in the atria because of a lack of complete emptying of the atria. These
clots can break free and cause embolic strokes and pulmonary emboli. Atrial fibrillation does
not indicate impending myocardial infarction or an increased risk of deep venous thrombosis.
Atrial fibrillation decreases cardiac output from the loss of atrial kick.
63. Which of the following is most often found in ventricular dysrhythmias?

a. Retrograde P waves
b. Wide QRS complexes
c. No P waves
d. An inverted T wave
ANS: B
Ventricular dysrhythmias result from an ectopic focus in any portion of the ventricular
myocardium. The usual conduction pathway through the ventricles is not used, and the wave
of depolarization must spread from cell to cell. As a result, the QRS complex is prolonged and
is always greater than 0.12 second. It is the width of the QRS, not the height, that is important
in the diagnosis of ventricular ectopy.
64. The patient has an HR of 84 beats/min and an SV of 65 mL. Calculate the CO.
a. 149 mL
b. 500 mL
c. 4650 mL
d. 5460 mL
ANS: D
Cardiac output (CO) is the product of heart rate (HR) multiplied by stroke volume (SV). SV is
the volume of blood ejected by the heart during each beat (reported in milliliters). 84 x 65 =
5460 mL.
65. After an MI, a patient presents with an increasing frequency of PVCs. The patient’s heart rate
is 110 beats/min, and ECG indicates a sinus rhythm with up to five unifocal PVCs per minute.
Which of the following should be done? The patient is alert and responsive and denies any
chest pain or dyspnea.
a. Administer lidocaine 100 mg bolus IV push stat.
b. Administer Cardizem 20 mg IV push stat.
c. Notify the physician and monitor the patient closely.
d. Nothing; PVCs are expected in this patient.
ANS: C
Although premature ventricular contractions (PVCs) are frequently present after myocardial
infarction, they are not always benign. In individuals with underlying heart disease, PVCs or
episodes of self-terminating ventricular tachycardia (VT) are potentially malignant.
Nonsustained VT is defined as three or more consecutive premature ventricular beats at a rate
faster than 110 beats/min lasting less than 30 seconds. The patient does not appear
symptomatic from the PVCs at this time; therefore, lidocaine is not indicated. Cardizem is not
prescribed for ventricular ectopy.
66. A patient becomes unresponsive. The patient’s heart rate is 32 beats/min, idioventricular
rhythm; blood pressure is 60/32 mm Hg; SpO2 is 90%; and respiratory rate is 14 breaths/min.
Which of the following interventions would the nurse do first?
a. Notify the physician and hang normal saline wide open.
b. Notify the physician and obtain the defibrillator.
c. Notify the physician and obtain a temporary pacemaker.
d. Notify the physician and obtain a 12-lead ECG.
ANS: C
If the sinus node and the atrioventricular (AV) junction fail, the ventricles depolarize at their
own intrinsic rate of 20 to 40 times per minute. This is called an idioventricular rhythm and is
naturally protective mechanism. Rather than trying to abolish the ventricular beats, the aim of
treatment is to increase the effective heart rate (HR) and re-establish dominance of a higher
pacing site such as the sinus node or the AV junction. Usually, a temporary pacemaker is used
to increase the HR until the underlying problems that caused failure of the other pacing sites
can be resolved.
67. Ventricular tachycardia has which of the following hemodynamic effects?

a. Decreased cardiac output from increased ventricular filling time
b. Decreased cardiac output from decreased stroke volume
c. Decreased cardiac output from increased preload
d. Decreased cardiac output from decreased afterload
ANS: B
Tachycardia is detrimental to anyone with ischemic heart disease because it decreases the time
for ventricular filling, decreases stroke volume, and compromises cardiac output. Tachycardia
increases heart work and myocardial oxygen demand while decreasing oxygen supply by
decreasing coronary artery filling time.
68. Which of the following has become the first-line hemodynamic assessment tool in the critical
care unit?
a. Echocardiogram
b. ECG
c. Exercise stress test
d. 24-hour Holter monitor
ANS: A
Echocardiography is quickly becoming a first-line hemodynamic assessment tool in critical
care units. Echocardiography is used to detect structural heart abnormalities such as mitral
valve stenosis and regurgitation, prolapse of mitral valve leaflets, aortic stenosis and
insufficiency, hypertrophic cardiomyopathy, atrial septal defect, thoracic aortic dissection,
cardiac tamponade, and pericardial effusion.
69. The target INR range is

a. 1.0 to 2.0.
b. 1.5 to 3.0.
c. 1.5 to 2.5.
d. 2.0 to 3.0.
ANS: D
A target international normalized ratio of 2.5 (range, 2.0–3.0) is desirable.
70. Which of the following AV blocks can be described as a gradually lengthening PR interval
until ultimately the final P wave in the group fails to conduct?
a. First-degree AV block
b. Second-degree AV block, type I
c. Second-degree AV block, type II
d. Third-degree AV block
ANS: B
In Mobitz type I block, the atrioventricular (AV) conduction times progressively lengthen
until a P wave is not conducted. This typically occurs in a pattern of grouped beats and is
observed on the electrocardiogram (ECG) by a gradually lengthening PR interval until
ultimately the final P wave in the group fails to conduct. When all atrial impulses are
conducted to the ventricles but the PR interval is greater than 0.20 second, a condition known
as first-degree AV block exists. Mobitz type II block is always anatomically located below the
AV node in the bundle of His in the bundle branches or even in the Purkinje fibers. This
results in an all-or-nothing situation with respect to AV conduction. Sinus P waves are or are
not conducted. When conduction does occur, all PR intervals are the same. Because of the
anatomic location of the block, on the surface, ECG the PR interval is constant and the QRS
complexes are wide. Third-degree, or complete, AV block is a condition in which no atrial
impulses can conduct from the atria to the ventricles. This is also described by the term
complete heart block.
71. The blood test used to standardize PT results among clinical laboratories worldwide is known
as
a. aPTT.
b. ACT.
c. HDL.
d. INR.
ANS: D
The international normalized ratio was developed by the World Health Organization in 1982
to standardize prothrombin time results among clinical laboratories worldwide. High-density
lipoproteins are particles of the total serum cholesterol. Activated coagulation time (ACT) is
also known as the activated clotting time. The ACT is a point of care test that is performed
outside of the laboratory setting in areas such as the cardiac catheterization laboratory, the
operating room, or critical care units. The activated partial thromboplastin time is used to
measure the effectiveness of intravenous or subcutaneous ultrafractionated heparin therapy.
72. On returning from the cardiac catheterization laboratory, the patient asks if he can get up in
the chair. The most appropriate response would be
a. “You cannot get up because you may pass out.”
b. “You cannot get up because you may start bleeding.”
c. “You cannot get up because you may fall.”
d. “You cannot get up until you urinate.”
ANS: B
After catheterization, the patient remains flat for up to 6 hours (varies by institutional protocol
and catheter size) to allow the femoral arterial puncture site to form a stable clot. Most
bleeding occurs within the first 2 to 3 hours after the procedure.
73. Which of the following statements made by a patient would indicate the need for further
education before an electrophysiology procedure?
a. “I need to take all my heart medications the morning of the procedure.”
b. “The doctor is going to make my heart beat wrong on purpose.”
c. “I will be awake but relaxed during the procedure.”
d. “I will be x-rayed during the procedure.”
ANS: A
All antidysrhythmic medications are discontinued several days before the study so that any
ventricular dysrhythmias may be readily induced during the electrophysiology procedure
(EPS). Anticoagulants, especially warfarin, are also stopped before EPS. Premedication is
administered before the study to induce a relaxed state, and during the procedure, the patient
is conscious but receives sedative agents (midazolam) at regular intervals.
74. Zeroing the pressure transducer on hemodynamic monitoring equipment occurs when the
displays reads
a. 0.
b. 250.
c. 600.
d. 760.
ANS: A
The monitor is adjusted so that “0” is displayed, which equals atmospheric pressure.
Atmospheric pressure is not zero; it is 760 mm Hg at sea level. Using zero to represent current
atmospheric pressure provides a convenient baseline for hemodynamic measurement
purposes.
75. Which of the following expresses the correct order when working with an invasive pressure
monitor?
a. Level the transducer, locate the phlebostatic axis, zero the transducer, and take the
reading.
b. Locate the phlebostatic axis, level the transducer, zero the transducer, and take the
reading.
c. Take the reading, level the transducer, locate the phlebostatic axis, and zero the
transducer.
d. Locate the phlebostatic axis, zero the transducer, level the transducer, and take the
reading.
ANS: B
The correct order is locate the phlebostatic axis, level the transducer, zero the transducer, and
take the reading. The transducer cannot be zeroed before it is leveled. Readings cannot be
taken before the transducer is zeroed, and leveling the transducer cannot occur until the
phlebostatic axis has been identified.
76. A patient’s CVP reading suddenly increased from 10 to 48 mm Hg. His lungs are clear except
for fine rales at the bases. Immediate response should be which of the following?
a. Nothing; this reading is still within normal limits.
b. Place a stat call into the physician.
c. Administered ordered prn Lasix.
d. Check the transducer level.
ANS: D
If the transducer falls below the correct level, the reading would be falsely elevated. This rise
is consistent with a transducer having fallen from the correct level on the bed to the floor.
Lasix is not indicated. Central venous pressure (CVP) of 45 mm Hg, if true, is severely
elevated. Not enough information has been provided to call the physician. If the CVP value is
true and the patient’s condition is poor, a call to the physician would be appropriate after
assessment.
77. The Allen test is used before radial arterial line placement to assess
a. collateral circulation to the hand.
b. patency of the radial artery.
c. neurologic function of the hand.
d. pain sensation at the insertion point.
ANS: A
The Allen test involves occluding the radial or ulnar artery after blanching the hand. If the
hand turns pink, then the nonoccluded artery provides enough circulation to the hand. If the
hand remains blanched, then no collateral circulation exists, and that wrist should not be used
for arterial line placement.
78. A patient’s arterial line waveform has become damped. The nurse should
a. check for kinks, blood, and air bubbles in the tubing.
b. prepare for a normal saline fluid challenge for hypotension.
c. discontinue the arterial line.
d. check the patient’s lung sounds.
ANS: A
A damped waveform occurs when communication from the artery to the transducer is
interrupted and produces false values on the monitor and oscilloscope. Damping is caused by
a fibrin “sleeve” that partially occludes the tip of the catheter, by kinks in the catheter or
tubing, or by air bubbles in the system.
79. Which of the following is most indicative of decreased left ventricular preload?
a. Increased PAOP/PAWP
b. Decreased PAOP/PAWP
c. Increased CVP
d. Decreased CVP
ANS: A
Pulmonary artery occlusion pressure (PAOP) and pulmonary artery wedge pressure (PAWP)
normally reflect the pressure in the left ventricle at the end of diastole. Left ventricular
end-diastolic pressure is preload, and so an increase in preload will first increase the PAOP
and PCWP measurements. Although central venous pressure increases in severe cases of
increased preload, it can increase for other reasons. The other changes are not associated with
increased preload.
80. Which of the following conditions can cause an artificial increase in the PAOP/PCWP?
a. Aortic regurgitation
b. Aortic stenosis
c. Mitral stenosis
d. Mitral regurgitation
ANS: D
If mitral regurgitation is present, the mean pulmonary artery occlusion pressure reading is
artificially elevated because of abnormal backflow of blood from the left ventricle to the left
atrium during systole.
81. The patient’s admitting 12-lead ECG shows wide, M-shaped P waves. Which of the following
admitting diagnoses could be responsible for this finding?
a. Mitral stenosis
b. Chronic pulmonary disease
c. Hypotension
d. Pericarditis
ANS: A
Wide, M-shaped P waves are seen in left atrial hypertrophy and are called P mitrale because
left atrial hypertrophy is often caused by mitral stenosis.
82. Identify the rhythm.

a. Junctional escape rhythm
b. Atrial fibrillation
c. Unifocal premature ventricular contractions
d. Ventricular tachycardia
ANS: B
The electrocardiographic tracing in atrial fibrillation is notable for an uneven atrial baseline
that lacks clearly defined P waves and instead shows rapid oscillations or fibrillatory wavelets
that vary in size, shape, and frequency. Junctional escape rhythm has a rate of 40 to 60
beats/min and regular rhythm but P waves maybe present or absent, inverted in lead II, PR
interval less than 0.12 sec, and QRS complex is 0.06 to 0.10 seconds. With premature
ventricular contractions, the QRS can manifest in an unlimited number of shapes or patterns.
If all of the ventricular ectopic beats look the same in a particular lead, they are called
unifocal, which means that they probably all result from the same irritable focus. Ventricular
tachycardia is caused by a ventricular pacing site firing at a rate of 100 times or more per
minute, usually maintained by a re-entry mechanism within the ventricular tissue. The
complexes are wide, and the rhythm may be slightly irregular, often accelerating as the
tachycardia continues.

ANS: A
Under normal conditions, the junction never has a chance to escape and depolarize the heart
because it is overridden by the sinus node. However, if the sinus node fails, the junctional
impulses can depolarize completely and pace the heart. In this strip, the ventricular rate is 38.
P waves are absent, and the QRS has a normal width.

ANS: C
When all of the ventricular ectopic beats look the same in a particular lead, they are called
unifocal, which is what is shown in this strip. This means that that they probably all result
from the same irritable focus.

ANS: D
Ventricular tachycardia is caused by a ventricular pacing site firing at a rate of 100 times or
more per minute, usually maintained by a re-entry mechanism within the ventricular tissue.
The complexes are wide, and the rhythm may be slightly irregular, often accelerating as the
tachycardia continues. In most cases, the sinus node is not affected, and it continues to
depolarize the atria on schedule. P waves can sometimes be seen on the electrocardiographic
tracing. They are not related to the QRS and may even appear to conduct a normal impulse to
the ventricles if their timing is just right.
a. Ventricular tachycardia
b. Ventricular fibrillation
c. Supraventricular tachycardia
d. Torsades de pointes
ANS: B
On an electrocardiogram, ventricular fibrillation appears as a continuous, undulating pattern
without clear P, QRS, or T waves.
MULTIPLE RESPONSE
1. Which of the following describe(s) S1, the first heart sound? (Select all that apply.)
a. It is associated with closure of the mitral and tricuspid valves.
b. It is a high-pitched sound.
c. It can be heard most clearly with the diaphragm of the stethoscope.
d. The best listening point is in the aortic area.
e. The “split” sound can best be detected in the tricuspid area.
ANS: A, B, C, E
S1 is the sound associated with mitral and tricuspid valve closure and is heard most clearly in
the mitral and tricuspid areas. S1 sounds are high pitched and heard best with the diaphragm of
the stethoscope.
2. Heart murmurs are characterized by which of the following criteria? (Select all that apply.)
a. Intensity
b. Location
c. Quality
d. Pitch
e. Pathologic cause
ANS: A, B, C, D
Murmurs are characterized by specific criteria: Timing is the place in the cardiac cycle
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dilatation, gain in conductivity, etc., indicate that some internal
change or reorganization takes place in the iron itself.
Such changes seem to indicate what are known as “allotropic”
modifications. More familiar examples of allotropic forms of
materials may be mentioned. Phosphorus, for example, may exist,
either as the “yellow” variety which is poisonous and so inflammable
that it must be kept constantly under water, or as the “red” variety
which is non-poisonous and non-inflammable. Too, there is carbon,
which may exist in any one of several forms such as amorphous
carbon (soot), graphite, and the diamond. It is believed that iron,
itself, exists in three allotropic states. These have been named
“alpha,” “beta” and “gamma” iron. We do not need to go into this
part of the great subject except to state that at ordinary temperatures
and up to Ar2, we have alpha iron, between Ar2 and Ar3, beta iron,
and above Ar3, gamma iron. Both beta and gamma iron are non-
magnetic, while alpha iron is strongly magnetic. In cooling through
Ar3, i.e., from gamma to beta iron, some rearrangement of its
molecules produces the dilatation or expansion and the change in
conductivity which was noted above.
From the fact that by chemical analysis any certain steel must have
the same composition in its hardened that it has in its unhardened
condition, it will readily be seen how futile it would be to expect
chemical analysis to give us complete information regarding it. Too,
tensile strength and the other usual physical tests can hardly tell us
all that we wish to know. Microscopic analysis or metallography,
however, shows us internal structure of properly prepared pieces of
either the hardened or unhardened alloy that we may see the actual
condition or grouping of the constituents. The view points given by
all three of these methods, chemical, physical and metallographical,
are, of course, much better than any one or two alone.
The Structures of Quenched and Unquenched
Steel
We saw that the lag or tardiness is greater the more rapid the
cooling. Along with this very great lag which is brought about by very
rapid cooling comes increasing slowness, i.e., less ability to catch up,
as the temperature is lowered. Hence quenching produces such a
wide lag and so slows the changes which should take place that they
do not take place at all, i.e., the structure which the piece had at the
higher temperatures cannot change but is set or fastened by the
quickness of the cooling.
Though no degree of suddenness is sufficient to set completely the
structure existing at very high temperatures, for our present
purposes we can say that by quenching in cold water we can freeze or
fix any structure. Then after we have quenched a piece of steel, it will
have when cold, the structure which corresponded with or resulted
from the temperature which it had at the moment before the
quenching.
If so, the microscope should give us aid.
By breaking off pieces of a quenched
piece and very carefully and slowly
grinding and polishing without heating
a surface which was an interior part we
find after etching that we can actually
see the kind of structure which
corresponded with the temperature
from which the piece was quenched.
Photomicrograph No. 80 shows the
appearance of a piece of hardened
carbon steel. Note the needle-like
structure under the microscope at
magnification of 400 diameters. This
structure is characteristic.
Illumination of the
Sample under the
Microscope The constituent, having this needle-
like appearance has been named
“martensite” in memory of a
distinguished European metallurgist, A. Martens. It is supposed to
be “beta” iron, much the hardest allotropic variety of iron, and to
hold in solution the carbon of the alloy, either as carbon alone or as
the extremely hard chemical compound, iron carbide, Fe3C.
Martensite, then, is the extremely hard structure, necessarily
containing considerable carbon or iron carbide in solution which
gives to our carbon tool steels their hardness and great usefulness.
Unhardened steels never look like this. Their appearance is shown
in photomicrographs Nos. 3b, 5, 22 and 24a.
In unhardened steels having less
than .90% of carbon we find two
constituents.
“Ferrite” is the name which has been
given to one, the soft and ductile
constituent, pure iron. With ordinary
etching the ferrite usually shows as
light-colored or white grains bounded
by black lines, which, if the patch is
large enough, give a fish-net No. 80. Martensite, the
appearance. It is soft and ductile like Constituent of
copper, for pure iron and pure copper Hardened Steel
are not so greatly different in
malleability and ductility as one might (Magnification 400
suppose. Diameters)
The darker and more or less
triangular patches at the corners of the
ferrite grains are “pearlite,” a name originating because of their
“pearly” appearance under the microscope. How this pearly
appearance comes about will be readily understood from
photomicrograph No. 23e which was taken at a magnification of 400
diameters. It is seen that it results from alternate black and white
layers.
Again we must give up the idea of any finality in the things we
learn or think we have learned. We just learned, for instance, that
ferrite usually was light or white in color. Well, in pearlite, as shown
in photomicrograph No. 23e, every other plate is of ferrite but they
are not the white but the black ones.
You may not have understood before
that color as shown under the
metallographic microscope depends
not so much upon actual color of the
material itself as upon its ability to
reflect light. For metallographic
observations it is necessary to have
very strong illumination. Usually the
powerful beam from an electric arc is
No. 23e. Pearlite at concentrated by means of condensing
Magnification of 400 lenses upon a thin disc of glass called
Diameters an oblique reflector which directs the
beam upon the polished and etched
specimen beneath the objective of the
microscope. Often a prism is used. The rays of light returning from
this highly illuminated “field” under observation return up through
the tube and eye piece of the microscope and can be focused upon a
small screen convenient for observation or upon the ground glass of
the attached camera by means of which the pictures are taken.
Unless the surface of the specimen being examined is perfectly plain
and level, not all of the vertical rays thrown down upon it will be
reflected back up through the tube and eye piece. Those portions of
the field which are absolutely at right angles to the vertical rays
appear at the eye piece or upon the screen as white or light-colored
portions, while those which, during the polishing or etching have
been dug or eaten away reflect the light imperfectly or in directions
other than up the tube of the microscope, wherefore such portions
show as darker or black sections.
The pearlite, then, is made up of little plates of soft ferrite
alternating with others of a very much harder constituent. The
harder plates are much less affected during polishing and etching
than are those of the softer ferrite, hence they stand out in relief and
reflect abundant rays of light, whereas the “dug-out” ferrite plates
reflect the light imperfectly or not at all and therefore appear as dark
lines.
These white, hard plates of the pearlite contain all of the carbon of
the low carbon alloys. They are this other constituent, “cementite,” so
named because it was first discovered in steel made by the
“cementation” process. It is a very hard and brittle substance, hard
enough to scratch glass. It is the chemical compound (Fe3C),
unvarying in composition as chemical compounds always are. It
consists of just three atoms of iron (93.4% by weight) and one of
carbon (6.6%).
Pearlite, therefore, is a sort of mechanical mixture of two separate
constituents, ferrite or pure iron, and this chemical compound,
carbide of iron, which is called cementite. Pearlite is common to all
unhardened steels whether of low, medium or high carbon content
and may be considered characteristic.
That we may understand clearly the structures of the annealed
steels, let us start with pure iron and gradually change it into higher
and higher carbon steels by gradual addition of carbon. Pages 328
and 329 show such a series.
Photomicrograph No. 99b is open-hearth iron which is entirely
made up of free ferrite. In No. 3b there is considerable pearlite, here
appearing black, though the sample of steel yet contains but .10% of
carbon. In No. 5, which is of a steel containing .30% of carbon, we
have more pearlite and in No. 22c with .50% carbon we have yet
more. Manifestly at this rate the comparative pearlite areas are
growing so that there will soon be room for no ferrite at all. In No.
23g this has occurred. This, the photomicrograph of a steel
containing .86% of carbon is one of the steels in which we found that
the point of recalescence, loss of magnetism, decrease in electrical
conductivity and rate of expansion take place all at the one point.
(Magnification 60 Diameters.)
Now as we go still farther on up in percentage of carbon content,
i.e. (beyond .86%, we have a white constituent beginning to appear
as cell walls around the grains of the pearlite and this increases with
increase of carbon until, with alloys having carbon around 3%, we
have a proportionately small amount of pearlite while the white areas
have so increased that it appears that the more or less round patches
of pearlite float in a lake of white. This white which appears first as
cell walls, and later in greater and greater quantity is free cementite.)
(Magnification 60 Diameters.)
Such are illustrated in
photomicrographs Nos. 24a, 36b
and 109 which contain 1.25%,
1.98% and 3.00% of carbon
respectively. While steels with
the typical white, free ferrite
areas are so soft that a needle-
point will plow furrows across
them, those with over 1.25% of
carbon have such excess of free
No. 99b. Carbonless Iron cementite that they are very hard
to scratch and too brittle to use
except for special purposes.
So during ordinary cooling
from the molten alloy or the
slower cooling of the steel during
the annealing process, the
martensitic structure breaks
down at the recalescent
temperature into pearlite and
ferrite (soft iron) if the carbon
content of the steel is lower than
about .90%, or pearlite and the
other and very hard constituent,
“cementite,” if the steel has more No. 3b. Steel with .1 Per Cent
than .90% of carbon. If the Carbon
carbon content happens to be
just .90%, or thereabouts, there
is exactly sufficient pearlite to make up the total area of the field
shown under the microscope.
Another constituent which is of great interest scientifically, though
not at all commercially, is “austenite.” By quenching very high
carbon steels from a very high temperature very suddenly and
completely, we can fasten the “austenite” structure, which exists only
at temperatures higher than martensite, i.e., austenite is our gamma
iron with the carbon of the alloy in solid solution, perhaps as iron
carbide, while martensite is
thought to be the beta iron solid
solution, perhaps with some
gamma iron mixed with it.
While ordinary quenching
fastens structures pretty well, it is
not usually quick enough to
prevent the austenite from
sliding along down into
martensite. However, carbon
discourages such slipping, so,
with high carbon to act as a
No. 5. Steel with .3 Per Cent brake, we can fasten some of it by
Carbon chilling very suddenly and
completely from a very high
temperature. Steels with 1.5% of
carbon and temperatures of
2000° F., or over, are usually
necessary to accomplish it.
However, austenite, after we
get it, is not as hard as martensite
and we have little use for it
commercially. As was stated
before, martensite is the useful
and proper structure for carbon
steel tools.
No. 22c. Steel with .5 Per Cent
Carbon
Tempering or
Drawing
“Tempering” is done to relieve
the intense brittleness of steel
after quenching to martensite.
While we dislike to sacrifice any
of the hardness, it pays to temper
or “toughen” the steel, as the
No. 23g. Steel with .9 Per Cent toolmaker calls it, by reheating it
Carbon to somewhere between 400° and
570° F.
The higher the temperature,
the freer and quicker is the
change from one structure to
another, as, for instance, the
austenite to martensite. At the
low drawing temperatures the
changes from martensite to the
pearlitic structure may be said to
just creep along. A second
quenching then fastens it at the
new structure which gives a trifle
less hard but a tougher steel. As No. 24a. Steel with 1.25 Per
you would guess, the microscope Cent Carbon
shows on these what we may
term a “transition” or “breaking-
down” appearance and structures not at all definite. These, of course,
give to the steels the various degrees of hardness and brittleness and
other qualities which are so desirable from the practical standpoint.
The production of these fine shades of temper by the practical tool
maker or blacksmith may almost be considered a fine art.
How and Why Do the
Steels Harden?
Now, from all of these facts,
what, shall we say, is the cause of
the hardening of steel?
The explanation most generally
accepted seems to be, that, of the
No. 36b. Steel with 2 Per Cent three allotropic forms of iron the
Carbon gamma and beta varieties are
very much harder than alpha
iro
n,
whi
ch
is
the
one
whi
ch
we
hav
e in No. 109. White Cast Iron with
Austenite (White) and an 3 Per Cent Carbon
Martensite (Dark) nea
Magnified 1,000 Times led
Their Actual Size steel at
ordinary
temperat
ures, and, of the two, the beta is harder
than the gamma variety. It is thought
also, that carbon, perhaps as carbide of
iron, is held in solution in gamma or
beta iron after the quenching, and
increases the hardness proportionately No. 73. Annealed Steel
with increase of the carbon content of has Fine Grain
the steel. While this carbon or iron-
carbide solid solution may and (Magnification 70
probably does itself confer additional Diameters)
hardness to the steel, its main function
is to retard or slow down the change
from gamma into beta and alpha iron, which change in carbonless
iron and low carbon steels is so insistent and extremely rapid that
not even the most severe quenching, as in ice-water or liquid air, can
prevent or stop it. Not only do we fail to get austenite, which is
gamma iron, until we get 1% or more of carbon present and quench
from very high to very low temperatures, but we cannot even stop the
transition at beta iron, the next lower allotropic variety until we have
at least .30% of carbon, and, for serviceable hardening fully .60% of
carbon in the steel.
Fortunately for us, this beta form of iron is the one we want, for it
is harder and more useful than the gamma form.
Our most serviceable constituent, martensite, then, is a solid
solution of carbon or iron carbide in beta iron. It is magnetic but this
probably results from its containing some alpha iron through
incomplete stoppage of the change by the quenching.
As has been stated, “tempering,” which means careful reheating to
400° F., 500° F., or 600° F., allows the slight “slipping” of enough of
the beta solution, always eager at temperatures below the point of
recalescence to return to alpha condition, to relieve the excessive
brittleness of the hardened steel.
Annealing is the complete release of
beta iron and the “trapped” carbon
which allows of their return to the
normal condition of pearlite with alpha
iron. To accomplish this, the hardened
steel has to be heated above its point of
recalescence and cooled more or less
slowly. Different speeds of cooling give
different grain size, structures and
No. 72. The “Sorbite” physical properties.
Grain Is Produced by
Cooling in a Blast of Air This explanation of hardening,
after Annealing. It Gives which is known as the “allotropic”
Good Wearing theory, is not universally accepted,
Properties conclusive evidence being lacking at
more than one point.
(Magnification 70 It must be stated also that some who
Diameters) hold the “allotropic theory” of
hardening doubt the existence of beta
iron. These contend that the so-called
beta iron and martensite are only decomposition or transition forms
of gamma iron and austenite.
Two or three other theories have been more or less strongly
advocated but these also suffer from lack of evidence. The one which
perhaps ranks next in number of advocates is the “carbon theory.” Its
supporters contend that by quenching, alpha iron is made to hold
carbon or iron carbide in solid solution and that it is this solution of
carbon or carbide which gives to the steel hardness in proportion to
its carbon content. Others hold that the great density or strain under
which quenched steel exists accounts for the hardness.
Like many other great problems of the universe this one is not yet
conclusively or satisfactorily solved, so reluctantly does Nature yield
her secrets. But while it may not have explained all of the “whys” and
“wherefores,” the work which investigators have done has brought
about great improvement in methods of manufacture and quality of
the alloys which are making our civilization greater and this Age
more wonderful.
CHAPTER XXIII
THE EQUILIBRIUM DIAGRAM OF THE
IRON-CARBON ALLOYS
It was a great day for metallurgy when it was discovered that

molten mixtures were governed by the same natural laws which
govern our ordinary liquid solutions. Probably it was because most
metallic alloys are solid at ordinary temperatures and liquid only at
very high ones that for so long a time we failed to suspect their
similarity.
If a sensitive pyrometer is inserted into an ordinary solution or a
molten alloy which is being gradually cooled, it indicates the first
instant that solidification (freezing) begins as well as the termination
of the freezing period. Unlike the freezing of water or a pure metal,
complete solidification ordinarily does not take place at a definite
single temperature but over a greater or lesser range of temperature.
By taking such upper and lower freezing-point measurements for
many different percentage compositions of a binary (two metal)
alloy, for instance, curves can be plotted which show accurately the
habits of any and all of the possible combinations (i.e., alloys) of
those two metals.
Such are called “freezing-point” curves, and, as we shall see later
on, a study of them will give us much valuable and interesting
information.
Such curves have been constructed for a great many alloys since
the discovery of the analogy between their behavior and that of
aqueous solutions led us to study alloys after the manner which
physical chemists found so satisfactory for the study of ordinary
solutions. Since the study of binary or two metal alloys is often very
difficult, it can be readily understood why the determination and
interpretation of the curves of alloys which contain three, four or
more metals is a very much more serious matter. Much of it has to be
done by methods which are long and tedious, such as quenching and
microscopic study of innumerable specimens taken during the
freezing and subsequent cooling of various alloys of each series. The
value of the results depends upon the skill, devotion and clear
sightedness of those who carry out the work.
The Freezing-Point Curves of the Iron-Carbon Alloys
The “freezing-point” and “decomposition” curves of the iron-

carbon series of alloys have been brought to their present stage of
development after something like twenty years of labor by
investigators in many lands. If we look at the diagram on page 345,
we note at once that the curves are quite complicated. Even yet they
are not complete for all percentage combinations of iron and carbon,
and those who have given the most time and study to the subject
have not yet been able to interpret with entire satisfaction to all
concerned all of the discoveries so far made.
Without endeavoring to take up in detail the technique of the
manner of their production, which would be unprofitable for us
without a great deal more of preliminary study than we have time
and space to give, we will at once examine the freezing curves of the
iron-carbon alloys as now developed. The works named on page 354
as references for Chapters XXII and XXIII may be consulted for the
various types and methods of construction and for explanation of
freezing curves by those who desire to study them.
Referring to the freezing-point diagram on page 336, the upper or
broad V-shaped line, ABC, indicates the temperatures at which the
alloys of various percentages of iron and carbon begin to freeze, and
the lower one, AED, the temperatures at which the freezing of these
alloys ends. From the diagram it is readily seen that pure iron
(100%), has a very high freezing-point and solidifies at once. Iron
which contains about 2% of carbon begins to freeze at a much lower
temperature and has a long period of solidification, while iron with
4.3% of carbon has the lowest freezing-point of the series with an
extremely short solidification period or range.
Since we have been unable to go sufficiently into the methods and
technique of freezing-curve construction to be able to understand
their general classification, we must accept the statement that the
curve of the iron-carbon series is really a double one. The part of it
that lies to the left of the dividing line UV of the diagram on page
336, is of the type exhibited by liquids which freeze from “liquid
solutions” into what are known as “solid solutions,” which by aid of
the microscope are found to be homogeneous mixtures of crystals.
On the other hand, alloys which lie to the right of UV, are of the type
which form “eutectics.” This will be described later. This dividing line
UV, which occurs at about 1.7% of carbon, divides the iron-carbon
alloys into these two natural divisions. It was the basis for calling
those having 2% of carbon or less, “steels,” and those with over this
amount, “cast irons.”
Molten iron is so greedy for carbon, that, when it can get it, it
readily holds in solution from 7% to 10% of this element. But solid
(frozen) iron cannot retain anything like this amount. As we learned
in the last chapter, gamma iron is the only variety which can exist
above our lines of loss of conductivity, magnetism and recalescence,
i. e., Ar3, Ar3·2, etc. It is, too, the only variety of solid iron which is
able to retain carbon in solution, and it can retain only about 1.7% of
it.
So when molten steel containing 1.5% of carbon, say, cools until it
reaches the temperature represented by the line, AB, which, at its
intersection with the 1.5% carbon line would be at about 2582° F.,
particles or crystals begin to freeze out and float in the molten alloy.
As the temperature falls, more crystals separate until, when the
temperature determined by intersection of the 1.5% carbon line with
the lower freezing curve, AE, is reached, the last of the now mushy
alloy solidifies.
Alloys of all other compositions below 1.7% of carbon do just this
way except that the temperatures at which freezing begins and ends
are different and distinctive for each composition.[10] Upon freezing,
every one of them retains in “solid solution” in the “gamma” iron
whatever carbon it had in the liquid or molten solution. But, as
stated above, it can not be over the 1.7% limit.
10. Temperatures of beginning and end of freezing may always be ascertained
by locating on the freezing-point diagram the points at which the vertical line
representing the desired composition intersects and crosses the lines of the
freezing-point curves—in these cases, AB and AE.
Of the iron-carbon alloys of compositions lying to the right of the
line UV, we find the case to be different, for each one of them has
more than the 1.7% of carbon which is the maximum amount which
“gamma” iron can retain. Now the lowest temperature at which any
iron-carbon alloy can exist without freezing is slightly above 2066°
F., and there is but one composition—95.7% of iron and 4.3% of
carbon—which can survive until this low temperature is reached. A
content of 4.3% of carbon then, is the greatest and also the least
concentration which Nature will allow to remain molten down to this
minimum temperature. This 4.3% carbon composition which is the
lowest melting, i.e., the easiest melted alloy, is called the “eutectic”
alloy from Greek words which mean “well melting.” This eutectic
composition may be said to divide or rather subdivide this group of
alloys into two groups, those containing between 1.7% and 4.3% of
carbon, and those which have 4.3% and over.
As stated before, freezing is not an instantaneous but a progressive
process. During the freezing period of any of these alloys which have
over 1.7% of carbon the still liquid portion which remains after
freezing begins to become smaller and smaller in quantity as freezing
progresses just as it did in alloys of the “solid solution” group. And as
Nature allows a concentration of 4.3% of carbon as the highest
concentration at the minimum temperature the very last of the
remaining liquid of every alloy eventually gets to this eutectic
composition just before the alloy freezes. Those to the left of the
eutectic or exact 4.3% composition do so by the gradual freezing out
of iron containing the maximum or 1.7% of carbon, i.e., iron is taken
out faster than carbon, hence there is gradual concentration of
carbon in the remaining liquid. This goes on until 4.3% is reached.
The compositions to the right of the line WX throw out the chemical
compound, Fe3C, which contains 6.6% of carbon, whereby carbon is
eliminated faster than iron and the desired 4.3% carbon alloy is
arrived at from the other direction.
To illustrate, take, say, the composition represented by the vertical
line at 3% carbon and 97% iron. As the molten alloy cools it reaches
the temperature 2330° F., at which temperature the vertical line
representing the 3% carbon composition cuts the line AB. Here the
alloy begins to freeze by the separation of small crystals of solidifying
iron containing definite amounts of carbon.[11] But as the carbon thus
taken along by the freezing crystals of iron is always less than 1.7%, a
proportionally greater amount of iron than carbon is removed from
the unfrozen part of the alloy and the remaining liquid or unfrozen
part, therefore, is left with slightly more than the 3% of carbon with
which it started.
11. The percentages of carbon carried by the particles of iron freezing at any
particular temperature of the solidification range may be determined from the
diagram but the works named in the reference list should be consulted for method
and explanation.
This we must now consider another alloy with a lower freezing-
point, the reason being, of course, its higher carbon content. At the
next lower temperature, more iron containing carbon is frozen out
and the remaining liquid is again left a little higher in carbon than
before. In this way the continually diminishing amount of remaining
liquid keeps concentrating, forming thereby a continuous succession
of alloys of higher and higher carbon content as the temperature
continuously drops.
Eventually, of course, the concentration of this remaining liquor
becomes 4.3% of carbon just before completion of the freezing at
2066° F.
Now with alloys containing more
than 4.3% of carbon, almost the
opposite occurs. Let us choose the one
having 5% carbon and 95% of iron.
This molten alloy cools until at 2215°
F., small crystals begin to freeze and
form in the molten mass. But, as the
liquid already has more than the
favored 4.3% of carbon, it is not free
iron which freezes out, but instead, the The “Eutectic,” the Part
chemical compound, Fe3C, which of the Alloy Which
contains 6.6% of carbon. This, of Solidifies Last
course, takes out carbon proportionally
faster than iron, hence, at each very (Magnification 700
slightly lower temperature, the liquid Diameters)
which remains unfrozen contains just a
little less of carbon than did its
predecessor. So the constantly decreasing amount of remaining
liquid progresses through a succession of compositions each
containing just a little less of carbon than the previous one, and
eventually, just before freezing we get back to the mixture which
contains 4.3% of carbon. Of course there is left unfrozen by this time
only a very small amount of the alloy and it is this which has the
composition stated.
The “Eutectic”
Now, having just the composition which she wants, whether
arrived at from alloys lower or higher than 4.3% in carbon, Nature
lets this composition freeze at once in thin alternating plates which
lie side by side about and among the earlier frozen crystals of the
alloy. The appearance of this typical eutectic formation under the
microscope is shown on page 341.
Had we chosen the 4.3% alloy itself, neither any of the solid
solution of carbon in iron nor the chemical compound, Fe3C, would
have frozen out, but the whole mass would have remained liquid
down to 2066° F., where the whole would have solidified at once in
the plate-like eutectic formation just described.
To sum up, iron-carbon alloys which contain less than 1.7% of
carbon, in other words, the steels, freeze as solid solutions of carbon
in gamma iron. This, of course, is the metallographic constituent
which is called austenite. It is not of a definite composition as it
contains whatever carbon is available up to 1.7%. Alloys containing
between 1.7% and 4.3% of carbon gradually freeze out this solid
solution, austenite, more and more being formed in the freezing alloy
until, upon arriving at a concentration of 4.3% of carbon for the
remaining liquid, the latter, too, freezes as a eutectic of alternating
plates of more of this same constituent, austenite, and the carbide of
iron, Fe3C, about and among the crystals of the previously formed
austenite. From alloys which contain more than 4.3% of carbon, iron
carbide, Fe3C, gradually freezes out as the temperature falls, until, at
concentration of 4.3% of carbon, the eutectic of remaining carbide
and austenite forms about and among the earlier frozen carbide
crystals, always at the same temperature, 2066° F., no matter what
the original composition of the alloy.
Upon reheating, the constituents melt in reverse order, the
eutectic liquifying first at 2066° F., the remainder of the alloy
gradually becoming liquid between this temperature and the
temperature at which the first freezing began during cooling.
Transformations and Decompositions
So far we have considered only the freezing of the iron-carbon
alloys from the molten to the solid condition. Now what happens to
them at temperatures below 2066° F.? Do they remain as we left
them above, until and after they are fully cold?
We must now combine the little sketch which we made on page
319, by plotting the points, Ar1, Ar2 and Ar3, with the freezing-point
diagram which we have just now been considering. You remember
that we found all sorts of things happening to our 0% to 1.7% alloys—
the steels—at temperatures around 1290° F., 1395° F., and 1650° F.
Similarly, a great deal happens to these other alloys, as they cool
from their solidifying temperatures downward.
The Freezing-Point and Critical-Point Curves Make up the Equilibrium
Diagram
But for the moment considering only the steels, i.e., the third of
the diagram to the left of the 1.7% carbon line, we remember that
upon completion of the solidification of any alloy, we had only a
frozen solution of all the carbon in iron. Now in the bottom part of
this left third of our diagram on page 344, the line GOSE does not
look so very much different than the freezing line, ABC, does it? It
resembles it not only in appearance but also in actual experience. But
in this case it represents not a freezing from liquid to solid but a
decomposition, or better perhaps, a transformation. The solid
solutions or alloys which contain less than .9% of carbon give up
their excess of pure iron upon getting down to temperatures lying
along the line GOS, by gradual decomposition of the austenite. In

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