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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.

11. 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 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.

12. 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. 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)
a. acute mitral regurgitation.
b. aortic insufficiency.
c. chronic mitral regurgitation.
d. pericardial friction rub.
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
a. acute mitral regurgitation.
b. aortic insufficiency.
c. chronic mitral regurgitation.
d. pericardial friction rub.
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.
d. pericardial friction rub.
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.
Another random document with
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Aird in London; but I suppose they were afraid something might be
sprung on them and they wanted their references handy.
“Peter Hay, I suspect, they fastened on as being the most
dangerous witness. Probably Aird made an appointment for the
claimant, and they called at the poor old chap's cottage at night. He
evidently refused to have anything to do with them; and he was too
dangerous to leave alive; so they killed him. Then they went after the
diary—probably Aird knew about that, or else Peter may have let the
information out somehow—and they took Hay's keys to get into
Foxhills. The silver plant was an obvious muddle. They hadn't Cargill
at the back of them at the time, and they made that mistake on the
spur of the moment.
“By that time they'd got in touch with Miss Fordingbridge. Aird
would know all about her spiritualistic leanings, and they played on
that string. But soon they learned they were up against Paul
Fordingbridge; and they began to see that it would be easiest to put
him out of their road.
“Meanwhile Staveley took it into his head to work on his own by
trying to blackmail the Fleetwoods. And you know what came of that.
The rest of the gang thought they could kill two birds with one stone
—at least, the gang minus Billingford, for really I don't think
Billingford was much more than a tool.
“Now, inspector, how far does that square with all the confidences
you extracted last night from that precious pair of scoundrels? Do I
get a box of chocolates or only a clay pipe in this competition?”
The inspector made no attempt to suppress the admiration in his
tone.
“It's wonderfully accurate, sir. You're right on every point of
importance—even down to what happened in the war.”
“That's a relief,” the chief constable admitted with a laugh. “I was
rather afraid that I'd

. . . Summed it so well that it came to far more

Than the witnesses ever had said!

And now I think I'll go back to the hotel and try to make my peace
with the Fleetwoods. I like them, and I'd hate to leave a false
impression of my character on their minds. Care to come along,
squire?”

THE END
 Transcriber’s Note
This transcription follows the text of the Grosset & Dunlap edition
published in 1928. The following alterations have been made to
correct what are believed to be unambiguous printer's errors.

“Laurent-Desrousseux” has been changed to “Laurent-

Desrousseaux” (Ch. XI).
“tha” has been changed to “that” (Ch. XI).
“Stavely” has been changed to “Staveley” (Ch. XVII).
“coudn't” has been changed to “couldn't” (Ch. XVII).
 *** END OF THE PROJECT GUTENBERG EBOOK MYSTERY AT
LYNDEN SANDS ***

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