CARDIAC SURGERY CSC EXAM QUESTIONS WITH
CORRECT ANSWERS LATEST UPDATE WITH
RATIONALES
The nurse caring for the post operative cardiac surgery patient recognizes the following as
potential contributors to post-operative vasodilation that can cause hypotension:
A. Cooling that occurs while on cardiopulmonary bypass, and use of vasodilators post op.
B. Use of norepinephrine or dopamine to support BP immediately post-op.
C. Inflammatory response due to CPB and use of norepinephrine to support BP
D. Rewarming that occurs after return to the ICU, and the inflammatory response to use of
cardiopulmonary bypass during surgery --CORRECT ANSWER--D. Intraoperative cooling
results in vasoconstriction; rewarming after surgery causes vasodilation and can contribute to
hypotension if volume administration is inadequate for the increased size of the vascular
space caused by vasodilation. The use of CPB stimulates an inflammatory response that
results in vasodilation that contributes to hypotension.
Norepinephrine and dopamine cause peripheral vasoconstriction, not vasodilation.
A characteristic of a fast-track pathway after CABG would include:
A. anticipated discharge between post-op days 7 and 8.
B. a defined medication strategy to prevent postoperative atrial fibrillation.
C. liberal use of opioid medications to increase patient comfort during the ventilator weaning
process.
D. extubation by the third post-op day --CORRECT ANSWER--C. Low-risk patients can be
selected for fast tracking after CABG. These patients are targeted for early extubation, early
ambulation, and early discharge. Patients who are fast tracked receive sedation and analgesia
to allow for early extubation. Pharmacological strategies to prevent atrial fibrillation and
early phase I cardiac rehabilitation are also key components of fast tracking.
Page | 1
,You are caring for an early post-operative CABG patient who remains hypotensive despite
treatment with adequate fluid administration and an alpha constricting agent. You know that
one potential post-operative complication responsible for this persistent hypotension could
be:
A. Acute kidney injury.
B. Acute saphenous vein graft closure.
C. Acute respiratory distress syndrome (ARDS).
D. Vasoplegia. --CORRECT ANSWER--D. Vasoplegia is a form of vasodilatory shock that
can occur after separation from CPB. It is characterized by significant hypotension despite
adequate fluid resuscitation, low SVR(due to vasodilation), and is resistant to vasopressors.
When vasopressors (norepinephrine, epinephrine, high dose dopamine, or vasopressin) are
not able to maintain blood pressure in the presence of adequate filling pressures, then
vasoplegia may be present. There are several theories behind the cause of vasoplegia,
including leukocyte activation and the release of pro-inflammatory mediators during
cardiopulmonary bypass, and vasoplegia has been associated with long-term use of ACE
inhibitors, calcium channel blockers, amiodarone, and heparin. Patients with EF <35%, heart
failure and diabetes are at higher risk. Vasoplegia can also be seen after OPCAB.
Acute respiratory distress syndrome (ARDS) and acute kidney failure can both be
complications in the cardiac surgery patient, but do not typically occur early in the post-
operative course and are not necessarily associated with hypotension and failure to respond to
vasopressors.
An acute saphenous vein occlusion can occur as a result of persistent hypotension. The most
direct clinical signs of acute saphenous vein graft closure would be those of ischemia.
Mediastinal drainage in the following amount meets criteria for re-exploration:
A. > 300 ml/hr for 2-3 hours.
B. > 200 ml/hr for 4 hours.
C. > 400 ml to 500 ml for 1 hour.
Page | 2
,D. All of the above. --CORRECT ANSWER--D. Chest tube drainage criteria for surgical re-
exploration:
• > 400 to 500 ml for 1 hour
• > 300 ml/hr for 2 to 3 hours
• > 200 ml/hr for 4 hours
• Acute onset of bleeding >300 ml/hr after period of stable and minimal bleeding
Patients with prolonged CPB times are likely to experience:
A. An increased likelihood of early extubation.
B. An increase in coagulopathies.
C. A decrease in total body fluid due to dehydration.
D. A decrease in chest tube drainage. --CORRECT ANSWER--B. Coagulopathy is present to
some degree with all CPB. During CPB, blood contacts the non-physiological surfaces of the
bypass circuit and an inflammatory response is initiated. A coagulopathy can develop from
activation of platelets and the fibrinolytic system. Clotting factors, platelets, and RBCs are
diluted during CPB. A longer pump time is associated with increased coagulopathies.
Postoperatively, patients have an increased amount of total body fluid due to priming of the
CPB pump and administration of fluids during surgery. Extra volume is given to the patient
during cardiopulmonary bypass to assure adequate circulating volume through the
cardiopulmonary circuit.
Long pump times are associated with increased bleeding and therefore increased chest tube
drainage, and prolongs time to extubation.
Coagulopathy is present to some degree with all CPB. During CPB, blood contacts the non-
physiological surfaces of the bypass circuit and an inflammatory response is initiated. A
coagulopathy can develop from activation of platelets and the fibrinolytic system. Clotting
factors, platelets, and RBCs are diluted during CPB. A longer pump time is associated with
increased coagulopathies.
Page | 3
, Postoperatively, patients have an increased amount of total body fluid due to priming of the
CPB pump and administration of fluids during surgery. Extra volume is given to the patient
during cardiopulmonary bypass to assure adequate circulating volume through the
cardiopulmonary circuit.
A. Long pump times are associated with increased bleeding and therefore increased chest
tube drainage, and prolongs time to extubation.
B. The patient is excessively dry from the hemoconcentration that occurs during
cardiopulmonary bypass.
C. The patien --CORRECT ANSWER--D. Failure of fluid challenges to raise preload may
indicate the presence of capillary leak and fluid shifting into the interstitial space. Patients
with longer CPB times are at greater risk for capillary leak. In patients with capillary leak, a
large amount of fluid is required to maintain adequate circulating volume. Administration of
large amounts of volume also increases the interstitial volume. Inotropes and vasopressors
may also be needed for hemodynamic support in the patient with capillary leak.
Vasoconstriction from hypothermia results in an increase in preload not a decrease. Venous
vasodilation will result in decreased preload.
Cardiopulmonary bypass results in hemodilution, not hemoconcentration. Extra volume is
given to the patient during cardiopulmonary bypass to assure adequate circulating volume
through the cardiopulmonary circuit.
The first line strategy to maintain an adequate cardiac index in the immediate postoperative
period includes:
A. Administering a vasodilator.
B. Administering a vasopressor.
C. Optimizing pre-load with volume administration.
D. Administering an inotrope. --CORRECT ANSWER--C. Cardiac index (CI) is dependent
on HR, preload, afterload and contractility. Preload must be adequate before an inotrope or a
vasopressor will work. 'You have to fill the tank before you step on the gas.' Volume
administration is usually the first therapy when CI is low unless preload indicators (CVP,
Page | 4
CORRECT ANSWERS LATEST UPDATE WITH
RATIONALES
The nurse caring for the post operative cardiac surgery patient recognizes the following as
potential contributors to post-operative vasodilation that can cause hypotension:
A. Cooling that occurs while on cardiopulmonary bypass, and use of vasodilators post op.
B. Use of norepinephrine or dopamine to support BP immediately post-op.
C. Inflammatory response due to CPB and use of norepinephrine to support BP
D. Rewarming that occurs after return to the ICU, and the inflammatory response to use of
cardiopulmonary bypass during surgery --CORRECT ANSWER--D. Intraoperative cooling
results in vasoconstriction; rewarming after surgery causes vasodilation and can contribute to
hypotension if volume administration is inadequate for the increased size of the vascular
space caused by vasodilation. The use of CPB stimulates an inflammatory response that
results in vasodilation that contributes to hypotension.
Norepinephrine and dopamine cause peripheral vasoconstriction, not vasodilation.
A characteristic of a fast-track pathway after CABG would include:
A. anticipated discharge between post-op days 7 and 8.
B. a defined medication strategy to prevent postoperative atrial fibrillation.
C. liberal use of opioid medications to increase patient comfort during the ventilator weaning
process.
D. extubation by the third post-op day --CORRECT ANSWER--C. Low-risk patients can be
selected for fast tracking after CABG. These patients are targeted for early extubation, early
ambulation, and early discharge. Patients who are fast tracked receive sedation and analgesia
to allow for early extubation. Pharmacological strategies to prevent atrial fibrillation and
early phase I cardiac rehabilitation are also key components of fast tracking.
Page | 1
,You are caring for an early post-operative CABG patient who remains hypotensive despite
treatment with adequate fluid administration and an alpha constricting agent. You know that
one potential post-operative complication responsible for this persistent hypotension could
be:
A. Acute kidney injury.
B. Acute saphenous vein graft closure.
C. Acute respiratory distress syndrome (ARDS).
D. Vasoplegia. --CORRECT ANSWER--D. Vasoplegia is a form of vasodilatory shock that
can occur after separation from CPB. It is characterized by significant hypotension despite
adequate fluid resuscitation, low SVR(due to vasodilation), and is resistant to vasopressors.
When vasopressors (norepinephrine, epinephrine, high dose dopamine, or vasopressin) are
not able to maintain blood pressure in the presence of adequate filling pressures, then
vasoplegia may be present. There are several theories behind the cause of vasoplegia,
including leukocyte activation and the release of pro-inflammatory mediators during
cardiopulmonary bypass, and vasoplegia has been associated with long-term use of ACE
inhibitors, calcium channel blockers, amiodarone, and heparin. Patients with EF <35%, heart
failure and diabetes are at higher risk. Vasoplegia can also be seen after OPCAB.
Acute respiratory distress syndrome (ARDS) and acute kidney failure can both be
complications in the cardiac surgery patient, but do not typically occur early in the post-
operative course and are not necessarily associated with hypotension and failure to respond to
vasopressors.
An acute saphenous vein occlusion can occur as a result of persistent hypotension. The most
direct clinical signs of acute saphenous vein graft closure would be those of ischemia.
Mediastinal drainage in the following amount meets criteria for re-exploration:
A. > 300 ml/hr for 2-3 hours.
B. > 200 ml/hr for 4 hours.
C. > 400 ml to 500 ml for 1 hour.
Page | 2
,D. All of the above. --CORRECT ANSWER--D. Chest tube drainage criteria for surgical re-
exploration:
• > 400 to 500 ml for 1 hour
• > 300 ml/hr for 2 to 3 hours
• > 200 ml/hr for 4 hours
• Acute onset of bleeding >300 ml/hr after period of stable and minimal bleeding
Patients with prolonged CPB times are likely to experience:
A. An increased likelihood of early extubation.
B. An increase in coagulopathies.
C. A decrease in total body fluid due to dehydration.
D. A decrease in chest tube drainage. --CORRECT ANSWER--B. Coagulopathy is present to
some degree with all CPB. During CPB, blood contacts the non-physiological surfaces of the
bypass circuit and an inflammatory response is initiated. A coagulopathy can develop from
activation of platelets and the fibrinolytic system. Clotting factors, platelets, and RBCs are
diluted during CPB. A longer pump time is associated with increased coagulopathies.
Postoperatively, patients have an increased amount of total body fluid due to priming of the
CPB pump and administration of fluids during surgery. Extra volume is given to the patient
during cardiopulmonary bypass to assure adequate circulating volume through the
cardiopulmonary circuit.
Long pump times are associated with increased bleeding and therefore increased chest tube
drainage, and prolongs time to extubation.
Coagulopathy is present to some degree with all CPB. During CPB, blood contacts the non-
physiological surfaces of the bypass circuit and an inflammatory response is initiated. A
coagulopathy can develop from activation of platelets and the fibrinolytic system. Clotting
factors, platelets, and RBCs are diluted during CPB. A longer pump time is associated with
increased coagulopathies.
Page | 3
, Postoperatively, patients have an increased amount of total body fluid due to priming of the
CPB pump and administration of fluids during surgery. Extra volume is given to the patient
during cardiopulmonary bypass to assure adequate circulating volume through the
cardiopulmonary circuit.
A. Long pump times are associated with increased bleeding and therefore increased chest
tube drainage, and prolongs time to extubation.
B. The patient is excessively dry from the hemoconcentration that occurs during
cardiopulmonary bypass.
C. The patien --CORRECT ANSWER--D. Failure of fluid challenges to raise preload may
indicate the presence of capillary leak and fluid shifting into the interstitial space. Patients
with longer CPB times are at greater risk for capillary leak. In patients with capillary leak, a
large amount of fluid is required to maintain adequate circulating volume. Administration of
large amounts of volume also increases the interstitial volume. Inotropes and vasopressors
may also be needed for hemodynamic support in the patient with capillary leak.
Vasoconstriction from hypothermia results in an increase in preload not a decrease. Venous
vasodilation will result in decreased preload.
Cardiopulmonary bypass results in hemodilution, not hemoconcentration. Extra volume is
given to the patient during cardiopulmonary bypass to assure adequate circulating volume
through the cardiopulmonary circuit.
The first line strategy to maintain an adequate cardiac index in the immediate postoperative
period includes:
A. Administering a vasodilator.
B. Administering a vasopressor.
C. Optimizing pre-load with volume administration.
D. Administering an inotrope. --CORRECT ANSWER--C. Cardiac index (CI) is dependent
on HR, preload, afterload and contractility. Preload must be adequate before an inotrope or a
vasopressor will work. 'You have to fill the tank before you step on the gas.' Volume
administration is usually the first therapy when CI is low unless preload indicators (CVP,
Page | 4
