AACN CSC EXAM QUESTIONS AND
CORRECT SOLUTIONS|CARDIAC
SURGERY
CERTIFICATION AACN EXAM PREP
WITH RATIONALE
Which of the following patients is at highest risk for neurological complications after CABG?
A. A 63-year- old patient with a BMI of 30 undergoing OPCAB
B. A 85-year-old patient with an atherosclerotic aorta undergoing CPB
C. A previously healthy 50-year-old woman undergoing CPB
D. A 67-year-old man having a MIDCAB to the LAD with no known history of hypertension -
✔✔✔ Correct Answer > B. Severe atherosclerosis of the aorta, advanced age, use of CPB, aortic
cross-clamping, diabetes, hypertension, female sex, and history of stroke place patients at high risk for
neurological complications following cardiac surgery. Other factors contributing to neurological
complications include alcohol abuse, heart failure, arrhythmias, and hyperglycemia.
The nurse caring for the post operative cardiac surgery patient recognizes the following as potential
contributors to postoperative 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
Page 1 of 163
,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. Lowrisk 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.
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.
Page 2 of 163
,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.
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.
Page 3 of 163
, 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.
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.
Page 4 of 163
CORRECT SOLUTIONS|CARDIAC
SURGERY
CERTIFICATION AACN EXAM PREP
WITH RATIONALE
Which of the following patients is at highest risk for neurological complications after CABG?
A. A 63-year- old patient with a BMI of 30 undergoing OPCAB
B. A 85-year-old patient with an atherosclerotic aorta undergoing CPB
C. A previously healthy 50-year-old woman undergoing CPB
D. A 67-year-old man having a MIDCAB to the LAD with no known history of hypertension -
✔✔✔ Correct Answer > B. Severe atherosclerosis of the aorta, advanced age, use of CPB, aortic
cross-clamping, diabetes, hypertension, female sex, and history of stroke place patients at high risk for
neurological complications following cardiac surgery. Other factors contributing to neurological
complications include alcohol abuse, heart failure, arrhythmias, and hyperglycemia.
The nurse caring for the post operative cardiac surgery patient recognizes the following as potential
contributors to postoperative 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
Page 1 of 163
,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. Lowrisk 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.
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.
Page 2 of 163
,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.
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.
Page 3 of 163
, 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.
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.
Page 4 of 163
