ECC- Final Exam with Accurate
Solutions
What would you do if this was occurring with a transcutaneous pacemaker? - ANS-
Adjust the sensitivty
A pt with ST-elevation myocardial infarction (STEMI) suddenly develops a 3rd degree
heart block with a rate of 38 bpm. BP is 62/38. Skin is cool, moist, and pale. After
ensuring a patent airway and adequate ventilation , the nurses priority intervention
would be the: - ANS-Anticipation of transcutaneous pacemaker
A pt in hypertensive crisis has an intial BP of 220/120. An hour after initiating treatment,
the pts blood pressure is 170/108. What should the nurse report during interdisciplinary
rounds? - ANS-Blood pressure decreased an ideal amount
A newly admitted develops positive JVD, HR 168, BP 84/78, and muffled heart tones.
What is your assessment of the situation - ANS-Cardiac tamponade
Which of the following represents right heart failure? - ANS-Positive jugular vein
distention, peripheral edema, S3 heart sound
A pt has heart failure. What education will you provide upon discharge ? - ANS-1500
mg/day sodium diet
Daily weights
Which intervention should be performed first for the above rhythm ? - ANS-Defibrillation
Which of the following are symptoms of aortic stenosis? - ANS-Pulmonary edema
The ECG monitor indicates a patient is in ventricular tachycardia. The patient is awake,
alert, anxious, and complains of chest pain. Vitals: HR 190, BP 80/40, Respirations 24,
O2 sat 92% on 2 liters nasal cannula. Which of the following interventions should the
nurse anticipate? - ANS-Synchronized cardioversion
Which 2 of the following would be indicative of dilated cardiomyopathy ? - ANS-Bilateral
lower extremity edema
15% ejection fraction (EF)
Which of the following can cause acute respiratory distress syndrome (ARDS) select 2
answers - ANS-Sepsis
, Aspiration of gastric contents
A patient with sepsis has become increasingly hypoxia despite titrating oxygen from 4L
NC to a non-rebreather throughout the morning. The chest X-ray shows diffuse bilateral
opacities and crackles are heard on auscultation. Which of the following conditions is
most likely based on these findings? - ANS-Acute respiratory distress syndrome
(ARDS)
Which of the following are contraindications for noninvasive positive pressure ventilation
(NPPV) select 4 answers - ANS-GCS of 6
Uncontrolled vomiting
Resp rate of 4 (agonal)
Bilateral wrists restraints
Which type of the following shock states would benefit most from dobutamine? - ANS-
Cardiogenic
A post op open aortic aneurysm repair patient has vitals: HR:130, BP: 82/70, RR:28,
O2: 91% 4L via nasal cannula. Assessment demonstrates shortness of breath, firm &
tender abdomen, and urine output 20ml/hr for 2hrs. Which of the following complications
do you suspect? - ANS-Hypovolemic shock
The best method to rapidly infuse fluids during resuscitation in a patient with sepsis that
is hypotensive or with a lactate greater than 4 is to - ANS-Use a pressure bag
You performed the critical care pain observation tool (CPOT) on your patient and the
score is 6. What is the best intervention? - ANS-Give morphine 2mg IV push
A patient is admitted with the following assessment findings : nausea, vomiting,
abdominal pain , and yellow sclera. Based on these findings, the nurse expects an
overdose of: - ANS-Acetaminophen
How would you interpret this dynamic response, square wave, for this arterial line? -
ANS-Overdamped
What is preload? - ANS-The volume of blood in the ventricle at the end of diastole
When measuring arterial pressure the transducer should be at the level of: - ANS-
Fourth intercostal space, mid axillary line/midchest
The nurse understands that weak pulses, sinus tachycardia, hypotension, oliguria, and
altered mental status could be caused by: - ANS-Decreased cardiac output
What can cause a false low blood pressure on an arterial line? - ANS-The transducer is
HIGHER than the phlebostatic axis
Solutions
What would you do if this was occurring with a transcutaneous pacemaker? - ANS-
Adjust the sensitivty
A pt with ST-elevation myocardial infarction (STEMI) suddenly develops a 3rd degree
heart block with a rate of 38 bpm. BP is 62/38. Skin is cool, moist, and pale. After
ensuring a patent airway and adequate ventilation , the nurses priority intervention
would be the: - ANS-Anticipation of transcutaneous pacemaker
A pt in hypertensive crisis has an intial BP of 220/120. An hour after initiating treatment,
the pts blood pressure is 170/108. What should the nurse report during interdisciplinary
rounds? - ANS-Blood pressure decreased an ideal amount
A newly admitted develops positive JVD, HR 168, BP 84/78, and muffled heart tones.
What is your assessment of the situation - ANS-Cardiac tamponade
Which of the following represents right heart failure? - ANS-Positive jugular vein
distention, peripheral edema, S3 heart sound
A pt has heart failure. What education will you provide upon discharge ? - ANS-1500
mg/day sodium diet
Daily weights
Which intervention should be performed first for the above rhythm ? - ANS-Defibrillation
Which of the following are symptoms of aortic stenosis? - ANS-Pulmonary edema
The ECG monitor indicates a patient is in ventricular tachycardia. The patient is awake,
alert, anxious, and complains of chest pain. Vitals: HR 190, BP 80/40, Respirations 24,
O2 sat 92% on 2 liters nasal cannula. Which of the following interventions should the
nurse anticipate? - ANS-Synchronized cardioversion
Which 2 of the following would be indicative of dilated cardiomyopathy ? - ANS-Bilateral
lower extremity edema
15% ejection fraction (EF)
Which of the following can cause acute respiratory distress syndrome (ARDS) select 2
answers - ANS-Sepsis
, Aspiration of gastric contents
A patient with sepsis has become increasingly hypoxia despite titrating oxygen from 4L
NC to a non-rebreather throughout the morning. The chest X-ray shows diffuse bilateral
opacities and crackles are heard on auscultation. Which of the following conditions is
most likely based on these findings? - ANS-Acute respiratory distress syndrome
(ARDS)
Which of the following are contraindications for noninvasive positive pressure ventilation
(NPPV) select 4 answers - ANS-GCS of 6
Uncontrolled vomiting
Resp rate of 4 (agonal)
Bilateral wrists restraints
Which type of the following shock states would benefit most from dobutamine? - ANS-
Cardiogenic
A post op open aortic aneurysm repair patient has vitals: HR:130, BP: 82/70, RR:28,
O2: 91% 4L via nasal cannula. Assessment demonstrates shortness of breath, firm &
tender abdomen, and urine output 20ml/hr for 2hrs. Which of the following complications
do you suspect? - ANS-Hypovolemic shock
The best method to rapidly infuse fluids during resuscitation in a patient with sepsis that
is hypotensive or with a lactate greater than 4 is to - ANS-Use a pressure bag
You performed the critical care pain observation tool (CPOT) on your patient and the
score is 6. What is the best intervention? - ANS-Give morphine 2mg IV push
A patient is admitted with the following assessment findings : nausea, vomiting,
abdominal pain , and yellow sclera. Based on these findings, the nurse expects an
overdose of: - ANS-Acetaminophen
How would you interpret this dynamic response, square wave, for this arterial line? -
ANS-Overdamped
What is preload? - ANS-The volume of blood in the ventricle at the end of diastole
When measuring arterial pressure the transducer should be at the level of: - ANS-
Fourth intercostal space, mid axillary line/midchest
The nurse understands that weak pulses, sinus tachycardia, hypotension, oliguria, and
altered mental status could be caused by: - ANS-Decreased cardiac output
What can cause a false low blood pressure on an arterial line? - ANS-The transducer is
HIGHER than the phlebostatic axis
