Critical Care Exam 1 with Complete
Solutions
A, D
HF is a result of structural and functional abnormalities of the heart tissue muscle. The
heart muscle becomes weak and does not adequately pump the blood out of the
chambers. As a result, blood pools in the left ventricle and backs up into the left atrium,
and eventually into the lungs. Therefore, greater amounts of blood remain in the
ventricle after contraction thereby decreasing cardiac output. In addition, this pooling
leads to thrombus formation and ineffective tissue perfusion because of the decrease in
blood flow to the other organs and tissues of the body. Typically, these clients have an
ejection fraction of less than 50% and poorly tolerate activity. Activity intolerance is
related to a decrease, not increase, in cardiac output. Gas exchange is impaired.
However, the decrease in cardiac output triggers compensatory mechanisms, such as
an increase in sympathetic nervous system activity. - ANS-Which of the following
nursing diagnoses would be appropriate for a client with heart failure? Select all that
apply.
A
Ineffective tissue perfusion related to decreased peripheral blood flow secondary to
decreased cardiac output.
B
Activity intolerance related to increased cardiac output.
C
Decreased cardiac output related to structural and functional changes.
D
Impaired gas exchange related to decreased sympathetic nervous system activity.
A,C,E
In a client who has had an ECG, the P wave represents the activation of the electrical
impulse in the SA node, which is then transmitted to the AV node. In addition, the P
wave represents atrial muscle depolarization, not ventricular depolarization. The normal
duration of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height.
- ANS-When interpreting an ECG, the nurse would keep in mind which of the following
about the P wave? Select all that apply.
A
Reflects electrical impulse beginning at the SA node
B
Indicated electrical impulse beginning at the AV node
C
Reflects atrial muscle depolarization
D
,Identifies ventricular muscle depolarization
E
Has duration of normally 0.11 seconds or less
A,B,C,D
Pulmonary edema is a life-threatening event that can result from severe heart failure. In
pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases
in the lungs because of the accumulated blood. Oxygen is always prescribed, and the
client is placed in a high Fowler's position to ease the work of breathing. Furosemide, a
rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to
accurately measure output. Intravenously administered morphine sulfate reduces
venous return (preload), decreases anxiety, and reduces the work of breathing.
Transporting the client to the coronary care unit is not a priority intervention. In fact, this
may not be necessary at all if the client's response to treatment is successful - ANS-A
nurse in a medical unit is caring for a client with heart failure. The client suddenly
develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects
pulmonary edema. The nurse immediately notifies the registered nurse and expects
which interventions to be prescribed? Select all that apply.
A
Administering oxygen
B
Inserting a Foley catheter
C
Administering furosemide (Lasix)
D
Administering morphine sulfate intravenously
E
Transporting the client to the coronary care unit
F
Placing the client in a low Fowler's side-lying position
A,B,E,F
In cardiac catheterization contrast dye is injected into the coronary artery and provides
info on patency. Informed consent must be signed prior to any invasive procedure. The
physician is responsible for explaining the procedure, the nurse can reinforce. Patient
would be NPO 6-18 hours prior. An ECG would be done, but measures electrical not
blood flow. Peripheral pulses is important afterwards. Shellfish is an indicator of an
allergy to the medium injected. - ANS-The nurse is preparing a client for cardiac
catheterization. Which nursing interventions are necessary in preparing the client for
this procedure. Select all that apply:
A
Verify consent has been signed.
B
Explain procedure to client.
C
Provide clear liquid, no caffeine diet.
, D
Evaluate peripheral pulses.
E
Obtain a 12 lead ECG
F
Obtain history of shellfish allergy.
Correct Answer: 1,2,3,4
Rationale 1: Failure to pace occurs when the pacemaker fails to deliver an electrical
stimulus (fire) when it should have fired. This can be seen on the ECG as an absence of
pacer spikes when the patient's heart rate is less than the demand pacer rate is set,
indicating that the pacemaker did not fire.
Rationale 2: Failure to capture occurs when the pacemaker fires, but the chamber that
is being paced (atria or ventricles, or both) does not depolarize. This is seen on the
ECG strip as a pacer spike that is not followed by a P wave or QRS complex.
Rationale 3: Failure to sense occurs when the pacer fails to recognize, or sense, the
heart's natural electrical activity. This is seen on the ECG as pacer spikes that occur too
closely behind the patient's QRS complex.
Rationale 4: Oversensing occurs when the pacer senses extraneous electrical stimuli,
or artifact, for actual atrial or ventricular de - ANS-The nurse is assessing the rhythm
strip of a patient for pacemaker malfunctions. What will the nurse assess when
analyzing this patient's rhythm strip?
Select all that apply.
1. Failure to pace
2. Failure to capture
3. Failure to sense
4. Oversensing
5. Failure to discharge
Correct Answer: 1,2,3
Rationale 1: Digoxin enhances the contractility of the heart.
Rationale 2: Dopamine enhances the contractility of the heart.
Rationale 3: Epinephrine enhances the contractility of the heart.
Rationale 4: Morphine does not enhance the contractility of the heart.
Rationale 5: Atropine is an anticholinergic drug that blocks the cholinergic and
parasympathetic stimulation of the heart. - ANS-The nurse is reviewing the list of a
patient's prescribed scheduled and prn medications. Which of them will affect cardiac
contractility?
Select all that apply.
1. Digoxin
2. Dopamine
3. Epinephrine
4. Morphine
5. Atropine
Correct Answer: 2
Solutions
A, D
HF is a result of structural and functional abnormalities of the heart tissue muscle. The
heart muscle becomes weak and does not adequately pump the blood out of the
chambers. As a result, blood pools in the left ventricle and backs up into the left atrium,
and eventually into the lungs. Therefore, greater amounts of blood remain in the
ventricle after contraction thereby decreasing cardiac output. In addition, this pooling
leads to thrombus formation and ineffective tissue perfusion because of the decrease in
blood flow to the other organs and tissues of the body. Typically, these clients have an
ejection fraction of less than 50% and poorly tolerate activity. Activity intolerance is
related to a decrease, not increase, in cardiac output. Gas exchange is impaired.
However, the decrease in cardiac output triggers compensatory mechanisms, such as
an increase in sympathetic nervous system activity. - ANS-Which of the following
nursing diagnoses would be appropriate for a client with heart failure? Select all that
apply.
A
Ineffective tissue perfusion related to decreased peripheral blood flow secondary to
decreased cardiac output.
B
Activity intolerance related to increased cardiac output.
C
Decreased cardiac output related to structural and functional changes.
D
Impaired gas exchange related to decreased sympathetic nervous system activity.
A,C,E
In a client who has had an ECG, the P wave represents the activation of the electrical
impulse in the SA node, which is then transmitted to the AV node. In addition, the P
wave represents atrial muscle depolarization, not ventricular depolarization. The normal
duration of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height.
- ANS-When interpreting an ECG, the nurse would keep in mind which of the following
about the P wave? Select all that apply.
A
Reflects electrical impulse beginning at the SA node
B
Indicated electrical impulse beginning at the AV node
C
Reflects atrial muscle depolarization
D
,Identifies ventricular muscle depolarization
E
Has duration of normally 0.11 seconds or less
A,B,C,D
Pulmonary edema is a life-threatening event that can result from severe heart failure. In
pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases
in the lungs because of the accumulated blood. Oxygen is always prescribed, and the
client is placed in a high Fowler's position to ease the work of breathing. Furosemide, a
rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to
accurately measure output. Intravenously administered morphine sulfate reduces
venous return (preload), decreases anxiety, and reduces the work of breathing.
Transporting the client to the coronary care unit is not a priority intervention. In fact, this
may not be necessary at all if the client's response to treatment is successful - ANS-A
nurse in a medical unit is caring for a client with heart failure. The client suddenly
develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects
pulmonary edema. The nurse immediately notifies the registered nurse and expects
which interventions to be prescribed? Select all that apply.
A
Administering oxygen
B
Inserting a Foley catheter
C
Administering furosemide (Lasix)
D
Administering morphine sulfate intravenously
E
Transporting the client to the coronary care unit
F
Placing the client in a low Fowler's side-lying position
A,B,E,F
In cardiac catheterization contrast dye is injected into the coronary artery and provides
info on patency. Informed consent must be signed prior to any invasive procedure. The
physician is responsible for explaining the procedure, the nurse can reinforce. Patient
would be NPO 6-18 hours prior. An ECG would be done, but measures electrical not
blood flow. Peripheral pulses is important afterwards. Shellfish is an indicator of an
allergy to the medium injected. - ANS-The nurse is preparing a client for cardiac
catheterization. Which nursing interventions are necessary in preparing the client for
this procedure. Select all that apply:
A
Verify consent has been signed.
B
Explain procedure to client.
C
Provide clear liquid, no caffeine diet.
, D
Evaluate peripheral pulses.
E
Obtain a 12 lead ECG
F
Obtain history of shellfish allergy.
Correct Answer: 1,2,3,4
Rationale 1: Failure to pace occurs when the pacemaker fails to deliver an electrical
stimulus (fire) when it should have fired. This can be seen on the ECG as an absence of
pacer spikes when the patient's heart rate is less than the demand pacer rate is set,
indicating that the pacemaker did not fire.
Rationale 2: Failure to capture occurs when the pacemaker fires, but the chamber that
is being paced (atria or ventricles, or both) does not depolarize. This is seen on the
ECG strip as a pacer spike that is not followed by a P wave or QRS complex.
Rationale 3: Failure to sense occurs when the pacer fails to recognize, or sense, the
heart's natural electrical activity. This is seen on the ECG as pacer spikes that occur too
closely behind the patient's QRS complex.
Rationale 4: Oversensing occurs when the pacer senses extraneous electrical stimuli,
or artifact, for actual atrial or ventricular de - ANS-The nurse is assessing the rhythm
strip of a patient for pacemaker malfunctions. What will the nurse assess when
analyzing this patient's rhythm strip?
Select all that apply.
1. Failure to pace
2. Failure to capture
3. Failure to sense
4. Oversensing
5. Failure to discharge
Correct Answer: 1,2,3
Rationale 1: Digoxin enhances the contractility of the heart.
Rationale 2: Dopamine enhances the contractility of the heart.
Rationale 3: Epinephrine enhances the contractility of the heart.
Rationale 4: Morphine does not enhance the contractility of the heart.
Rationale 5: Atropine is an anticholinergic drug that blocks the cholinergic and
parasympathetic stimulation of the heart. - ANS-The nurse is reviewing the list of a
patient's prescribed scheduled and prn medications. Which of them will affect cardiac
contractility?
Select all that apply.
1. Digoxin
2. Dopamine
3. Epinephrine
4. Morphine
5. Atropine
Correct Answer: 2
