Cardiac/Vascular Nurse Exam Secrets Study Guide (46 page)

130. D. Using transesophageal Doppler ultrasonography to measure cardiac output, a short waveform with a rounded apex may indicate left ventricular failure. Decreased preload (hypovolemia) is indicated by a pointed wave with a narrow base. As preload increases with fluid administration, the base widens. Increased systemic vascular resistance (high afterload) is indicated by a pointed short waveform with a narrow base, with both height and base increasing with vasodilation, which reduces afterload.

131 A. Troponin levels (cTnT and cTnI) should be measured 8–12 hours after the onset of symptoms. Earlier testing may result in false negatives. Levels rise within 3–4 hours and peak at 4–24 hours but do not return to normal for 1–3 weeks. Myoglobin (MB) begins to rise within 1–3 hours and peaks at 4–12 hours, returning to normal usually in about 12– 36 hours, but it is nonspecific for cardiac damage. Measurement of low-density lipoprotein levels is not usually ordered because troponin tests are more specific. Creatinine kinase (CK) levels rise in 3–6 hours, peaking at 24–36 hours, and return to normal in 3 days. The more specific CK-MB (found only in cardiac cells) increases at 4–8 hours and peaks at 12–24 hours, returning to normal in 3–4 days. CK/CK-MB should be tested on admission and in 24 hours.

132. C. Reperfusion after compressing the nail bed long enough to cause blanching should occur within 2–3 seconds, and the color in the nail bed should return to normal. Nail polish should be removed before the test, and the hand should be held above the level of the heart. If the capillary refill time is increased, then this indicates slower peripheral blood flow, as is commonly found with hypotension, dehydration, hypothermia, and congestive heart failure.

133. B. When a nurse forgets to record a headache when it occurs, he or she should document the correct information in the next available space with the current date and time: “07-09-09, 1400; Late entry (07-09-09, 1100): Patient states he has a headache.” The nurse must never alter the record by inserting information out of place or between lines and should never use arrows to indicate the correct chronological placement. This omission did not result in a medical error and, thus, does not need to be reported in an incident report.

134. C. A cardiac care center provides tertiary care, as it is a specialized center with a variety of programs to meet the needs of the cardiac patient. Primary care is usually provided by the first physician the patient sees, such as a general practitioner or an internist. Secondary care is provided by a specialist, such as a cardiologist, to whom the patient is referred. Quaternary care is provided by those who are highly specialized in very specific and limited areas of medicine or involved in special experimental programs.

135. D. The absolute indication for stopping an exercise test is a decrease in blood pressure of 10 mm Hg or more from baseline despite increased workload with evidence of ischemia. The other choices are relative indications and depend upon the patient’s general condition and the assessment of the observer. Other absolute indications include moderate-to-severe angina, cyanosis or pallor, nervous system symptoms (dizziness, ataxia), sustained ventricular tachycardia, ST segment elevation of 10 mm or more in leads without Q waves (other than V1 or VR), and the patient’s wish to stop the test.

136. B. The best procedure to assess a patient’s use of tobacco is to establish a protocol that includes asking every patient at every visit about tobacco use. Every smoker should be advised to quit at each visit. Smokers who are motivated or willing to try quitting should be identified and assisted to develop an individual plan for smoking cessation. Usually setting a quit day within 2 weeks is advised, but if patients have been hospitalized without smoking, they should be encouraged to continue with abstinence. Follow-up should be part of the smoking cessation plan.

137. C. Initially, a physician must certify that a patient who is eligible for Medicare A is terminal with a life expectancy 6 months or less (two 90-day periods), but if the patient remains alive, the physician can extend coverage by authorizing care every 60 days. The goal is to maintain the patient in the home environment with home health aides, homemakers, durable goods, pain management, case management, counseling, and social worker assistance. Routine intermittent home care must comprise 80% of the total care with in-home continuous care and in-patient hospice care available for short periods.

138. A. The patient described in the question is demonstrating symptoms of post-pump delirium psychosis (PPD). Patients may exhibit symptoms ranging from memory loss, alterations of personality, and apathy to clinical psychosis. Risk factors include increasing age, poor cardiac status preoperatively or postoperatively, comorbidities, hypoxia, sepsis, CPB for more than 2–3 hours, and valvular surgery. Postoperative infection, sleep deprivation, and medications can also be factors. Usually, PPD occurs 48 hours or less postoperatively and lasts 2–5 days.

139. D. The treatment goal would be to lower total cholesterol to 200 or less and LDL to 130 or less and raise the HDL to 40 or more. Treatment usually includes an increase in exercise, such as daily walking; dietary modifications, such as a decrease in saturated fats; and antilipid medications, such as the statins. Normal cholesterol ranges include:

· Total cholesterol: 120–200 mg/dL; borderline high is 200–239 mg/dL.

· Triglyceride: 0–150 mg/dL; borderline high is 150–199 mg/dL.

· HDL: 40–70 mg/dL. This is the “good” cholesterol.

· LDL: 50–129 mg dL; borderline high is 130–159 mg/dL. This is the “bad” cholesterol.

140. B. The Mediterranean diet includes eating fish at least two to three times a week but avoiding red meat because of high levels of saturated fat. Patients should have at least nine servings of fruits and vegetable daily, including legumes, tomatoes, olives, and avocados. Olive oil and canola oil are recommended as well as small amounts of nuts daily, especially walnuts, which include omega-3 fatty acids. Margarine, which is often high in trans fats, should be avoided. Olive oil can be used in place of butter.

141. A. This patient is exhibiting dependence in response to stress. Typical psychological responses to stress include:

· Dependence, when the patient is unable to make decisions, requires constant reassurance, and calls nurses or family members frequently.

· Depression, when the patient is withdrawn and sad, fails to take treatments or keep appointments, and is at risk for suicide.

· Anger, when the patient is belligerent, uncooperative, and blames others.

· Confusion, when the patient is forgetful and disoriented.

· Passivity, when the patient defers to others, feeling he or she has no control.

142. C. All staff members are responsible for identifying quality performance improvement projects. Performance improvement must be a continuous process. Continuous Quality Improvement (CQI) is a management philosophy that emphasizes the organization and the systems and processes within that organization rather than individuals. Total Quality Management (TQM) is a management philosophy that espouses a commitment to meeting the needs of the customers (patients, staff) at all levels within an organization. Both management philosophies recognize that change can be made in small steps and should involve staff at all levels.

143. D. Atrial arrhythmias, including fibrillation, flutter, and tachycardia, are very common after cardiac surgery, occurring in over half of patients with valvular surgery. Arrhythmias occur usually in the first 2–3 postoperative days and are often transient but may recur. Arrhythmias are usually related to surgical manipulation. Treatment includes digoxin, b-blockers, calcium channel blockers, and amiodarone (often given preoperatively for 7 days to reduce the incidence of postoperative arrhythmias. Electrical cardioversion may be indicated after 24 hours if sinus rhythm remains abnormal.

144. B. The self-monitoring skill that is most essential for a patient with heart failure is daily weight as increased weight can indicate fluid overload and edema before it becomes evident (usually after about 5 L of retained fluid or a 10-pound weight increase). Patients may also need to monitor sodium intake. Self-management skills require an initial discussion of needs and presentation of scenarios to help the patient determine appropriate responses and practice self-management.

145. C. A patient whose organs and systems have begun to deteriorate is in the exhaustion phase. Selye believed that stress is a body response to any demand requiring adaptation (negative or positive). The “generalized adaptation syndrome” has three phases:

· Alarm, which results in the physiological “fight or flight” response.

· Resistance, which is evident when the body mobilizes forces to resist threat, focusing on those organs most involved in response. Chronic resistance can lead to damage of organs and systems.

· Exhaustion, which results when the body is overwhelmed and weakened, and organs and systems begin to deteriorate (hypertrophy of adrenal glands, ulcerations of the gastrointestinal tract, and atrophy of thymus gland), leading to stress-related diseases and death.

146. D. While home intravenous (IV) antibiotic therapy is appropriate for many patients, the patient in the question is frail and elderly and not a good candidate for home treatment, so transferring the patient to an extended care facility is probably the best option. Extended treatment in an acute hospital is probably not necessary since the patient’s condition is stable. A few patients may be able to self-administer IV medications if they have adequate instruction and family or other support, but the patient in the question is frail, elderly, and lives alone.

147. B. If a patient asks for pain medication after 4 hours when it has been prescribed for every 6 hours, the pain control is not adequate to prevent breakthrough pain, and the routine medication may need to be increased in dosage or frequency. While tolerance to pain varies, pain is what the individual perceives it to be, and distraction is rarely effective in relieving severe pain. Since breakthrough pain commonly occurs, this most likely reflects inadequate control. Patients have a right to pain control, and almost all pain can be controlled with proper analgesia.

148. A. In the stage-based approach to assessing readiness to change, the stage of pre-contemplation is the first of five stages:

· Precontemplation is the unwillingness to acknowledge the need for change or being unaware of the need. People may be defensive.

· Contemplation is a demonstration of ambivalence.

· Preparation is the evaluation of disadvantages and advantages of changing behavior.

· Action is demonstrated by instability and relapses; patients may regress to an earlier stage or progress.

· Maintenance is demonstrated by relapses or a decrease or gain in confidence; patients make plans to deal with relapse.

149. B. The most likely cause of a bruit (or pulsatile mass) near the insertion site after percutaneous transluminal coronary angioplasty is a pseudoaneurysm and arteriovenous fistula caused by vessel trauma. Bleeding or a hematoma, evidenced by a hard lump or blue discoloration at sheath insertion site, may be caused by coughing, vomiting, hypertension, or bladder distention. An arterial thrombus or embolus will result in a cool, cyanotic extremity and a loss of pulse distal to the sheath insertion site. A retroperitoneal tear causes bleeding into the flank area with resultant pain, hypotension, tachycardia, decreased levels of hemoglobin, and a lowered hematocrit.

Secret Key #1 - Time is Your Greatest Enemy

Pace Yourself

Wear a watch. At the beginning of the test, check the time (or start a chronometer on your watch to count the minutes), and check the time after every few questions to make sure you are “on schedule.”

If you are forced to speed up, do it efficiently. Usually one or more answer choices can be eliminated without too much difficulty. Above all, don’t panic. Don’t speed up and just begin guessing at random choices. By pacing yourself, and continually monitoring your progress against your watch, you will always know exactly how far ahead or behind you are with your available time. If you find that you are one minute behind on the test, don’t skip one question without spending any time on it, just to catch back up. Take 15 fewer seconds on the next four questions, and after four questions you'll have caught back up. Once you catch back up, you can continue working each problem at your normal pace.

Furthermore, don’t dwell on the problems that you were rushed on. If a problem was taking up too much time and you made a hurried guess, it must be difficult. The difficult questions are the ones you are most likely to miss anyway, so it isn’t a big loss. It is better to end with more time than you need than to run out of time.

Lastly, sometimes it is beneficial to slow down if you are constantly getting ahead of time. You are always more likely to catch a careless mistake by working more slowly than quickly, and among very high-scoring test takers (those who are likely to have lots of time left over), careless errors affect the score more than mastery of material.

Secret Key #2 - Guessing is not Guesswork

You probably know that guessing is a good idea. Unlike other standardized tests, there is no penalty for getting a wrong answer. Even if you have no idea about a question, you still have a 20-25% chance of getting it right.