Cardiac, Vascular, and Pulmonary Systems

Scenarios and questions in this section focus on the cardiac, vascular, and pulmonary systems. These concepts are considered together because of their interconnectedness and interdependence. The concepts reviewed in the context of this body system include:



• Pharmacology


• Pathophysiology


• Technology


• Nursing process and standards




































































































































































ESSENTIAL CORE CONCEPTS AFFILIATED CORE CURRICULUM CHAPTERS
Nursing Process Chapter 3
Assessment
Planning and Implementation
Evaluation
Preexisting Medical Conditions Chapter 19
Cardiovascular Diseases
Pulmonary Diseases
Obesity
Immediate Preoperative Preparation Chapter 23
Medication Protocol
Acid-Base Balance Chapter 25
Anesthetic Agents and Adjuncts Chapter 26
Anesthesia Continuum
Anesthesia Options
Regional Techniques
IV Anesthetic Induction Agents
IV Opioid Anesthetics
IV Anesthetic Adjuncts
Gaseous and Volatile Inhalational Anesthetics
Depolarizing and Nondepolarizing Muscle Relaxants
Reversal Agents
Moderate Sedation/Analgesia Chapter 27
Thermoregulation Chapter 28
Thermoregulation
Malignant Hyperthermia
Hemodynamic Monitoring Chapter 30
Physiologic Variables
Pressure Monitoring and Troubleshooting
Respiratory Care Chapter 31
Postoperative Oxygen Therapy
Airway Management
Postoperative Mechanical Ventilation
Difficult Airway
Administration of Aerosolized Medications
Select Postoperative Respiratory Care Issues
Cardiovascular Care Chapter 32
Anatomy and Physiology
Assessment and Management
Cardiovascular Operative Procedures
Cardiac Complications
Cardioactive Drugs
Neurologic Care Chapter 33
Neurologic Assessment
Dynamics of Increased Intracranial Pressure (ICP)
Neurologic Complications
Immediate Postoperative Assessment Chapter 35
Respiratory Adequacy
Circulatory Adequacy
Fluid and Electrolyte Balance
Temperature Regulation
Level of Consciousness
Peripheral Circulation
Perianesthesia Complications Chapter 36
Critical Postanesthesia Assessments
Airway Integrity
Cardiovascular Stability
Gastrointestinal (GI) Issues
Neurologic Concerns and Anesthesia
Thermal Balance
Respiratory Surgery Chapter 38
Respiratory Anatomy and Physiology
Respiratory Assessment
Respiratory Pathophysiology
Surgical Procedures
Care of the Patient Undergoing Pulmonary Surgery
Postoperative Nursing Concerns
Cardiovascular Surgery Chapter 39
Primary Myocardial Diseases
Special Procedures Chapter 55
Bronchoscopy


ITEMS 6.1–6.50




6.1. In the preoperative setting, a patient states that he always gets antibiotics before dental procedures. Which of the following items in the patient’s history would explain his statement?


a. Pacemaker placed 2 years ago


b. Coronary artery bypass graft (CABG) 2 years ago


c. Atrial septal defect (ASD) repair as a child


d. Prosthetic repair of mitral valve


6.2. The nurse should be aware that recommendations for the prevention of subacute bacterial endocarditis (SBE) are based on which of the following pieces of information?


a. Prophylaxis always includes a regimen of multiple antibiotics.


b. Antibiotic regimen is usually based on procedural/patient risk assessments.


c. Antibiotics for SBE prophylaxis are effective only if given pre-procedure.


d. Vancomycin is usually not given for prophylaxis because of its side-effect profile.


6.3. Which of the following procedures would not require SBE prophylaxis?


a. Cranial wound abscess drainage under general anesthesia


b. Insertion of myringotomy tubes under moderate sedation


c. Cystoscopy with bladder fulguration under general anesthesia


d. Circumcision with local anesthetic

NOTE: Consider the scenario and items 6.4-6.5 together.

A 62-year-old woman 10 days post–triple CABG presents to the PACU after an uncomplicated débridement of her infected sternal incision. She begins to complain of dyspnea and sharp, stabbing chest pain. There is ST segment elevation on her ECG. The pain subsides when the patient sits upright.


6.4. Upon auscultation, the perianesthesia nurse hears a pericardial friction rub. The priority nursing intervention after notifying a physician is to:


a. assess for signs and symptoms of cardiovascular compromise.


b. position and medicate the patient to adequate comfort level.


c. prepare for immediate pericardiocentesis.


d. Begin ACLS algorithm depending on cardiac dysrhythmia.


6.5. The patient becomes increasingly hemodynamically unstable. The nurse suspects cardiac tamponade from which of the following assessments?


a. Central venous pressure (CVP) reading of 6 mmHg


b. No output from mediastinal chest tubes


c. Bradycardia


d. Distinct S1/S2 heart sounds


6.6. A patient in the preoperative setting has a history of congestive heart failure (New York Heart Association functional classification type II). Which of the following observations are most concerning?


a. The only patient weight noted was from 2 weeks ago.


b. The patient was short of breath after walking to the bathroom.


c. The patient’s maintenance IV has infiltrated.


d. The patient’s ankles are noted to be edematous.

NOTE: Consider the scenario and items 6.7-6.9 together.

A moderately obese male patient, recently extubated after a left-sided thoracotomy, continues to be sedate and occasionally has desaturations of his oxygen saturation levels despite stimulation and encouragement to cough and deep breathe. The patient is wearing a simple facemask with a flow of 8 L/min. Arterial blood gases are drawn, and the values are as follows:

















pH 7.32 Normal 7.35-7.45
PaCO2 50 Normal 35-45 mmHg
HCO3 25 Normal 22-26 mEq/L
PaO2 65 Normal 80-100 mmHg



6.7. These laboratory results indicate:


a. metabolic acidosis.


b. metabolic alkalosis.


c. respiratory acidosis.


d. respiratory alkalosis.


6.8. Which of the following could be ruled out as a risk factor for this particular acid-base imbalance?


a. Obesity


b. Thoracic surgical procedure


c. Potential for obstructive sleep apnea


d. Residual endotracheal tube irritation


6.9. In this situation, the nurse would first:


a. prepare for immediate reintubation.


b. reposition the patient’s head and give a jaw thrust/support.


c. do a full cardiovascular assessment.


d. consider narcotic reversal.


6.10. A patient arrives to the PACU hypothermic. The patient’s last set of arterial blood gases indicates metabolic alkalosis. Physiologically, these factors would:


a. increase oxygen’s affinity to the hemoglobin molecule.


b. lead to a decrease in cardiac oxygen demand.


c. eventually initiate aerobic cellular processes.


d. decrease the risk of cardiac ischemia.


6.11. A partial pressure of oxygen below 60 to 100 mmHg generally indicates that a patient is experiencing:


a. a myocardial infarction.


b. rapid dissociation of oxygen from hemoglobin.


c. hypercapnia.


d. a drop in systolic blood pressure.

NOTE: Consider the scenario and items 6.12-6.14 together.

An extubated patient awakens in the PACU and realizes that no major surgical procedure has occurred, leading the patient to believe that he probably has a grave diagnosis and an inoperable tumor. The patient immediately begins to hyperventilate and is inconsolable.


6.12. Hyperventilation and the panicked state of the patient can lead to which of the following acid-base imbalances?


a. Metabolic acidosis


b. Metabolic alkalosis


c. Respiratory acidosis


d. Respiratory alkalosis


6.13. The perianesthesia nurse’s primary intervention is to:


a. coach the patient to assist in reducing respirations.


b. provide airway support with a bag-valve-mask set up.


c. provide emotional support and coach breathing.


d. apply limb restraints.


6.14. Which of the following set of arterial blood gas (ABG) values indicates that the anxiolytic sedative that was given is beginning to be effective?


a. pH = 7.45 CO2 = 34 HCO3 = 22


b. pH = 7.34 CO2 = 47 HCO3 = 26


c. pH = 7.32 CO2 = 31 HCO3 = 24


d. pH = 7.45 CO2 = 30 HCO3 = 23


6.15. Which of the following statements is true regarding the impact of sedation level on the cardiac and respiratory systems?


a. Moderate sedation may require airway intervention.


b. Spontaneous ventilation is maintained for a moderately sedated patient.


c. Minimal sedation should not alter cardiac function but will alter respiratory function.


d. Cardiac function is not impaired by general anesthesia.




6.17. An anesthesiologist rushes to the PACU to put an epidural into a patient who is having intractable pain from a thoracoabdominal procedure. Other attempts have been made to insert an epidural, and the physician decides to try to place one at what he believes to be the T3 level. The nurse observes for which of the following complications?


a. Blunted consciousness


b. Tachycardia or bradycardia


c. Parasympathetic blockade


d. Complete cardiopulmonary collapse

NOTE: Consider items 6.18-6.20 together.


6.18. An elderly patient not receiving optimal pain relief, despite treatment with the recommended dose of narcotics, has ketamine additionally ordered. Which of the following interventions would the nurse anticipate to be carried out first?


a. Preparing for insertion of nasal trumpet/airway


b. Inserting and adjusting the patient’s hearing aids and warning of side effects


c. Administering a premedication fluid bolus


d. Warning the patient that it may take some time for the medication to work


6.19. The patient becomes agitated and confused and is attempting to climb off the cart. Pharmacologic intervention will most likely entail:


a. naloxone (Narcan).


b. flumazenil (Romazicon).


c. diphenhydramine (Benadryl).


d. midazolam (Versed).


6.20. The patient quickly grows calm but then becomes apneic and unresponsive. What would be considered as the primary cause of this effect?


a. Inadequate reversal of administered medications


b. Synergistic effect of administered medications


c. Delayed onset of ketamine


d. Expected side effect of ketamine


6.21. A patient’s arterial line is showing a dampened waveform and readings that are 50 mmHg higher than the measurement with the blood pressure cuff. Which of the following interventions is most appropriate?


a. Move the blood pressure cuff to the arm with the arterial line.


b. Inject 20 mL of normal saline directly into the arterial line.


c. Discontinue the arterial line.


d. Reposition the patient’s wrist.


6.22. Mean arterial pressure (MAP) is an important clinical indicator of:


a. perfusion of both vital and non-vital organs.


b. perfusion of only vital organs.


c. perfusion of only nonvital organs.


d. vascular muscle disinhibition.


6.23. Which of the following statements is correct regarding the placement of a central venous catheter?


a. Radiographic verification is not needed if hemodynamic readings are normal.


b. The transducer should be zeroed 3 above the phlebostatic access point.


c. Auscultation of lung sounds is necessary to rule out pneumothorax.


d. Full inflation of the wedge pressure balloon must be verified.



NOTE: Consider items 6.25-6.27 together.

A 35-year-old African-American woman is admitted to the PACU after an open cholecystectomy that was complicated by extensive bleeding. The postoperative hemoglobin was 7.5 g/dL. The nurse is having difficulty seeing a clear plethysmographic (pleth) wave and is getting pulse oximetry readings of 65% to 90% that are inconsistent with the nurse’s visual assessment of the patient and stability of the patient’s hemodynamics.


6.25. Which of the following might the nurse rule out as a potential cause of the wide range of readings?


a. The patient’s anemia


b. The patient’s dark skin


c. The patient’s clear acrylic nails


d. The probe being attached to the patient’s ear


6.26. Considering the patient’s oxygen saturations and a poor pleth waveform, the nurse’s primary intervention is to:


a. call the anesthesiologist.


b. apply oxygen per unit protocols.


c. relocate the probe until a satisfactory waveform is seen.


d. prepare to insert a nasal airway to assist with breathing.


6.27. What does the nurse need to consider when caring for this patient, after considering the oxyhemoglobin dissociation curve?


a. Pulse oximetry measures arterial oxygen saturation.


b. Pulse oximetry should be considered separately from direct patient assessment.


c. Pulse oximetry can be used to determine anemia.


d. Oxygen saturation percent (SpO2) is always a good indicator of oxygen-ation.


6.28. Which of the following oxygen delivery devices offers the highest concentration of oxygen (FiO2)?


a. Venturi mask (Venti mask)


b. Partial non-rebreather mask


c. Non-rebreather mask


d. Simple facemask


6.29. A patient with severe chronic obstructive pulmonary disease (COPD) requires both humidification of oxygen and a tightly controlled flow rate. Which of the following would be the best choice for oxygen therapy?


a. Venturi mask (Venti mask)


b. Partial non-rebreather mask


c. Non-rebreather mask


d. Simple facemask


6.30. An intubated patient with a central line has a sudden drop in blood pressure. Which of the following would reflect a priority intervention?


a. Check a CVP reading


b. Give a 200-mL normal saline fluid bolus


c. Run an ECG strip


d. Give a breath with a bag-valve-mask/Ambu bag


6.31. For which of the following patients would insertion of a nasopharyngeal airway be a safe intervention?


a. Facial trauma


b. Post–tonsillectomy/adenoidectomy


c. Diagnosed clotting disorder


d. Wired jaw


6.32. Which of the following would be an unexpected complication seen in a patient with a newly created tracheostomy?


a. Mediastinal subcutaneous emphysema


b. Pleural effusion


c. Pneumothorax


d. Feeling of shortness of breath despite adequate oxygenation




6.34. A patient has an intra-aortic balloon pump (IABP) inserted for treatment of cardiogenic shock. The perianesthesia nurse knows that:


a. the patient may lie prone or on the left side.


b. the catheter is generally inserted through the chest wall.


c. patients must be sedated while the IABP is functioning.


d. the IABP increases both stroke volume and myocardial perfusion.


6.35. Which of the following assessments should indicate to the nurse that an IABP balloon/catheter has migrated out of the descending aorta?


a. Carotid bruit heard upon auscultation


b. Patient complaint of blurred vision


c. Absent radial pulses


d. Increase in cardiac output


6.36. Which of the following could be ruled out as a cause of hypertension in a post-surgical patient?


a. Presence of endotracheal tube


b. Full bladder


c. High pressure ventilation


d. Sympathetic nervous system stim-ulation


6.37. A patient with a diagnosis of COPD presents postoperatively after bronchoscopy with worsening dyspnea and respiratory distress. Which modality of care might be considered to avoid intubation?


a. Continuous positive airway pressure (CPAP) or noninvasive nasal mask ventilation


b. Coughing and deep breathing every 5 minutes with oxygen per nasal cannula at 4 L/min


c. Close-fitting facemask with oxygen at 10 L/min


d. Nasal cannula with oxygen at 4 L/min


6.38. The perianesthesia nurse needs to be aware of which of the following in care of obese patients?


a. These patients are at a decreased risk of aspiration related to faster gastric emptying.


b. These patients experience an increase in the duration of action for highly lipid-soluble drugs.


c. Dose calculations for minimally lipophilic drugs are based on actual weight for this patient population.


d. This patient population has a low incidence of deep vein thrombosis (DVT).


6.39. The PACU nurse assesses a recently intubated patient and notes that lung sounds are not equal bilaterally nor does the chest rise and fall. After notifying the physician, the nurse immediately:


a. removes the endotracheal tube.


b. gives three large-volume breaths via anesthesia/Ambu bag.


c. pulls the endotracheal tube back 1 cm.


d. administers albuterol nebulizer treatment via endotracheal tube.


6.40. All the following can be used to evaluate a patient’s preload except:


a. right atrial pressure (RAP).


b. systemic vascular resistance (SVR).


c. central venous pressure (CVP).


d. pulmonary capillary wedge pressure (PCWP).




6.42. Which of the following symptoms would be indicative of the early symptoms of compartment syndrome?


a. Absent pulses in operative extremity


b. Blackened toes or fingers


c. Hypersensitivity in operative extremity


d. Extreme pain in extremity despite analgesics

NOTE: Consider items 6.43-6.44 together.

After repair of a congenital tibial bone disorder requiring osteotomy, a patient has been receiving narcotics for almost 3 hours in the PACU. The following laboratory results were obtained:





















LABORATORY TEST RESULT NORMAL
White blood cell (WBC) count 18,000 5,000-10,000
Blood urea nitrogen (BUN) 35 mg/dL 5-25 mg/dL
Potassium 4.8 mEq/L 3.5-5.3 mEq/L
Creatinine kinase MM-isoenzyme 40 mcg/mL 5-25 mcg/mL



6.43. The nurse suspects:


a. malignant hyperthermia.


b. muscle necrosis.


c. myocardial infarction.


d. hemorrhage.


6.44. Which co-morbidity would be of greatest concern for this patient?


a. A past history of a difficult intubation


b. COPD requiring home oxygen therapy


c. Type-II diabetes


d. A history of schizophrenia


6.45. A patient with severe facial trauma presents to the PACU after a motorcycle accident. In the OR the patient received 20 mg IV morphine and 300 mcg Fentanyl total and is now showing signs of an obstructive respiratory pattern. Initial airway management includes:


a. suctioning to clear secretions and insertion of an oral airway.


b. suctioning to clear secretions and insertion of a nasal airway.


c. preparing for oral intubation.


d. preparing for percutaneous tracheostomy.


6.46. When preparing to extubate a patient, the endotracheal tube is removed:


a. at the end of inspiration.


b. at the end of expiration.


c. as the patient coughs.


d. at the end of either inspiration or expiration.


6.47. A patient with an implanted cardioverter defibrillator (ICD) goes into ventricular fibrillation upon transfer into the PACU. Which of the following statements is true about an ICD?


a. Patients with an ICD will never require external defibrillation.


b. Cardiopulmonary resuscitation (CPR) should be interrupted when the ICD fires.


c. Defibrillation paddles/pads should be placed directly over the ICD to override it.


d. Defibrillation paddles/pads should not be placed directly over the ICD.


ITEMS 6.51–6.100




6.51. Tachycardia and tachypnea in the presence of rapidly rising expired carbon dioxide levels in a patient with a clenched jaw should cause the nurse to immediately suspect:


a. malignant hyperthermia.


b. thyroid storm.


c. seizure.


d. hypoglycemia.


6.52. A patient with an acute exacerbation of his asthma complains of tremors while receiving nebulized albuterol treatment. The nurse should:


a. offer a warm blanket or apply an active warming device.


b. switch over to nebulized racemic epinephrine.


c. explain to the patient that this is a normal side effect.


d. immediately discontinue the treatment.

NOTE: Consider items 6.53-6.54 together.


6.53. A 3-year-old child who has just undergone adenotonsillectomy presents to the perianesthesia nurse with a high-pitched, barky cough and oxygen saturations ranging from 85% to 92%. The nurse should suspect:


a. an acute exacerbation of asthma.


b. post-extubation laryngeal edema.


c. hemorrhage in tonsil/adenoid vascular bed.


d. aspiration of gastric contents into the lungs.


6.54. Primary interventions for this child should include:


a. nasopharyngeal airway and oral suctioning.


b. high-Fowler position with oxygen at 10 L/min per close-fitting mask at 10L.


c. positioning to child’s comfort and NSAIDs.


d. humidified oxygen and racemic epinephrine.


6.55. The PACU nurse is preparing to extubate a patient with a known difficult airway. Which of the following would be the least likely choice for airway intervention if a problem did arise?


a. Airway exchange catheter


b. Laryngeal mask airway


c. Fiberoptic bronchoscope


d. Venturi mask


6.56. After an abdominal hysterectomy, a patient with a known history of malignant hyperthermia begins to have dark, cola-colored urine output. Which of the following should the nurse be most concerned about?


a. Hypocalcemia


b. Shock-like vasodilation


c. Metabolic alkalosis


d. Renal failure


6.57. In a patient with a new onset of atrial fibrillation, which of the following would least likely be the cause?


a. Alcohol or drug use


b. Sepsis


c. Obstructive sleep apnea


d. Hyperthyroidism




6.59. A Phase II patient, after carpal tunnel repair under moderate sedation, has abnormal pleth-wave tracings. Upon attaching ECG leads the nurse recognizes the patient is in atrial fibrillation. Which of the following statements made by this patient should come as a surprise to the nurse?


a. “I feel short of breath and have a funny feeling in my chest.”


b. “Where am I and why does my chest hurt?”


c. “I feel like I am about to have a seizure.”


d. “I feel just fine.”


6.60. In a patient experiencing laryngospasm, the nurse would expect to find which of the following after doing a complete respiratory assessment?


a. Patient states that it is hard to breath and is visibly dyspneic


b. Audible wheezes and use of accessory muscles


c. Pink, frothy sputum


d. Inspiratory stridor with tracheal tug

NOTE: Consider items 6.61-6.62 together.

A 68-year-old patient with complications from colon cancer and a prolonged ICU stay presents to the PACU intubated and sedated requiring ventilator assistance after a 4-hour procedure to resect a portion of his colon.


6.61. The patient begins to breathe rapidly over the set rate of the ventilator, is diaphoretic, and has poor oxygen saturation readings despite an increase in the FiO2 level. The nurse should immediately:


a. increase the amount of sedation and analgesic administered.


b. contact the physician to consider a chest x-ray and 12-lead ECG.


c. remove the ventilator and administer breaths via bag-valve-mask.


d. move the patient to the left lateral position.


6.62. The decision is made to extubate the patient. The extubation occurs without difficulty, but the patient is noted to have poor respiratory effort and weak, floppy movements. The nurse should prepare to administer:


a. anxiolytics and intubation supplies.


b. narcotic and benzodiazepine reversal agents.


c. Benadryl and anticholinergics.


d. phenobarbital or valium.


6.63. Phenylephrine and ephedrine are both administered to patients experiencing hypotension in the perioperative period. Which of the following statements about these medications is true?


a. Both drugs act as vasoconstrictors with arterial effect greater than venous effect.


b. Phenylephrine and ephedrine are potent alpha-agonists.


c. The indirect action of ephedrine limits the quantity that can be used.


d. Phenylephrine must always be ad-ministered as a continuous infusion.


6.64. The most important indicator of extubation readiness is:


a. hand squeeze to command.


b. sustained head lift for longer than 5 seconds.


c. tongue protrusion to command.


d. tidal volumes greater than 5mL/kg.




6.66. A hypertensive patient (150-180 systolic blood pressure) who recently underwent right carotid endarterectomy begins to vomit. The nurse should:


a. hold pressure to the patient’s neck dressing when the patient vomits.


b. consider a vasoactive drip if vomiting is not controlled with antiemetics.


c. monitor for episodes of severe bradycardia.


d. place nasogastric tube for decompression of the stomach.


6.67. In evaluating a patient who recently had a right carotid endarterectomy, the nurse notices that the patient’s trachea is slightly deviated to the left. The nurse knows that:


a. this is a normal finding with this surgery.


b. crepitus or subcutaneous air can cause this finding.


c. this could indicate an emergent threat to the patient’s airway.


d. this is not a concern as long as neurologic function is intact.


6.68. A patient who has just arrived after a left-sided thoracotomy begins to show odd electrical signals on her ECG and is pulseless. The nurse, in attempting to rapidly determine the cause, should first check:


a. indwelling urinary catheter output.


b. chest tube output.


c. pulses in lower extremities.


d. heart and lung sounds.


6.69. Which of the following assessments is a low priority when caring for a patient who has just undergone a left-sided carotid endarterectomy?


a. Cranial nerve XII (hypoglossal)


b. Cranial nerve VIII (acoustic)


c. Blood pressure (invasive and/or noninvasive)


d. Glasgow Coma Scale

NOTE: Consider items 6.70-6.72 together.


6.70. An 85-year-old hypothermic patient has arrived after total knee arthroplasty under general anesthesia with oral intubation. He had a myocardial infarction (MI) with percutaneous transluminal coronary angioplasty (PTCA) when he was 75 years old. Which of the following factors puts him at increased risk for MI?


a. Surgical procedure


b. Distant cardiac history


c. Age


d. Hypothermia


6.71. Which of the following clinical manifestations is the least characteristic of an acute myocardial infarction?


a. ST depression or elevation on a 12-lead ECG with elevated serum lipase


b. Elevated CK-MB and troponin levels with appearance of U wave


c. Hypoglycemia and pericardial friction rub


d. S3/S4 heart sounds and diaphoresis


6.72. The nurse prepares to assist with interventions to reduce further myocardial ischemia. The nurse should be surprised if the physician requested:


a. fibrinolytic therapy.


b. active warming.


c. reintubation.


d. nitroglycerin drip.


6.73. Which of the following would most concern the nurse caring for a patient who has been in the PACU for 2 hours after an open repair of an abdominal aortic aneurysm?


a. Urine output of 50 ml/hr


b. Pulses in bilateral lower extremities attainable only by Doppler


c. Pain rating of 7/10 over the past 2 hours


d. Central line with a right atrial (RA) reading of 3 mmHg




6.75. The waveform after “shooting” a cardiac output is noted to be dampened. Which of the following would be considered a possible cause of the abnormal reading?


a. Tight connections and a lack of air bubbles in the line and transducer


b. Flush solution pressure is at 100 mmHg


c. Distal port balloon is deflated


d. Patient is in a side-lying position


6.76. The PACU nurse would understand which of the following to be true in caring for a patient with a ventricular ejection fraction (EF) of less than 40%?


a. The patient should be expected to have a cough and shortness of breath.


b. A greater percent of oxygenated and unoxygenated blood will be mixing.


c. Crackles and S3/S4 heart sounds would be expected.


d. High-dose NSAIDs are generally well-tolerated.


6.77. A patient with a difficult airway where facemask ventilation is hampered by a receding chin and redundant neck tissue is soon to be extubated in the PACU. Which of the following would be anticipated strategy to reduce complications?


a. Cricothyrotomy


b. Fiberoptic bronchoscope used to guide extubation


c. Placement of large-bore oral airway


d. Use of Combitube during the procedure

NOTE: Consider items 6.78-6.81 together.

An 18-year-old patient who was the unrestrained driver in a motor vehicle crash presents to the PACU nurse intubated and sedated after evacuation of a subdural hematoma. The neurosurgical team indicates in their orders that short episodes of hyperventilation via the ventilator are acceptable.


6.78. Which of the following is the best reason the therapeutic hyperventilation might be theoretically indicated?


a. To allow for respiratory adjustment in case of acid-base imbalance


b. As a means of decreasing intracranial pressure


c. To decrease blood pressure by increasing intrathoracic pressures


d. For recruitment of deflated alveoli as a means of increasing oxygenation


6.79. Which of the following cares would be contraindicated in this patient?


a. Cranial nerve assessment and frequent Glasgow Coma Scale evaluations


b. High-dose barbiturates for heavier sedation


c. Monitoring of intracranial pressure (ICP) via external device


d. Frequent endotracheal (ET)/oral suctioning to clear secretions


6.80. Which of the following reflects accurate information about cerebral perfusion pressure (CPP)?


a. CPP reflects both the intracranial pressure and the mean arterial pressure.


b. It will not hurt the patient to keep CPP elevated (>100 mmHg).


c. ICP does not directly influence CPP.


d. CPP can be determined by noninvasive means.


6.81. The patient’s respiratory pattern becomes extremely irregular, the pulse pressure begins to widen, and his heart rate drops into the 40s. The patient is unresponsive when the nurse attempts to wake him. The PACU nurse would immediately:


a. administer narcotics to further sedate the patient.


b. turn the patient to his side.


c. hyperventilate the patient with the Ambu bag.


d. raise the head of the bed to 90°.

NOTE: Consider items 6.82-6.83 together.

A 100-kg patient who is being mechanically ventilated because of flail chest, pneumothorax, and widespread atelectasis has just had a chest X-ray that shows that the atelectasis has not improved.


6.82. The PACU nurse should expect which of the following changes to the patient’s ventilator settings?


a. Addition of positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP)


b. An increase in the FiO2 to 75%


c. An increase of the tidal volume to 1200 mL


d. Adjust the inspiratory:expiratory (I:E) ratio to 4:1


6.83. The high pressure alarm on the ventilator begins to go off. Which of the following interventions would be most appropriate?


a. Lower the pressure support setting


b. Locate any tubing leaks and reconnect


c. Determine if the patient is apneic


d. Place a bite block in the patient’s mouth

NOTE: Consider items 6.84-6.85 together.

A patient experiences poor quality and depth of respirations as well as an uncoordinated respiratory pattern. The nurse suspects that it might be residual neuromuscular blockade.


6.84. Which of the following would signal that this was indeed the source of the patient’s difficulties?


a. Train-of-four measurement with peripheral nerve stimulator showing two strong twitches


b. Sustained head lift for longer than 5 seconds


c. Sticks out tongue for longer than 5 seconds


d. Tidal volumes of at least 5 mL/kg


6.85. Residual neuromuscular blockage can put a patient at risk for:


a. unplanned/accidental extubation.


b. pulmonary edema.


c. aspiration.


d. cor pulmonale.

NOTE: Consider items 6.86-6.89 together.

A patient newly diagnosed with sepsis is rushed from his ICU bed to the preoperative holding area for placement of a tracheostomy tube and drainage of abdominal abscess.


6.86. In assisting with this patient, the nurse should place top priority on:


a. placement of indwelling urinary catheter.


b. initiation of antibiotics as ordered.


c. placement of a central line.


d. drawing arterial blood gases.


6.87. Post-procedure, the patient arrives to the PACU intubated and mechanically ventilated. Which of the following would the PACU nurse verify as he or she continues caring for this septic patient?


a. Initiation of high-dose corticosteroids


b. Light sedation


c. Sequential compression devices and TED stockings


d. High-pressure jet ventilation through the tracheostomy site


6.88. The patient continues to be unstable, and a dopamine drip is ordered. The lowest priority for the PACU nurse related to the infusion of this medication is:


a. careful monitoring of vital signs and the ECG.


b. vigilance of the peripheral IV site where it is infusing.


c. determination of fluid volume status before and during administration.


d. close monitoring of blood glucose levels.

The patient begins to show signs of acute respiratory distress syndrome (ARDS), and the care team has decided to allow for permissive hypercapnia as a means of lowering tidal volumes and decreasing the risk of lung trauma. To determine if this is safe, arterial blood gases are drawn.

















pH 7.20 Normal 7.35-7.45
PaCO2 55 Normal 35-45 mmHg
HCO3 18 Normal 22-26 mEq/L
PaO2 70 Normal 80-100 mmHg



6.89. Which of the following actions are indicated considering the above ABG results?


a. Call for an order of sodium bicarbonate and calcium gluconate


b. Call for an order of sodium bicarbonate and an insulin sliding scale


c. Call for an order of magnesium sulfate and lidocaine per weight


d. Advocate for plasmapheresis


6.90. A patient who has just undergone femoral-popliteal artery bypass is receiving a nitroglycerin drip. The patient has a history of frequent sublingual nitroglycerin use because of poorly controlled angina. The PACU nurse knows that:


a. nitrate administration may lead to refractory hypertension.


b. nitrates have both a vasoconstrictive and antithrombic/antiplatelet effect.


c. the patient may not experience the full benefits and efficacy of the drip because of tolerance.


d. the patient may complain of bladder spasms while the infusion is running.


6.91. While flushing and capping the lumen on a newly placed central line, the perianesthesia nurse should:


a. clamp the line and have the patient bear down, if able, while the cap is off.


b. treat the capping and flushing as a “clean” procedure.


c. establish keep-vein-open (KVO) fluids to run at all times to keep lines clear of clots.


d. dress the site, especially if it is a tunneled central line with an implanted cuff.

NOTE: Consider items 6.92-6.93 together.


6.92. A patient with a spinal cord injury arrives after colonoscopy for suspected diverticula. He is hypertensive and sweating profusely, and as he begins to rouse, he has a grand mal seizure. Which of the following physician telephone orders should the nurse question?


a. Raise the head of the bed.


b. Deliver oxygen via bag-valve-mask.


c. Administer anticonvulsant and antihypertensive.


d. Administer epinephrine per weight.


6.93. To stabilize this patient’s blood pressure, oral nifedipine is given but seems to have little effect. The physician orders a nitroprusside drip to be started. Which of the following is true about nitroprusside?


a. Quickly becomes toxic to a patient so it should run only for a few hours


b. Should be considered along with bowel and bladder assessment


c. Reduces only preload and has no effect on afterload


d. Can alter sensorium and lead to refractory hypertension


6.94. The difference between bilevel positive airway pressure (BiPAP) and CPAP is:


a. CPAP allows for timed breaths much like a ventilator.


b. both deliver different pressures triggered by inhalation and exhalation.


c. both deliver pressure support and PEEP.


d. BiPAP may be considered in patients who cannot tolerate CPAP.


6.95. A patient with a complicated cardiac history has a syncopal episode followed by a rapid decline in blood pressure. The rhythm on the monitor appears to be a third-degree block. A code is called in the PACU. The nurse would be seen doing which of the following first?


a. Drawing up multiple doses of atropine


b. Placing paddles/patches on the patient’s chest


c. Determining if there is any relation between the QRS cycles and t waves


d. Call for a 12-lead ECG




6.97. Ramipril works by:


a. causing a direct blockade of beta-1 and beta-2 receptors.


b. decreasing production of angiotensin II.


c. altering cellular calcium re-uptake.


d. stimulating aldosterone secretion.


6.98. Which of the following would be the best intervention for a patient with known acute renal failure requiring an extended Phase II stay because of pain and extensive blood loss?


a. Calling the anesthesiologist for approval to administer Lasix


b. Administering 10 mEq potassium IV bolus over a 30-60 minute period


c. Canceling or delaying scheduled computed tomography (CT) with contrast appointment


d. Administering a renal-dose dopamine infusion and second ketorolac dose


ITEMS 6.101–6.150

NOTE: Consider items 6.101-6.102 together.

An obese man who just awakened from a 2-hour total hip arthroplasty begins to complain of tightness and pain in his non-operative leg. The nurse notes that the leg is edematous and highly suspicious for a deep vein thrombosis (DVT), a problem noted to have occurred with his past two surgeries.


6.101. How many risk factors for a DVT does the patient have?


a. 2


b. 3


c. 4


d. 5


6.102. Which of the following nursing actions would be most appropriate in this situation?


a. Call for an order to initiate IV infusion of unfractionated heparin


b. Apply cold packs to leg and massage site


c. Place leg in dependent position


d. Encourage ambulation


6.103. An intubated patient receiving his third infusion of packed red blood cells after complicated removal of a small bowel obstruction presents to the PACU. Thirty minutes later, the nurse notes that pink, frothy sputum is in the ET tube and course rhonchi and crackles can be heard throughout the lung fields. After suctioning the patient, the best nursing action(s) would be to:


a. call for albuterol treatment.


b. stop the infusion and KVO site with normal saline.


c. order stat chest x-ray film.


d. call for Lasix order and stop blood infusion.


6.104. The PACU nurse is caring for a patient who weighs 70 kg and is on a ventilator with the following ventilator settings and ABGs (see table). Which of the following adjustments to the ventilator would be most appropriate?


a. Increase respiratory rate to 14


b. Increase PEEP to 10 cm H20


c. Increase FiO2 to 70%


d. Increase tidal volume to 700 mL
































Arterial Blood Gases Ventilator Settings
pH 7.31 Normal 7.35-7.45 Mode Assist Control
PaCO2 69 Normal 35-45 mmHg FiO2 50%
HCO3 23 Normal 22-26 mEq/L Tidal Volume 500 mL
PaO2 75 Normal 80-100 mmHg Rate 10/min



PEEP 5 cm H20


6.105. When considering the anatomy of the lungs and how its anatomy might impact post-anesthesia care, which of the following statements is correct?


a. Aspiration is more common into the left rather than the right lobe of the lung.


b. Ventilation is generally greater in the left than the right lobe of the lung.


c. The left bronchus turns at a sharper angle toward the lung than the right bronchus.


d. Decreased or absent lung sounds are a more common finding on the left than the right after intubation.

NOTE: Consider items 6.106-6.108 together.


6.106. After free flap reconstruction of the right breast, the PACU nurse should be most concerned with which of the following?


a. White to light-gray coloration of flap site


b. Jackson-Pratt wound drain to thumb-print suction


c. Order for subcutaneous heparin


d. Core body temperature of 35.2° C (95.4° F)


6.107. The patient begins to complain of back pain and asks the nurse to help her reposition for comfort. Which of the following would be the correct option for the nurse?


a. Position in a right side-lying position


b. Allow the patient to lie prone


c. Adjust the head of the bed until a comfortable position is achieved


d. Allow the patient to stretch her arms and rest with her hands behind her head


6.108. The patient has now been in the PACU for 2 hours because of poor pain control, hypothermia, and hypotension. Which of the following assessments would be unexpected in this scenario and require a prompt call to the surgical team?


a. Blanching of the skin within 4 seconds


b. Flap site warm to the touch


c. Pulses faint but obtainable by Doppler over flap site


d. Purple/blue color to flap site

NOTE: Consider items 6.109-6.110 together.


6.109. After a traumatic motor vehicle crash, the nurse in the preoperative holding area stabilizes a patient before she is about to go to surgery. The preoperative nurse notes that a chest tube has been placed for blood in the pleural space. The nurse should expect that the tube(s) would be placed:


a. at the second intercostal space on the injured side.


b. at the seventh intercostal space on the injured side.


c. mediastinally at the nipple line.


d. at both the second and seventh intercostal spaces.


6.110. A new graduate nurse assisting that day asks the preoperative nurse about the chest tube drainage device that is attached. Which of the statements made by the new nurse is correct?


a. “Attaching the drainage system to wall suction does directly suck air and fluid out of the chest.”


b. “The up-and-down motion of the fluid in the water seal column means that the system is working incorrectly.”


c. “Bubbles in the suction chamber indicates there is no air leak.”


d. “Bubbles in the water seal column indicate there is an air leak.”


6.111. After endovascular stenting of a thoracic aneurysm, the patient complains of nagging chest and back pain. The surgical team and anesthesiologist are called, and cardiac origin of the pain is ruled out. There is discussion of an endoleak at the graft site. Which of the following should the nurse prepare for in this scenario?


a. Discharging the patient to CT


b. Fluid resuscitation


c. Application of direct pressure at femoral sites


d. Administration of nitroglycerin as needed


6.112. In reviewing an anesthesia record with a patient as the patient prepares to be discharged from the outpatient surgical center, the patient asks why lidocaine was given to him before he went to sleep. Which of the following would be an incorrect answer?


a. It decreases the urge to cough.


b. It counteracts increased pressure in the brain during intubation.


c. It sometimes limits the effect of induction on the heart.


d. It lowers the risk of pulmonary edema and aspiration.


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Jul 11, 2016 | Posted by in NURSING | Comments Off on Cardiac, Vascular, and Pulmonary Systems

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