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PCCN EXAM QUESTIONS AND ANSWERS
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PCCN EXAM QUESTIONS AND ANSWERS
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PCCN EXAM QUESTIONS AND ANSWERSCoronary artery perfusion is dependent upon:
A. diastolic pressure
B. systolic pressure
C. afterload
D. systemic vascular resistance (SVR) - Answers- A. diastolic pressure
Diastolic pressure in the aortic root is higher than left ventricular end-diastolic pressure
(LVEDP), the pressure exerted on the ventricular muscle at the end of diastole when the
ventricle is full. This enables blood to flow from a higher pressure through open arteries
to a lower pressure, a pressure gradient known as coronary artery prefusion pressure.
As diastolic pressure drops, there is a decrease in coronary artery blood flow. Coronary
artery perfusion is not affected by systolic pressure, afterload or SVR, but they all
increase the demand of oxygen in the heart.
A post-STEMI (ST elevation myocardial infarction) patient is started on an angiotensin-
converting enzyme (ACE) inhibitor during his hospital stay. Which of the following is the
most common serious side effect that may occur?
A. a nonproductive cough
B. pedal edema
C. swelling of the tongue and face
D. rhinorrhea - Answers- C. swelling of the tongue and face
Although all of the answers may occur, swelling og the tongue and face is the most
serious and may require intervention. Patients should be instructed to seek medical
attention immediately for any signs of swelling in the tongue or throat.
Which of the following best describes the fourth heart sound (S4):
A. It occurs after ventricular contraction
B. It is best heard with the diaphragm of the stethoscope
C. It is a normal finding in children
D. It occurs during late diastole when the atria contracts - Answers- D. It occurs during
late diastole when the atria contracts
The presence of the extra heart sound S4 signifies a poorly compliant (stiff) left
ventricle. An S4 is also called an atrial heart sound since it occurs at the end of diastolic
filling when the atria contracts and fully fills the left ventricle. Known as "atrial kick", this
filling is important to cardiac output. The increased end-diastolic volume in the ventricle
improves cardiac output. When the left ventricle is stiff (decreased compliance with long
term hypertension, aortic stenosis or with acute STEMI), the atrium has to pump harder
to move blood from the atrium to the ventricle, causing a turbulent blood flow and extra
heart sound. This heart sound is always pathologic. It occurs before ventricular
contraction, is best heard with the bell of the stethoscope and is never a normal heart
sound, even in children.
Which pathologic changes found on the 12-lead ECG indicate myocardial ischemia?
A. ST-segment elevation
,B. ST-segment depression and T-wave elevation
C. Q-wave formation
D. ST-segment depression and T-wave inversion - Answers- D. ST segment depression
and T wave inversion
Myocardial ischemia changes the repolarization of the ventricular muscle. That change
is seen on the 12 lead ECG as ST-segment depression and T wave inversion, which
demonstrate subendocardial ischemia -- the innermost layer of muscle in the
myocardium. ST-segment elevation indicates acute injury or infarction, ST segment
depression and T wave elevation may indicate an electrolyte abnormality, while Q wave
formation indicates total infarction.
Positive inotropic agents are used to:
A. improve cardiac output and tissue perfusion
B. decrease water loss through the kidneys
C. increase heart rate
D. vasodilate vessels - Answers- A. improve cardiac output and tissue perfusion
The term "inotropic" refers to affecting the force of myocardial contraction. Improvement
of cardiac muscle contraction leads to improved cardiac output and tissue perfusion.
A patient in the ED is now being admitted to telemetry bwith complaint of chest pain and
has been judged to be a possible candidate for therapy with alteplase (Activase). Which
of the following is not considered a contraindication for the use of this medication?
A. current antibiotic use
B. recent abdominal surgery
C. recent gastrointestinal bleed
D. recent intracranial bleed - Answers- A. current antibiotic use
Use of antibiotics is not a contraindication for the use of alteplase. All the other answers
-- recent abdominal surgery, recent gastrointestinal bleeding and a recent intracranial
bleed -- are contraindications for the use of any fibrinolytic.
The two major components that determine blood pressure are:
A. systemic vascular resistance (SVR) (afterload) and cardiac output
B. contractility and SVR (afterload)
C. preload and SVR (afterload)
D. contractility and SVR (afterload) - Answers- A. SVR (afterload) and cardiac output
The equation for BP is: BP = SVR x cardiac output.
BP is determined by resistance of the arterial bed and the cardiac output. If the SVR
(afterload) is high and the cardiac output low, the patient may still have a normal BP. the
pulse pressure will be lower, but this is a compensatory response by the heart to
maintain BP. If the SVR (afterload) is low (as in early septic shock), the cardiac output is
very high, thereby trying to support BP.
The layer of the arterial vessel wall responsible for changes in the diameter of the artery
is the:
A. media
B. intima
,C. externa
D. adventitia - Answers- A. media
The media layer of the arterial wall contains vascular smooth muscle cells and is
responsible for arterial tone. Vasoactive substances released in response to the
sympathetic nervous system and/or the renin-angiotensin system determine arterial
tone. Intima, externa and adventitia are incorrect.
A patient presents in acute distress with rales halfway up bilaterally; cool and clammy
extremities; elevated jugular venous distention (JVD); oxygen saturations at 95%, down
from 99%; and complaints of shortness of breath. Which of the following findings
correspond to the patient's cardiac status?
A. no pulmonary congestion, normal perfusion
B. no pulmonary congestion, low perfusion
C. pulmonary congestion, normal perfusion
D. pulmonary congestion, low perfusion - Answers- D. pulmonary congestion, low
perfusion
Rales indicate fluid in the alveolar sacs, possibly secondary to pulmonary edema,
causing pulmonary congestion. Pneumonia can also cause fluid in the alveolar sacs.
The patient is complaining of shortness of breath, and the oxygen saturations are
lowering, also indicating that the patient has pulmonary congestion. The patient's skin is
cool and clammy, indicating that the skin is poorly perfused. Skin does not require
oxygen and shunts blood away in decreased cardiac function; therefore, this patient has
pulmonary congestion and low perfusion state. The other answers are incorrect.
When listening to heart sounds, S1 signifies which of the following?
A. the beginning of ventricular systole
B. the beginning of ventricular diastole
C. the propulsion of blood into a non-compliant ventricle
D. the blood going in the wrong direction - Answers- A. the beginning of ventricular
systole
The heart sound of S1 indicates the opening of the aortic and pulmonic valves and
marks the beginning of ventricular systole or ejection. The beginning of diastole is after
S2, propulsion of blood into a noncompliant chamber is S4, and blood going in the
wrong direction will cause a murmur.
A patient with pulmonary edema has impaired diffusion due to:
A. increased thickness of the alveolar capillary membrane
B. retaining CO2
C. an elevated body temperature associated with pulmonary edema
D. low barometric pressure - Answers- A. increased thickness of the alveolar capillary
membrane
With increasing left ventricular pressures, blood moves back into the left atrium, then to
the pulmonary veins. When the pressure in the pulmonary veins increases, capillary
function decreases, and fluid then shifts to the interstitial space, causing interstitial
edema, thereby, increasing the thickness of the space oxygen must travel. When left
ventricular pressures increase, the fluid then shifts to the alveolar space, causing
, pulmonary edema. This fluid acts as a deterrent to oxygen diffusion. Retention of CO2
does not impair diffusion. An elevated body temperature associated with pulmonary
edema is not causing a diffusion abnormality; increased temperature shifts the
oxyhemoglobin curve to the right, more quickly releasing oxygen to the tissues. Low
barometric pressure has no effect on diffusion of gases in the lung.
A patient with an anterior-wall STEMI is in cardiogenic shock. What would be the
hemodynamic profile assessment?
A. decreased cardiac index, increased preload, increased afterload
B. decreased cardiac index, decreased preload, increased afterload
C. decreased cardiac index, decreased preload, decreased afterload
D. increased cardiac index, decreased preload, decreased afterload - Answers- A.
decreased cardiac index, increased preload, increased afterload
In a patient with cardiogenic shock, both preload and afterload are increased due to
severe vasoconstriction on both the venous and arterial side. Arterial vasoconstriction
increases afterload and therefore lowers cardiac index. Because the ventricle is failing
and contractility is also low, the left ventricular pressures increase and cause blood to
increase in the pulmonary bed, resulting in increased right ventricular pressures and
preload. In heart failure, there is an increase in preload and afterload with a decrease in
cardiac index and contractility. The other answers are incorrect.
A patient is discharged with the diagnosis of severe peripheral vascular disease (PVD).
In addition to medication and a walking regime, if applicable, which of the following is
essential education at time of discharge?
A. nutritional counseling
B. smoking cessation counseling
C. social work consult
D. speech therapy consult - Answers- B. smoking cessation counseling
Cessation of tobacco use is the most important non-pharmacological intervention that
can be done to improve signs and symptoms of peripheral bvascular disease. Social
work consult and speech therapy may not be indicated in this patient. All patients may
benefit from nutrition counseling; however, this is not a primary concern for this patient.
A medication that dilates both the venous and arterial beds will cause which of the
following results?
A. increased preload, decreased afterload
B. increased preload, increased afterload
C. decreased preload, decreased afterload
D. decreased preload, increased afterload - Answers- C. decreased preload, decreased
afterload
When both the venous and arterial beds are dilated, there will be less venous return,
causing a decreased preload (ex. nitroglycerin). With arterial vasodilation, the afterload
will decrease (ex nitroprusside, ACE-I). Afterload in this case is resistant to LV pumping.
Stable angina is best defined as:
A. pain that increases in severity
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