Hemodynamic Monitoring:

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1 Workbook for Hemodynamic Monitoring: Evolving Technologies and Clinical Practice Workbook By Marcie Scott, MSN, RN Upon successful completion of this course, continuing education hours will be awarded as follows: Nurses: 24 Contact Hours* *Western Schools is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation.

2 WESTERN SCHOOLS P.O. Box 1930 Brockton, MA About the WORKBOOK author Marcie Scott, MSN, RN, is a Nurse Planner at Western Schools with more than 25 years of professional nursing experience and a master s degree in cardiovascular nursing. Marcie began her nursing career on a cardiac telemetry unit and then held a clinical nursing position on a cardiothoracic intensive care unit, assuming charge nurse and preceptor roles as assigned. Later, as a program manager with a health maintenance organization, Marcie gathered much experience conducting health education seminars and developing disease management and health promotion written materials for patients with cardiovascular disease. An expert in evaluation/exam item writing, Marcie has trained nurse content experts to write certification exam items for the American Nurses Credentialing Center. Marcie Scott has disclosed that she has no significant financial or other conflicts of interest pertaining to this course book. Nurse Planner: Kim V. Cheramie, MSN, RN-BC The planner who worked on this continuing education activity has disclosed that she has no significant financial or other conflicts of interest pertaining to this course book. Copy Editor: Diane Hinckley Western Schools courses are designed to provide healthcare professionals with the educational information they need to enhance their career development as well as to work collaboratively on improving patient care. The information provided within these course materials is the result of research and consultation with prominent healthcare authorities and is, to the best of our knowledge, current and accurate at the time of printing. However, course materials are provided with the understanding that Western Schools is not engaged in offering legal, medical, or other professional advice. Western Schools courses and course materials are not meant to act as a substitute for seeking professional advice or conducting individual research. When the information provided in course materials is applied to individual cases, all recommendations must be considered in light of each case s unique circumstances. Western Schools course materials are intended solely for your use and not for the purpose of providing advice or recommendations to third parties. Western Schools absolves itself of any responsibility for adverse consequences resulting from the failure to seek medical, or other professional advice. Western Schools further absolves itself of any responsibility for updating or revising any programs or publications presented, published, distributed, or sponsored by Western Schools unless otherwise agreed to as part of an individual purchase contract. Products (including brand names) mentioned or pictured in Western Schools courses are not endorsed by Western Schools, any of its accrediting organizations, or any state licensing board. ISBN: COPYRIGHT 2016 Western Schools. All Rights Reserved. No part(s) of this material may be reprinted, reproduced, transmitted, stored in a retrieval system, or otherwise utilized, in any form or by any means electronic or mechanical, including photocopying or recording, now existing or hereinafter invented, nor may any part of this course be used for teaching without written permission from the publisher. FP0516WS ii

3 COURSE INSTRUCTIONS IMPORTANT: Read these instructions BEFORE proceeding! HOW TO EARN CONTINUING EDUCATION CREDIT To successfully complete this course you must: 1) Read the entire course 2) Pass the final exam with a score of 75% or higher* 3) Complete the course evaluation *You have three attempts to pass the exam. If you take the exam online, and fail to receive a passing grade, select Retake Exam. If you submit the exam by mail or fax and you fail to receive a passing grade, you will be notified by mail and receive an additional answer sheet. Final exams must be received at Western Schools before the Complete By date located at the top of the FasTrax answer sheet enclosed with your course. Note: The Complete By date is either 1 year from the date of purchase, or the expiration date assigned to the course, whichever date comes first. HOW TO SUBMIT THE FINAL EXAM AND COURSE EVALUATION ONLINE: best option! For instant grading, regardless of course format purchased, submit your exam online at Benefits of submitting exam answers online: Save time and postage Access grade results instantly and retake the exam immediately, if needed Identify and review questions answered incorrectly Access certificate of completion instantly Note: If you have not yet registered on Western Schools website, you will need to register and then call customer service at to request your courses be made available to you online. Mail or Fax: To submit your exam and evaluation answers by mail or fax, fill out the FasTrax answer sheet, which is preprinted with your name, address, and course title. If you are completing more than one course, be sure to record your answers on the correct corresponding answer sheet. Complete the FasTrax Answer Sheet using blue or black ink only. If you make an error use correction fluid. If the exam has fewer than 100 questions, leave any remaining answer circles blank. Respond to the evaluation questions under the heading Evaluation, found on the right-hand side of the FasTrax answer sheet. See the FasTrax Exam Grading & Certificate Issue Options enclosed with your course order for further instructions. CHANGE OF ADDRESS? Contact our customer service department at , or customerservice@westernschools.com, if your postal or address changes prior to completing this course. WESTERN SCHOOLS GUARANTEES YOUR SATISFACTION If any continuing education course fails to meet your expectations, or if you are not satisfied for any reason, you may return the course materials for an exchange or a refund (excluding shipping and handling) within 30 days, provided that you have not already received continuing education credit for the course. Software, video, and audio courses must be returned unopened. Textbooks must not be written in or marked up in any other way. Thank you for using Western Schools to fulfill your continuing education needs! WESTERN SCHOOLS P.O. Box 1930, Brockton, MA iii

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5 Western Schools course evaluation Hemodynamic Monitoring: Evolving Technologies and Clinical Practice INSTRUCTIONS: Using the scale below, please respond to the following evaluation statements. All responses should be recorded in the right-hand column of the FasTrax answer sheet, in the section marked Evaluation. Be sure to fill in each corresponding answer circle completely using blue or black ink. Leave any remaining answer circles blank. A B C D Agree Agree Disagree Disagree Strongly Somewhat Somewhat Strongly OBJECTIVES: After completing this course, I am able to: 1. Identify established monitoring methods and their implications in patient assessment. 2. Describe emerging technologies in hemodynamic monitoring. 3. Identify appropriate hemodynamic monitoring in clinical practice. COURSE CONTENT 4. The course content was presented in a well-organized and clearly written manner. 5. The course content was presented in a fair, unbiased and balanced manner. 6. The course content presented current developments in the field. 7. The course was relevant to my professional practice or interests. 8. The final examination was at an appropriate level for the content of the course. 9. The course expanded my knowledge and enhanced my skills related to the subject matter. 10. I intend to apply the knowledge and skills I ve learned to my practice. A. Yes B. Unsure C. No D. Not Applicable CUSTOMER SERVICE The following section addresses your experience in interacting with Western Schools. Use the scale below to respond to the statements in this section. A. Yes B. No C. Not Applicable 11. Western Schools staff was responsive to my request for disability accommodations. 12. The Western Schools website was informative and easy to navigate. 13. The process of ordering was easy and efficient. 14. Western Schools staff was knowledgeable and helpful in addressing my questions or problems. ATTESTATION 15. I certify that I have read the course materials and personally completed the final examination based on the material presented. Mark A for Agree and B for Disagree. v continued on next page

6 vi Course Evaluation Hemodynamic Monitoring: Evolving Technologies and Clinical Practice COURSE RATING 16. My overall rating for this course is A. Poor B. Below Average C. Average D. Good E. Excellent You may be contacted within 3 to 6 months of completing this course to participate in a brief survey to evaluate the impact of this course on your clinical practice and patient/client outcomes. Note: To provide additional feedback regarding this course, Western Schools services, or to suggest new course topics, use the space provided on the Important Information form found on the back of the FasTrax instruction sheet included with your course.

7 CONTENTS Evaluation...v Introduction...ix Lesson Plan...1 Pretest...3 s...5 Final Exam...11 vii

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9 INTRODUCTION Course Objectives After completing this course, the learner 1. Identify established monitoring methods and their implications in patient assessment. 2. Describe emerging technologies in hemodynamic monitoring. 3. Identify appropriate hemodynamic monitoring in clinical practice. LEARNING OUTCOME After completing this course, the learner will be able to distinguish the appropriate hemodynamic monitoring application for the patient to effectively and accurately measure physiologic responses to disease process and nursing interventions. OVERVIEW Hemodynamic monitoring has greatly improved during the past decade. New hemodynamic monitoring systems are less invasive, but require greater emphasis on assessing the functional status of the patient. Therefore, today s healthcare practitioner has a demonstrated need for continuing education that will increase his or her knowledge and understanding of human physiologic and pathophysiologic mechanisms. Continuing education is also needed for explaining the current role of hemodynamic monitoring in the management of human pathophysiology. The purpose of this course is to explain established and emerging hemodynamic monitoring methods to critical care and other healthcare practitioners who are interested in applying their hemodynamic monitoring knowledge and experience to specific clinical practice situations. This course is targeted to registered nurses (RNs) and advanced practice registered nurses (APRNs) who currently practice or wish to practice in a healthcare setting where hemodynamic monitoring is used. This course stresses critical thinking and practical application as essential nursing skills in understanding the relevance of hemodynamic monitoring to the care and education of patients and their families. After completing this course, the healthcare practitioner will demonstrate expert nursing care that is based on current, evidence-based practice and increased knowledge for evaluating hemodynamic monitoring systems and their potential impact on patient outcomes. ix

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11 lesson plan HEMODYNAMIC MONITORING This educational offering incorporates the information contained in Hemodynamic Monitoring: Evolving Technologies and Clinical Practice (first ed.) by Mary E. Lough into an integrated learning experience. Learning outcomes and chapter objectives are provided for each chapter. Chapter objectives focus individual study on information contained within each chapter of the textbook. The final exam questions are based on the individual chapter objectives and are meant to evaluate the reader s learning of each objective. To complete this course, study the objectives provided in this workbook (pages 5-10) pertaining to each chapter of the textbook. Read each chapter in the textbook and answer the final exam questions (workbook pages 11-23) as indicated in this Lesson Plan. Answer final exam questions online at my-courses for instant results, or log answers on the FasTrax answer sheet provided with the course. NOTE: Before getting started, log into your account at com/my-courses to take your exam as you read the course. You can save your progress and return to it at any time. If completing by mail or fax, please be sure you are using the FasTrax answer sheet labeled Hemodynamic Monitoring. CHAPTER 1: Physiologic Principles of Hemodynamic Monitoring Read Chapter 1 and answer questions 1-4. CHAPTER 2: Physical Assessment and Hemodynamic Monitoring Read Chapter 2 and answer questions 5-8. CHAPTER 3: Arterial Pressure Monitoring Read Chapter 3 and answer questions CHAPTER 4: Central Venous Pressure Monitoring Read Chapter 4 and answer questions CHAPTER 5: Pulmonary Artery Pressure and Thermodilution Cardiac Output Monitoring Read Chapter 5 and answer questions CHAPTER 6: Oxygenation and Acid-Base Balance Monitoring Read Chapter 6 and answer questions CHAPTER 7: Venous Oxygen Saturation Monitoring Read Chapter 7 and answer questions CHAPTER 8: Capnography Monitoring Read Chapter 8 and answer questions CHAPTER 9: Vasoactive Medications Read Chapter 9 and answer questions

12 Lesson Plan 2 Hemodynamic Monitoring: Evolving Technologies and Clinical Practice CHAPTER 10: Doppler Hemodynamic Monitoring Read Chapter 10 and answer questions CHAPTER 11: Ultrasonography-Based Hemodynamic Monitoring Read Chapter 11 and answer questions CHAPTER 12: Arterial Waveform and Pressure-Based Hemodynamic Monitoring Read Chapter 12 and answer questions CHAPTER 13: Implantable Hemodynamic Monitoring Read Chapter 13 and answer questions CHAPTER 14: Hemodynamics of Mechanical Ventilation and Acute Respiratory Distress Syndrome Read Chapter 14 and answer questions CHAPTER 15: Hemodynamics of Mechanical Circulatory Support Read Chapter 15 and answer questions CHAPTER 16: Hemodynamic Management Following Cardiac Surgery Read Chapter 16 and answer questions CHAPTER 17: Hemodynamic Management of Heart Failure and Cardiogenic Shock Read Chapter 17 and answer questions CHAPTER 18: Hemodynamics of Acute Right Heart Failure and Pulmonary Hypertension Read Chapter 18 and answer questions CHAPTER 19: Hemodynamic Management in Hypovolemia and Trauma Read Chapter 19 and answer questions CHAPTER 20: Hemodynamics of Sepsis Read Chapter 20 and answer questions CHAPTER 21: Hemodynamic and Intracranial Dynamic Monitoring in Neurocritical Care Read Chapter 21 and answer questions CHAPTER 22: Goal-Directed Hemodynamics Read Chapter 22 and answer questions

13 PRETEST 1. Begin this course by taking the pretest. Circle the answers to the questions on this page, or write the answers on a separate sheet of paper. Do not log answers to the pretest questions on the FasTrax test sheet included with the course. 2. Compare your answers to the answers in the pretest key located at the end of the pretest. The pretest key indicates the page where the content of that question is discussed within the textbook. Make note of the questions you missed, so that you can focus on those areas as you complete the course. 3. Read the entire course and complete the exam questions at the end of the course. Answers to the exam questions should be logged on the FasTrax test sheet included with the course. Note: Choose the one option that BEST answers each question. 1. According to Starling s law, if the volumetric preload becomes too great, then cardiac muscle fibers become overdistended and have a. greater pumping ability. b. less contractility. c. less pressure to pump against. d. more type 1 fibers. 2. Cardiac output is calculated by multiplying the patient s heart rate by the a. quantity of blood in the right ventricle. b. volumetric pressure of blood in the aorta. c. end-diastolic volume. d. stroke volume. 3. Central venous catheters are used far more today for fluid infusions, intravenous medications, parenteral nutrition, and monitoring of venous a. oxygen saturation. b. return to the brain. c. insufficiency. d. thrombosis When using a capnography monitor, a comparison of exhaled carbon dioxide values with arterial carbon dioxide values is possible with a(n) a. colorimetric device. b. endotracheal tube. c. waveform analysis. d. neurological assessment. 5. Implantable hemodynamic monitoring is commonly used in patients with a. acute respiratory distress syndrome. b. cardiac arrhythmias. c. heart failure. d. cardiac surgery procedures. PRETEST KEY 1. B Chapter 1 2. D Chapter 2 3. A Chapter 4 4. C Chapter 8 5. C Chapter 13

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15 LEARNING OUTCOMES CHAPTER 1: Physiologic Principles of Hemodynamic Monitoring will be able to describe the basic measurements of blood flow and pressure dynamics based on cardiac and circulatory physiologic principles. 1. Discuss blood flow through the heart during the five phases of the cardiac cycle. 2. Identify the normal value ranges of cardiac hemodynamic parameters. 3. List the four components providing the foundation for hemodynamic intervention in clinical practice. 4. Describe normal blood circulation, including arterial and venous vascular dynamics. CHAPTER 2: Physical Assessment and Hemodynamic Monitoring will be able to identify the physical manifestations of impaired tissue perfusion and altered hemodynamics. 1. Identify the three physiologic concepts involved in oxygen delivery to the cells. 2. Summarize physical assessment findings suggestive of impaired tissue perfusion and altered hemodynamics. 3. List measurements providing objective assessment of cardiopulmonary dysfunction. CHAPTER 3: Arterial Pressure Monitoring will be able describe how arterial blood pressure readings and waveforms assist in determining hemodynamic function. 1. Identify features of arterial pressure waveforms. 2. Describe the clinical procedure and technical considerations for inserting arterial catheters. 3. Recognize possible complications associated with arterial catheters. 4. Discuss arterial waveform derived variables and volume responsiveness. CHAPTER 4: Central Venous Pressure Monitoring will be able to explain current and future approaches to central venous pressure monitoring. 5

16 s 6 Hemodynamic Monitoring: Evolving Technologies and Clinical Practice 1. State the clinical role of central venous pressure measurements. 2. Review the procedure for measurement of central venous pressure. 3. Discuss recent thinking in evaluating central venous pressure readings. CHAPTER 5: Pulmonary Artery Pressure and Thermodilution Cardiac Output Monitoring will be able to review indications for use and precautions with pulmonary artery catheter monitoring. 1. Discuss indications for using pulmonary artery catheter monitoring. 2. Review risks and patient safety measures associated with pulmonary artery catheter monitoring. 3. Explain how to obtain accurate measurements with a pulmonary artery catheter. CHAPTER 6: Oxygenation and Acid-Base Balance Monitoring will be able to explain how assessment of oxygenation and ventilation are critical to hemodynamic evaluation. 1. Describe oxygen transport and the oxyhemoglobin curve. 2. Review pulmonary blood flow and gas exchange. 3. Review methods of monitoring oxygenation. 4. Explain ventilation and assessment of partial pressure of arterial carbon dioxide. 5. Discuss how the arterial blood gas provides information about ventilation and oxygenation. CHAPTER 7: Venous Oxygen Saturation Monitoring will be able to describe the relationship between venous oxygen saturation monitoring and assessment of oxygen delivery and uptake by tissues. 1. Describe the normal exchange of oxygen and carbon dioxide in the lungs and tissues. 2. Discuss how to obtain reliable mixed venous oxygen saturation values and what these values reveal about oxygen supply and demand. 3. Review compensatory mechanisms for an imbalance between oxygen delivery and consumption. 4. Explain the rationale for comparing central venous oxygen saturation to mixed venous oxygen saturation. CHAPTER 8: Capnography Monitoring will be able to describe how capnography monitoring assists in detecting pathophysiologic mechanisms and mechanical ventilation malfunction.

17 s Hemodynamic Monitoring: Evolving Technologies and Clinical Practice 7 1. Review carbon dioxide measurement devices used in the clinical setting. 2. Describe the normal capnogram for a nonintubated patient. 3. Summarize current applications of capnography in clinical practice. 4. Identify the benefits of capnography in the care of mechanically ventilated patients. CHAPTER 9: Vasoactive Medications will be able to identify the role of vasoactive medications in restoring tissue perfusion and aerobic cellular metabolism. 1. State the clinical effects of vasopressor medications and the pathology for which they are used. 2. State the clinical effects of vasodilator medications and the pathology for which they are used. 3. State the clinical effects of positive inotropic agents and the pathology for which they are used. 4. State the clinical effects of inodilators and the pathology for which they are used. 5. State the clinical effects of beta-blockers, alphablockers, and combined alpha-beta blockers and the pathology for which they are used. CHAPTER 10: Doppler Hemodynamic Monitoring will be able to discuss the major uses and benefits of using Doppler hemodynamic monitoring. 1. Identify the fundamental measure of heart function by Doppler ultrasound. 2. Review applications for Doppler monitoring in the clinical setting. 3. Describe the two types of Doppler monitoring currently available. CHAPTER 11: Ultrasonography- Based Hemodynamic Monitoring will be able to describe the effectiveness of using bedside ultrasonography across different clinical conditions and settings. 1. State the primary purpose for using bedside ultrasonography. 2. Review the components of the ultrasound machine and how they evaluate body structures. 3. Identify bedside ultrasonography protocols used to guide systematic assessment of patients. CHAPTER 12: Arterial Waveform and Pressure-Based Hemodynamic Monitoring will be able to explain the use of arterial waveform and pressure-based technologies in hemodynamic assessment.

18 s 8 Hemodynamic Monitoring: Evolving Technologies and Clinical Practice 1. Describe technologies that use arterial pressure or waveforms to determine cardiac output. 2. Discuss dynamic parameters that assist in calculating fluid responsiveness. 3. Review functional physiologic challenges that can predict a patient s response to volume therapy. 4. Summarize the care of patients with invasive and noninvasive hemodynamic monitoring devices. CHAPTER 13: Implantable Hemodynamic Monitoring will be able to describe current management of patients who have heart failure with implantable hemodynamic monitoring. 1. Discuss traditional management of patients with heart failure. 2. Identify how implantable hemodynamic monitoring assists in the day-to-day management of patients with heart failure. 3. Summarize current features of implantable hemodynamic monitoring devices. 4. Review the potential health benefits and risks associated with implantable hemodynamic monitoring devices. CHAPTER 14: Hemodynamics of Mechanical Ventilation and Acute Respiratory Distress Syndrome will be able to understand the effects of positive pressure mechanical ventilation and acute respiratory distress syndrome (ARDS) on hemodynamic function. 1. Explain the effect of venous return on ventilation and hemodynamics. 2. Describe the hemodynamic consequences of positive end-expiratory pressure (PEEP) and positive pressure ventilation. 3. Identify hemodynamic impairments in patients with ARDS. CHAPTER 15: Hemodynamics of Mechanical Circulatory Support will be able to summarize the application of mechanical circulatory support in clinical practice. 1. Review the different categories of mechanical circulatory support devices. 2. Describe the benefits, risks, and limitations of the various types of mechanical circulatory support devices. 3. Compare long-term mechanical circulatory support and heart transplantation. CHAPTER 16: Hemodynamic Management Following Cardiac Surgery will be able to describe the purpose of hemodynamic monitoring for patients undergoing cardiac surgery. 1. Describe the impact of cardiac surgery on hemodynamics.

19 s Hemodynamic Monitoring: Evolving Technologies and Clinical Practice 9 2. Review the advantages of hemodynamic monitoring prior to cardiac surgery. 3. Discuss potential adverse outcomes detected by hemodynamic monitoring following cardiac surgery. CHAPTER 17: Hemodynamic Management of Heart Failure and Cardiogenic Shock will be able to describe appropriate management of the patient with left heart failure and cardiogenic shock. 1. Review the continuum of heart failure in patients. 2. Summarize the body s compensatory mechanisms in heart failure. 3. Discuss the subcategories of heart failure. 4 Recognize the signs and symptoms of heart failure and cardiogenic shock. CHAPTER 18: Hemodynamics of Acute Right Heart Failure and Pulmonary Hypertension will be able to describe the two distinct diagnoses of acute right heart failure and pulmonary hypertension. 1. Compare key physiologic differences between the right and left heart chambers. 2. Discuss the clinical conditions, including pulmonary hypertension, which cause right heart failure. 3. Describe physical assessment, tests, and hemo dynamic measures useful for diagnosing right heart failure. 4. Identify the goals of treatment for right heart failure. 5. Summarize the five classifications of pulmonary hypertension identified by the World Health Organization criteria. CHAPTER 19: Hemodynamic Management in Hypovolemia and Trauma will be able to describe utilization of hemodynamic data in caring for trauma patients during the resuscitation and critical care phases of recovery. 1. Discuss the unique needs of older adult patients with cardiac disease who experience trauma. 2. Identify common syndromes experienced by patients in the resuscitation phase following trauma. 3. Review hemodynamic parameters for assessing the status of patients following trauma. 4. Describe patient management and potential complications in the critical care phase following trauma. CHAPTER 20: Hemodynamics of Sepsis will be able to summarize early goal-directed therapy for patients with sepsis.

20 s 10 Hemodynamic Monitoring: Evolving Technologies and Clinical Practice 1. State the goals of the most recent guidelines for managing patients with sepsis. 2. Describe the pathophysiology of sepsis along a continuum of severity. 3. Discuss the altered hemodynamics of patients with sepsis. 4. Review management of patients diagnosed with sepsis. CHAPTER 21: Hemodynamic and Intracranial Dynamic Monitoring in Neurocritical Care will be able to describe hemodynamic and intracranial dynamic monitoring for the patient with catastrophic neurologic injury or illness. 1. Define multimodality monitoring for the patient with catastrophic neurologic injury or illness. 2. Discuss normal intracranial pressure and other key physiologic concepts in hemodynamic and intracranial monitoring. 3. Review central nervous system and adjunctive measurement methods used for patients with neurologic injury and illness. 4. Describe hemodynamic and intracranial dynamic monitoring for specific neurologic injury and illness. CHAPTER 22: Goal-Directed Hemodynamics will be able to explain the continuing challenges of caring for patients in life-threatening physiologic states despite advances in hemodynamic monitoring. 1. Describe functional hemodynamic monitoring using dynamic measures. 2. Discuss the role of hemodynamic monitoring in improving outcomes for the patient who is critically ill. 3. Explain early, goal-directed therapy for the patient who is critically ill.

21 Final Exam HEMODYNAMIC MONITORING Questions Note: Choose the one option that BEST answers each question. CHAPTER 1 1. Each phase of the cardiac cycle begins and ends with a. a heartbeat. b. a valve movement. c. an electrical stimulation. d. an isovolumetric ventricular contraction. 2. The mean arterial pressure (MAP) value range is normally a mm Hg. b mm Hg. c mm Hg. d mmhg. 3. The right atrial preload volume is influenced by a. venous return. b. afterload. c. contractility. d. heart rate. 4. All the major systemic organs receive arterial blood of a very similar a. resistance level. b. flow rate. c. quantity. d. oxygenation quality. CHAPTER 2 5. The major determinants of oxygen delivery to the cells are cardiac output, oxygen, and a. carbon dioxide. b. respiratory rate. c. normal sinus rhythm. d. hemoglobin. 6. Central cyanosis in patients is most sensitive to visual observation by inspecting the a. sublingual portion of the tongue. b. mucous membranes. c. skin on the hands. d. nail beds. 7. Displacement of the apical pulse either laterally or downward, or a point of maximal impulse greater than 2 cm in diameter, is indicative of a. pulmonary congestion. b. atrial fibrillation. c. left ventricular enlargement. d. tachycardia. 8. A narrow pulse pressure can be a sign of a. tachypnea. b. hypovolemia. c. ascites. d. pulsus paradoxus. 11

22 Final Exam 12 Hemodynamic Monitoring: Evolving Technologies and Clinical Practice CHAPTER 3 9. The dicrotic notch on the arterial pressure waveform represents the a. passive filling of the atria. b. onset of ventricular systole. c. end of systole with closure of the aortic valve. d. end of diastole with closure of the atrioventricular valve. 10. The radial artery is the preferred site for insertion of an arterial catheter because the hand has a second arterial supply, and the radial artery a. is often the most easily accessible artery in an emergency. b. is associated with peripheral neuropathy. c. runs together with a nerve. d. runs over a bone. 11. Before an arterial catheter is inserted into the radial artery, Doppler assessment or the modified Allen test is used to assess for a. collateral circulation. b. hemodynamic pressure readings. c. ultrasound guidance. d. adequate blood pressure control. 12. The Centers for Disease Control and Prevention Guidelines for Prevention of Infection for Arterial Catheters and Pressure Monitoring Devices in Adult Patients include preferred use of the radial, brachial, or dorsalis pedis sites, keeping all components of the pressure monitoring system sterile, and a. developing a routine replacement schedule for arterial catheters. b. using an open flush system instead of a continuous flush system. c. avoiding administration of dextrosecontaining solutions through the pressure monitoring circuit. d. using sterilized reusable transducers instead of disposable transducers when possible. 13. Pulse pressure variation (PPV) is calculated as a percentage and is available on many advanced hemodynamic monitoring systems to assist in predicting the patient s a. ventricular stroke volume. b. fluid volume responsiveness. c. right ventricular preload. d. mean arterial pressure. CHAPTER Central venous pressure is of clinical interest because it is a determinant of a. right heart preload. b. heart rate. c. arterial pressure. d. pulse pressure.

23 Final Exam Hemodynamic Monitoring: Evolving Technologies and Clinical Practice To record accurate central venous pressure readings, the nurse places the patient in a supine position, elevates the patient s head of the bed to no more than 60 degrees, and levels the pressure tranducer to the patient s a. ventricle. b. second intracostal space. c. third intracostal space. d. phlebostatic axis. 16. A hemodynamic assessment to predict a patient s fluid responsiveness includes determining trends in central venous pressure (CVP) along with a. placing the patient in a slight Trendelenburg position. b. performing a passive leg raise maneuver. c. positioning the patient supine and at 45 degrees elevation. d. administering a fluid bolus. CHAPTER The pulmonary artery catheter is used to assess volume status, regulate fluid management, monitor cardiac output, and a. measure preload. b. detect electrolyte abnormalities. c. titrate vasoactive and inotropic medications. d. monitor end-systolic pressures in the left heart. 18. The most common arrhythmia associated with movement of the pulmonary artery catheter (PAC) through the right side of the heart during PAC insertion is a. right bundle branch block. b. premature ventricular contractions. c. atrial fibrillation. d. paroxysmal supraventricular tachycardia. 19. To accurately measure right atrial pressure with a pulmonary artery catheter, the clinician places the patient on his back with the head of the bed at 0 to 45 degrees, correlates the right atrial tracing with an ECG reading, and obtains the measurement a. during voluntary cough. b. during slow, deep breathing. c. after deep inspiration. d. at end expiration. 20. When using the Fick method to calculate cardiac output, the practitioner draws blood from the distal port of the pulmonary artery catheter to measure a. venous oxygen content (CvO 2 ). b. arterial oxygen content (CaO 2 ). c. cardiac index (CI). d. tissue oxygen consumption (VO 2 ). CHAPTER In a patient with an increased demand for oxygen, the saturation mechanism of hemoglobin allows for a. movement of oxygen from low-pressure to high-pressure areas. b. greater release of oxygen to a dissolved state. c. less binding to oxygen in the lungs. d. a left shifted oxyhemoglobin curve. 22. The optimal amount of blood flow for pulmonary gas exchange is about a. 1 liter per minute. b. 3 liters per minute. c. 5 liters per minute. d. 7 liters per minute.

24 Final Exam 14 Hemodynamic Monitoring: Evolving Technologies and Clinical Practice 23. The concentration of oxygen that is bound to hemoglobin is measured with the a. co-oximeter. b. pulse oximeter. c. hemoglobin test. d. lung function test. 24. To measure ventilation capacity, or the ability to regulate carbon dioxide, the practitioner must first calculate the patient s a. arterial partial pressure of oxygen. b. volume of inspired air. c. retention of carbon dioxide. d. minute ventilation. 25. When interpreting a patient s arterial blood gas, the clinician assesses ventilation status by examining the a. arterial partial pressure of carbon dioxide. b. arterial partial pressure of oxygen. c. bicarbonate level. d. ph level. CHAPTER Normal cellular uptake of oxygen by the tissues at rest is approximately a. 15%. b. 25%. c. 35%. d. 45%. 27. Intermittent mixed venous oxygen saturation samples are drawn a. hourly from the venous port of the pulmonary artery catheter. b. daily from the venous port of the pulmonary artery catheter. c. slowly from the distal port of the pulmonary artery catheter. d. swiftly from the distal port of the pulmonary artery catheter. 28. With an acute reduction in oxygen delivery, the tissues remove a larger percentage of oxygen from the blood, causing an increase in the a. oxygen extraction ratio (O 2 ER). b. mixed venous oxygen saturation (SvO 2 ). c. arterial oxygen saturation (SaO 2 ). d. cardiac output (CO). 29. In a healthy adult patient, the measurement of blood oxygen saturation is higher in a. mixed venous oxygen saturation (SvO 2 ) blood. b. central venous oxygen saturation (ScvO 2 ) blood. c. blood returning from the brain. d. blood returning from the upper extremities. CHAPTER Due to the risk of false positive readings on the capnogram from acidic stomach contents or decreased circulation, it is best to avoid which carbon dioxide analysis method during emergency intubations and cardiopulmonary resuscitation? a. Infrared technology b. Mainstream capnography c. Sidestream capnography d. Colorimetric devices 31. A normal time capnogram for a patient who is breathing spontaneously without an endotracheal tube usually shows a. variations in shapes. b. distinct shapes. c. a rapid rise in phase 0 of the inspiratory segment. d. a downward slope in phase II of the expiratory segment.

25 Final Exam Hemodynamic Monitoring: Evolving Technologies and Clinical Practice The most widespread use of time capnography in clinical practice involves a. monitoring cardiac index. b. guiding nasogastric tube placement. c. confirming endotracheal tube placement. d. screening for hypermetabolic states. 33. A benefit of the capnography tracing for the patient who is mechanically ventilated is detection of small circuit leaks by a. a gradual rise in carbon dioxide concentration at the end of the breath (PetCO 2 ). b. a flat line. c. a downward slope of phase III. d. an increase in the alpha-angle. CHAPTER When administering epinephrine to a patient in shock, the clinician assesses for signs of adequate regional perfusion to the skin, kidneys, and abdominal viscera because of the drug s a. dopaminergic effects. b. weak beta-2 effects. c. weak beta-1 effects. d. strong alpha-1 effects. 35. Nitroprusside, a potent and rapid-acting vasodilator, is used to manage severe hypertension due to its action of a. relaxing vascular smooth muscle. b. dilating coronary arteries. c. generating nitric oxide. d. blocking the influx of calcium in vascular smooth muscle. 36. Appropriate fluid management is initiated prior to catecholamine administration to avoid the side effects of a. bronchospasm and bradycardia. b. hypotension and hypocontractility. c. tachydysrhythmia and myocardial ischemia. d. tachypnea and vomiting. 37. Because of their ability to decrease afterload while exerting a positive inotropic effect, inodilators are indicated for short-term therapy to maintain end-organ perfusion in patients with a. acute heart failure with systolic dysfunction. b. ventricular tachycardia. c. aortic valve stenosis. d. idiopathic hypertrophic subaortic stenosis. 38. Both alpha- and beta-receptor blocking drugs work by a. mimicking the effects of the sympathetic nervous system. b. decreasing the effects of the sympathetic nervous system. c. stimulating alpha and beta receptors. d. facilitating the actions of the hormone epinephrine. CHAPTER The hemodynamic parameter that Doppler ultrasound measures with very high fidelity is a. oxygen demand. b. stroke volume. c. preload. d. heart rate.

26 Final Exam 16 Hemodynamic Monitoring: Evolving Technologies and Clinical Practice 40. The use of a Doppler scan to measure stroke volume variation (SVV) is helpful to clinicians in assessing a. patient fluid responsiveness. b. patient respiratory disease. c. pulse arterial oxygen saturation. d. blood pressure variation. 41. Transcutaneous Doppler monitoring involves a hand-held transducer emitting a continuous ultrasound wave through the skin and body directed across the a. right and left atria. b. right and left pulmonary arteries. c. aortic and pulmonic valves. d. tricuspid and mitral valves. 42. Excellent assessment of blood flow in the aorta is possible with the esophageal Doppler monitoring device because its probe is correctly positioned where the a. esophagus and the arch of the aorta make contact. b. esophageal plexus and aorta meet. c. esophagus and ascending aorta meet. d. esophagus and descending aorta are side by side. CHAPTER The goal of bedside ultrasonography is to answer focused questions in real time in order to a. delay making clinical decisions until informed consent is obtained. b. avoid the need for serial evaluation of the patient s status. c. provide a limited, preoperative cardiac evaluation. d. provide immediate management of the patient. 44. The focused assessed transthoracic echocardiography (FATE) protocol is performed to identify cardiac abnormalities as well as a. neural abnormalities. b. pleural pathology. c. gastrointestinal injuries. d. traumatic brain injury. 45. To image a patient s heart or abdomen, the clinician selects an ultrasound machine with a a. low-frequency probe. b. high-frequency probe. c. linear probe. d. flat and broad probe. 46. Which bedside ultrasonography mode can detect the presence or absence of low flow vascular states within tissues? a. Motion mode b. Two-dimensional mode c. Power Doppler mode d. Color Doppler mode 47. A bedside ultrasonography protocol to rule out pulmonary embolism and other causes of cardiac arrest is a. Focused cardiac ultrasonography (FOCUS). b. Focused echocardiography evaluation in life support (FEEL). c. Focused assessed transthoracic echocardiography (FATE). d. Rapid ultrasonography in shock (RUSH).

27 Final Exam Hemodynamic Monitoring: Evolving Technologies and Clinical Practice 17 CHAPTER Technologies that use arterial pressure or waveform to determine cardiac output are based on the simple concept that pulse pressure is proportional to stroke volume and inversely related to a. the patient s age. b. the patient s height and weight. c. aortic compliance. d. pulse rate. 49. Continuous noninvasive arterial blood pressure monitoring devices determine stroke volume and cardiac output by means of a a. proprietary algorithm. b. finger cuff. c. dedicated monitor. d. brachial cuff pressure reading. 50. In response to a physiologic challenge, an elevated stroke volume variation of 10% to 15% is a sign of a. fluid overload. b. right ventricular failure. c. the presence of fluid responsiveness. d. the absence of fluid responsiveness. 51. Which is a functional physiologic challenge for confirming a patient s need for intravenous fluid therapy? a. Administering a mini-fluid bolus b. Administering supplemental oxygen c. Flexing the patient s hip to 90 degrees d. Asking the patient to cough 52. When caring for the patient with continuous noninvasive finger blood pressure monitoring, the clinician closely assesses the patient for a. appropriate waveforms. b. overdamping. c. decreased perfusion to the finger. d. finger joint swelling and redness. CHAPTER In the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial, the physical assessment finding with an 86% sensitivity in detecting a pulmonary arterial occlusion pressure (PAOP) greater than 22 mm Hg was a. orthopnea (two or more pillows). b. pulmonary crackles (rales). c. ascites. d. edema. 54. A hemodynamic monitor implanted in the right ventricle of a patient with heart failure allows a. direct measurement of left ventricular pressure. b. estimation of central aortic pressure. c. better treatment after exacerbation of clinical symptoms. d. notification of pressure elevations before clinical symptoms. 55. In addition to stand-alone devices, implantable hemodynamic monitoring is available with a. left ventricular assist devices. b. cardiac resynchronization therapydefibrillator devices. c. prosthetic heart valve devices. d. implantable neurostimulator devices.

28 Final Exam 18 Hemodynamic Monitoring: Evolving Technologies and Clinical Practice 56. A potential health risk in using implantable hemodynamic monitoring devices is a. considering the patient s emotions related to his or her heart failure. b. altering patient treatment plans. c. using the device data in isolation. d. relying on history and physical examination data. 57. With regard to management of heart failure, implantable hemodynamic monitoring provides an objective assessment of elevated pulmonary artery pressures and a. low intrathoracic impedance. b. low arterial oxygen content. c. mismatched ventilation/perfusion. d. bounding pedal pulses. CHAPTER The negative intrathoracic pressure from normal breathing leads to a. blood flow to the lower extremities. b. blood return to the central venous circulation. c. alveolar constriction. d. decreased pulmonary vascular volume. 59. Conditions that improve venous return include those that increase a. the pressure in the right atrium. b. the stressed volume of blood. c. venous compliance. d. venous resistance. 60. Central alveoli expand first, followed by peripheral alveoli, during a. positive pressure ventilation. b. negative pressure ventilation. c. normal breathing. d. labored spontaneous breathing. 61. Alterations in right heart hemodynamics from positive pressure ventilation are primarily associated with an increase in afterload and a. an increase in lung volume. b. an increase in preload. c. a decrease in preload. d. a decrease in mean systemic filling pressure. 62. In patients with acute respiratory distress syndrome who are on mechanical ventilation, larger tidal volumes resulting in higher inflation pressures in the lungs have the potential to significantly a. decrease bronchoconstriction. b. decrease vasoconstriction. c. increase left ventricular afterload. d. increase right ventricular afterload. CHAPTER Intentions for using short-term mechanical circulatory support (MCS) devices include allowing time for myocardial recovery and a. assisting the circulation of patients who are mobile. b. providing total support of circulation for extended periods. c. providing time to evaluate the need for long-term MCS devices. d. bridging a patient for several months until heart transplantation. 64. Intra-aortic balloon pump therapy is contraindicated in patients with aortic insufficiency because of the risk of a. greater regurgitation. b. aortic dissection. c. limb ischemia. d. uncontrolled bleeding.

29 Final Exam Hemodynamic Monitoring: Evolving Technologies and Clinical Practice Patients who are in acute cardiogenic shock or unable to wean from cardiopulmonary bypass, with unknown outcomes, are likely to receive a. a short-term mechanical circulatory support device. b. an intermediate-term mechanical circulatory support device. c. a HeartWare left ventricular assist system. d. a SynCardia total artificial heart. 66. Continuous flow pumps today have fewer moving parts, which makes them a. less durable. b. more prone to thrombogenicity. c. less prone to mechanical problems. d. beneficial for short-term circulatory support. 67. Patients are better candidates for destination therapy than for heart transplantation if they have comorbid conditions, are over the age of 80, or a. are obese. b. smoke cigarettes. c. have acute kidney injury. d. have a history of recent malignancy. CHAPTER Following cardiac surgery, the clinician monitors the patient s oxygen saturation of venous return to evaluate the a. balance between oxygen supply and consumption. b. accuracy of oxygen saturation level. c. partial pressure of oxygen in arterial blood. d. variable level of oxygen toxicity. 69. Normal baseline hemodynamic findings in the initial postoperative period for a patient undergoing cardiac surgery include decreased ventricular contractility and a. increased stroke volume. b. elevated systemic vascular resistance. c. increased cardiac index. d. generalized vasoconstriction. 70. Echocardiographic parameters, such as ejection fraction and end diastolic volume, are measured prior to cardiac surgery to better monitor for postoperative changes in patient a. pulmonary artery occlusion pressure. b. mean arterial pressure. c. contractile function. d. central venous pressure. 71. Hemodynamic findings of hypovolemia after cardiac surgery are often associated with a. infection and swelling. b. bleeding and hemothorax. c. arrhythmias. d. poor response to fluid therapy. 72. Appropriate management of right and left ventricular performance following cardiac surgery requires optimal therapy guided by the use of a pulmonary artery catheter or a a. central venous catheter. b. heart-lung bypass pump. c. ventricular assist device. d. transesophageal echocardiogram.

30 Final Exam 20 Hemodynamic Monitoring: Evolving Technologies and Clinical Practice CHAPTER A male patient with left heart failure who is managing his symptoms through lifestyle changes and medications is described as having a. compensated heart failure. b. acute decompensated heart failure. c. cor pulmonale. d. right ventricular failure. 74. The heart s consistent inability to pump enough blood from the left ventricle eventually leads to a. an increase in myocardial contractility. b. a decrease in afterload. c. remodeling. d. tachycardia. 75. Systolic versus diastolic heart failure is defined by determining whether a patient has a normal a. heart rate. b. ejection fraction. c. filling pressure. d. heart rhythm. 76. Symptoms of cardiogenic shock include clouded mentation, decreased urine output, and a. elevated cardiac output. b. low ventricular pressure-volume. c. cool extremities. d. flushing. 77. Hemodynamic parameters associated with acute decompensated heart failure include a cardiac index below 2.2 L/min/m 2, systolic blood pressure less than 100 mm Hg, and pulmonary artery occlusion pressure greater than a. 9 mm Hg. b. 12 mm Hg. c. 15 mm Hg. d. 18 mm Hg. CHAPTER In the absence of disease, the right ventricle is described as a a. high-pressure, low-capitance heart chamber. b. low-pressure, high-capitance heart chamber. c. conical-shaped heart chamber. d. passive chamber for deoxygenated blood. 79. Clinical conditions causing right heart failure from an increased afterload include pulmonary hypertension, pulmonary embolism, and a. acute tricuspid regurgitation. b. volume overload. c. atrial septal defect. d. left heart failure. 80. Hemodynamic measures used for evaluating right ventricular function are frequently derived from a. echocardiography. b. chest radiography. c. exercise testing. d. left heart catheterization.