Cardiac Monitoring (Cornelius) Exam 1

Question 1

Which of the following describes the configuration of bipolar limb leads?

A) One positive electrode and two negative electrodes
B) Two positive electrodes
C) One positive electrode and one negative electrode
D) No electrodes

Answer 1

C) One positive electrode and one negative electrode

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Question 2

Which of the following is a characteristic of augmented limb leads?

A) They use bipolar electrodes.
B) They use unipolar limb leads.
C) They do not require a positive electrode.
D) They measure electrical activity from the chest only.

Answer 2

B) They use unipolar limb leads.

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Question 3

In augmented limb leads, the lead labeled aVR corresponds to the positive electrode placed on the:

A) Left arm
B) Right arm
C) Left leg
D) Right leg

Answer 3

B) Right arm

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Question 4

In augmented limb leads, the lead labeled aVF corresponds to the positive electrode placed on the:

A) Left foot (leg)
B) Right arm
C) Left arm
D) Right foot (leg)
Correct Answer:

Answer 4

A) Left foot (leg)

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Question 5

In augmented limb leads, the lead labeled aVL corresponds to the positive electrode placed on the:

A) Right arm
B) Left arm
C) Right leg
D) Left leg

Answer 5

B) Left arm

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Question 6

Where is V1 placed during precordial lead placement?

A) Left fourth intercostal space at the midclavicular line
B) Right fourth intercostal space at the sternal border
C) Left fifth intercostal space at the midaxillary line
D) Right second intercostal space at the sternal border

Answer 6

B) Right fourth intercostal space at the sternal border

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Question 7

Where is V2 placed during precordial lead placement?

A) Left fourth intercostal space at the sternal border
B) Left fifth intercostal space at the midaxillary line
C) Right fourth intercostal space at the sternal border
D) Left fourth intercostal space at the sternal border

Answer 7

D) Left fourth intercostal space at the sternal border

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Question 8

Where is V3 placed during precordial lead placement?

A) Left fourth intercostal space above V5
B) Midway between V2 and V4 in the fourth rib space
C) Midway between V2 and V4 in the fifth rib space
D) Left fourth intercostal space at the midaxillary line

Answer 8

C) Midway between V2 and V4 in the fifth rib space

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Question 9

Where is V4 placed during precordial lead placement?

A) Left fifth intercostal space at the midclavicular line
B) Left fourth intercostal space at the sternal border
C) Right fourth intercostal space at the sternal border
D) Left fifth intercostal space at the midaxillary line

Answer 9

A) Left fifth intercostal space at the midclavicular line

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Question 10

Where is V6 placed during precordial lead placement?

A) Left fifth intercostal space at the midclavicular line
B) Left fifth intercostal space at the midaxillary line
C) Left fourth intercostal space at the sternal border
D) Right fourth intercostal space at the sternal border

Answer 10

B) Left fifth intercostal space at the midaxillary line

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Question 11

Which lead is most commonly used for continuous EKG monitoring in clinical settings?

A) Lead I
B) Lead II
C) aVR
D) V4

Answer 11

B) Lead II

Cornelius -V1 or V2 may be beneficial or even V5 depending on what’s going on with your patient… multi -lead monitoring will help keep an eye on all the different aspects of the heart.

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Question 12

A 12-lead EKG is useful for identifying which of the following conditions? (Select 3)

A) Cardiac damage
B) Conduction delays in the heart
C) Cardiac infections
D) Pulmonary embolism
E) Monitoring electrolyte levels

Answer 12

A) Cardiac damage
B) Conduction delays in the heart
C) Cardiac infections

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Question 13

Which leads are primarily used to evaluate the inferior wall of the heart?

A) Lead I, aVL
B) Lead II, Lead III, aVF
C) V1, V2
D) V5, V6

Answer 13

B) Lead II, Lead III, aVF

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Question 14

Which leads primarily monitor the anterior surface of the heart?

A) V1, V2
B) Lead II, Lead III, aVF
C) V3, V4
D) V5, V6

Answer 14

C) V3, V4

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Question 15

If you are concerned about septal wall damage, which leads would be most useful for evaluation?

A) V1, V2
B) Lead II, Lead III, aVF
C) V3, V4
D) Lead I, aVL

Answer 15

A) V1, V2

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Question 16

Which leads are most useful for monitoring the high lateral wall of the heart?
(Select 2)

A) V5
B) V6
C) Lead I
D) aVF
E) aVL

Answer 16

C) Lead I
E) aVL

V5 and V6 are lateral but not HIGH lateral

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Question 17

What is the minimum change in contiguous leads that is typically considered significant in evaluating ischemia or infarction?

A) 1 mm
B) 2 mm
C) 3 mm
D) 4 mm

Answer 17

B) 2 mm

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Question 18

When following the “turn signal rule” for bundle branch blocks, an upright QRS complex in V1 at the J point is indicative of which type of bundle branch block?

A) Left bundle branch block (LBBB)
B) Right bundle branch block (RBBB)
C) Left posterior fascicular block
D) Nonspecific intraventricular conduction delay

Answer 18

B) Right bundle branch block (RBBB)

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Question 19

When following the “turn signal rule” for bundle branch blocks, a downward QRS complex in V1 at the J point is indicative of which type of bundle branch block?

A) Left bundle branch block (LBBB)
B) Right bundle branch block (RBBB)
C) Left posterior fascicular block
D) Nonspecific intraventricular conduction delay

Answer 19

A) Left bundle branch block (LBBB)

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Question 20

Which of the following EKG characteristics is indicative of right atrial hypertrophy (RAH)?

A) Notched P wave in lead V1
B) Initial component of the P wave larger in V1
C) M-shaped P wave in lead II
D) Inverted T wave in limb leads

Answer 20

B) Initial component of the P wave larger in V1

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Question 21

A P wave height greater than how many millimeters in any limb lead suggests right atrial hypertrophy (RAH)?

A) 1.5 mm
B) 2.0 mm
C) 2.5 mm
D) 3.0 mm

Answer 21

C) 2.5 mm

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Question 22

Which component of the P wave in lead V1 is larger in left atrial hypertrophy LAH?

A) Initial component
B) Terminal component
C) Entire P wave
D) QRS complex

Answer 22

B) Terminal component of diphasic P in V1 larger

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Question 23

P-waves for lead II and Lead VI are shown below. What would be indicated by this EKG waveform?

A) Notched P wave in lead V1
B) Right atrial hypertrophy
C) M-shaped P wave in lead II
D) Bi-atrial enlargement

Answer 23

Bi-atrial enlargement

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Question 24

Right ventricular hypertrophy (RVH) is characterized by smaller R waves and more depolarization toward which lead?

A) V6
B) Lead II
C) V1
D) aVR

Answer 24

C) V1

Cornelius - *Be mindful of your QRS changes for V1, especially if you have RVH, and when we start worrying about patients with concentric hypertrophy, *

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Question 25

Which precordial lead shows a large R wave that is indicative of left ventricular hypertrophy?

A) V1
B) V3
C) V5
D) V6

Answer 25

C) V5

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Question 26

Which of the following EKG characteristics is indicative of left ventricular hypertrophy (LVH)?

A) Small R wave in V5
B) Large S wave in V1
C) Small S wave in V1
D) R wave progression through V1-V3

Answer 26

B) Large S wave in V1

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Question 27

What is the combined depth of the S wave in V1 and the height of the R wave in V5 used to diagnose LVH?

A) 25 mm
B) 30 mm
C) 35 mm
D) 40 mm

Answer 27

C) 35 mm

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Question 28

Which of the following EKG findings is most indicative of myocardial ischemia?

A) Elevated ST segment
B) Inverted, symmetrical T wave
C) Deep Q waves
D) Peaked T waves

Answer 28

B) Inverted, symmetrical T wave

Starts with reduced supply of O2 from the coronary arteries

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Question 29

What EKG finding is most indicative of an acute myocardial “acute injury”?

A) Inverted T waves
B) ST segment elevation
C) Deep Q waves
D) Widened QRS complex

Answer 29

B) ST segment elevation

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Question 30

Which EKG finding is most indicative of a past myocardial infarction (Transmural)?

A) ST segment elevation
B) Inverted T waves
C) Deep, significant Q waves
D) Shortened PR interval

Answer 30

C) Deep, significant Q waves

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Question 31

For a Q wave to be considered significant and indicate an old infarction, it must be at least how wide?

A) 0.5 mm
B) 1 mm
C) 2 mm
D) 1.5 mm

Answer 31

B) 1 mm

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Question 32

What other criteria, in addition to being at least 1 mm wide, must be met for a Q wave to signify an old infarction?

A) Must be at least 1/3 the height of the QRS complex
B) Must be present in all precordial leads
C) Must be present in only one lead
D) Must be present only in limb leads

Answer 32

A) Must be at least 1/3 the height of the QRS complex

and 2 related leads

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Question 33

What is the primary indication for the use of an artificial cardiac pacemaker?

A) Treatment of ventricular fibrillation
B) Correction of disturbances
C) Management of hypertrophic cardiomyopathy
D) Prevention of atrial fibrillation

Answer 33

B) Correction of disturbances in cardiac impulse conduction

Elderly….SSS
Anti-bradycardic treatment

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Question 34

Which of the following are components of an artificial cardiac pacemaker? (Select 2)

A) Pulse generator
B) Electrode leads
C) Defibrillator paddles
D) Electrode generator

Answer 34

A) Pulse generator
B) Electrode leads

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Question 35

Which of the following is not an example of an artificial cardiac pacemaker?

A) Transthoracic pacemaker
B) Transvenous pacemaker
C) Transverse pacemaker
D) Transcutaneous pacemaker

Answer 35

C) Transverse pacemaker

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Question 36

What is the primary function of the generator in a pacemaker system?

A) To detect heart rate
B) To transmit electrical impulses
C) To provide energy and electrical circuits
D) To monitor pacemaker battery life

Answer 36

C) To provide energy and electrical circuits

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Question 37

Which part of the pacemaker is the insulated wire that connects the generator to the heart?

A) Electrode
B) Lead
C) Pulse generator
D) Grounding wire

Answer 37

B) Lead

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Question 38

Which part of the pacemaker that comes into contact with the actual heart?

A) Electrode
B) Lead
C) Pulse generator
D) Grounding wire

Answer 38

A) Electrode

Cornelius - that’s where the energy is actually gonna be exposed to the heart itself, the lead goes down to the electrode from the generator and then the electrodes actually contacts the heart.

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Question 39

What is the difference between unipolar and bipolar electrodes in pacemaker systems?

A) Bipolar electrodes provide lower sensitivity to electromagnetic interference (EMI)
B) Unipolar electrodes are used for temporary pacing, and bipolar electrodes are permanent
C) Bipolar electrodes use the heart as a ground, while unipolar does not
D) Unipolar electrodes use more energy, and bipolar electrodes use less energy

Answer 39

D) Unipolar electrodes use more energy, and bipolar electrodes use less energy

Unipolar electrodes - neg electrode in chamber; positive electrode (grounding)
More sensitive to Electromagnetic interference (EMI)

Bipolar electrodes - both electrodes in chamber being paced

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Question 40

True or False

Bipolar electrodes are the most common pacemaker

Answer 40

True

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Question 41

Which of the following best describes a multipolar pacemaker system?

A) A system with multiple generators in one device
B) A system with one lead and multiple electrodes in different chambers
C) A pacemaker that uses external grounding for pacing
D) A pacemaker system designed for short-term use only

Answer 41

B) A system with one lead and multiple electrodes in different chambers

Cornelius - *You may also see that you use multiple electrodes. So for instance sometimes we’ll see leads that will go across the septum. So you may have like biatrial electrodes or you may have biventricular electrodes. *

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Question 42

What does Roman numeral I in the pacemaker code represent?

A) Chamber(s) paced
B) Chamber(s) sensed
C) Response to sensing
D) Rate modulation

Answer 42

A) Chamber(s) paced

Cornelius - you may have an atrial pacemaker, you may have a ventricular pacemaker, or you may have dual AV pacemakers, or you may have no pacers, not programmed at all.

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Question 43

What does Roman numeral II in the pacemaker code represent?

A) Multisite pacing
B) Chamber(s) sensed
C) Chamber(s) paced
D) Response to sensing

Answer 43

B) Chamber(s) sensed

Cornelius - *instead of it being a non -demand device, it’s actually on demand…it pays attention to see what the patient’s heart rate is, and then it determines its response.
Especially with ventricular pacemakers, where it’s just set for a default rate at a round number like 60, 70, or 80. So, if you’re looking at somebody and you see that they’ve got a big, wide QRS and it’s kind of that clock regular rate of like 60, 70, or 80, be very suspicious that they may have a pacemaker, even if you don’t see pacer spikes.
*

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Question 44

What does Roman numeral III in the pacemaker code represent?

A) Chamber(s) paced
B) Multisite pacing
C) Response to sensing
D) Rate modulation

Answer 44

C) Response to sensing

Cornelius - *What this means is that everything can be programmed differently depending on the device.

I - Inhibit - Sometimes there’s nothing done differently when it senses. If you have an inhibit, the pacemaker senses that there’s a traditional or a spontaneous depolarization, it will not activate, so the pacemaker doesn’t do anything.

T - Trigger - You may have a patient that falls outside of the set parameters, maybe they become bradycardic, so then the device will trigger.

D - Dual - You may have dual, which means it’s capable of doing both. The dual is the most common that you’re going to see as far as like response to sensing

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Question 45

What does Roman numeral IV in the pacemaker code represent?

A) Rate modulation
B) Chamber(s) paced
C) Multisite pacing
D) Chamber(s) sensed

Answer 45

A) Rate modulation

Cornelius - Rate modulation may mean that it is able to adapt a little bit.
That’s not very common. Usually, if you see that, it’s more in response to like overdrive pacing.

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Question 46

What does Roman numeral V in the pacemaker code represent?
A) Chamber(s) sensed
B) Response to sensing
C) Multisite pacing
D) Rate modulation

Answer 46

C) Multisite pacing

Cornelius - The last one is if you have multiple locations where it’s able to pace. So is it like by atrial, by ventricular, or is it both atria and ventricular

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Question 47

What happens when a pacemaker is inhibited?

A) The pacemaker discharges if intrinsic activity is sensed.
B) The pacemaker discharges regardless of intrinsic activity.
C) The pacemaker does not discharge if intrinsic activity is sensed.
D) The pacemaker paces at a default rate.

Answer 47

C) The pacemaker does not discharge if intrinsic activity is sensed.

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Question 48

Which setting allows a pacemaker to discharge only during testing of the device?

A) Inhibited
B) Triggered
C) Rate modulation
D) Multisite pacing

Answer 48

B) Triggered

Cornelius - They may be inhibiting/triggering to demonstrate that it’s able to pace. They use medications to alter the heart rate.
You may also see that they will increase the patient’s heart rate just to prove that they can do it and they have good capture

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Question 49

What factors can influence rate modulation in a pacemaker?
(Select all that apply-4)

A) Motion
B) Intrinsic atrial depolarization
C) Vibration
D) Heart rate only
E) Minute ventilation
F) Right ventricular pressure
G) Left ventricular pressure

Answer 49

A) Motion
C) Vibration
E) Minute ventilation
F) Right ventricular pressure

Cornelius - modulation is like an artifact setting, they may be able to use that to determine the patient’s heart rate actually hasn’t increased and its just artifact. You can separate out the real QRS complexes from the artifact. You may see that there’s some modulation settings in there where they’re able to kind of tailor that for the patient.

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Question 50

Which condition is multisite pacing most commonly used for?

A) Atrial fibrillation
B) Cardiomyopathies
C) Bradycardia
D) AV block

Answer 50

B) Cardiomyopathies

Cornelius - The biggest thing we’re seeing with as far as multisite pacing is gonna be ventricular pacers for people with like horrible dilated cardiomyopathies.

You will occasionally see it for AFib, but Bi -V is the most common one that we do see.

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Question 51

What type of pacemaker is represented by an atrial impulse followed by a ventricular pacer spike and QRS complex? (B in the picture)

A) Atrial sequential pacemaker
B) Ventricular pacemaker
C) Atrioventricular sequential pacemaker
D) Dual chamber pacemaker

Answer 51

Correct Answer: B) Ventricular pacemaker

Cornelius - the atria is still working normally on its own, but the ventricles aren’t working. So you see that pacer spike and then the big QRS complex that follows it.

Slide 23

Question 52

Which pacemaker type generates both atrial and ventricular spikes followed by corresponding depolarizations? (C in the picture)

A) Single chamber pacemaker
B) Ventricular sequential pacemaker
C) Atrioventricular sequential pacemaker
D) Atrial sequential pacemaker

Answer 52

C) Atrioventricular (AV) sequential pacemaker

Cornelius - there’s an atrial spike and then the atrial impulse is the atria depolarized. And then you have a ventricular spike and then a ventricular depolarization.

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Question 53

Which of the following are important considerations for perioperative care of patients with pacemakers? (Select 3)

A) Turn off the pacemaker during surgery
B) Ensure the grounding pad is placed distant from the pacemaker
C) Interrogate the pacemaker pre- and post-operatively
D) Turn the filter off on the cardiac monitor
E) Use monopolar electrocautery near the pacemaker
F) Place a magnet on the patients chest over the heart

Answer 53

B) Ensure the grounding pad is placed distant from the pacemaker
C) Interrogate the pacemaker pre- and post-operatively - NOT routinely done anymore or required
D) Turn the filter off on the cardiac monitor - there’s usually a pacer setting on the cardiac monitor…be familiar with whatever the kind of functionality of your monitor is. Some do it automatically. Some you have to do it manually

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Question 54

True or False

Monopolor Cautery is safe to use with patients with cardiac pacemakers

Answer 54

FALSE

Bipolar Cautery is safer to use with cardiac pacemakers

Cornelius - you want to try and avoid putting the grounding pad anywhere near it. You also want to try and avoid using monopolar electroconrading anywhere near the device if possible

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Question 55

What might happen if you place a magnet on an older pacemaker device?

A) It will deactivate the pacemaker
B) It will change the pacemaker to a non-demand mode
C) It will increase the heart rate to 100 bpm
D) It will trigger defibrillation

Answer 55

B) It will change the pacemaker to a non-demand mode

Cornelius - Historically putting a magnet on a device would put it into a non -demand mode So it would just go to a regular rate of 60 70 or 80 depending on what the backup programming was for.** Some newer devices don’t do that**, so just be very cautious

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Question 56

What chambers are paced with a BiV pacemaker?

A) Right atrium and both ventricles
B) Left atrium and both ventricles
C) Both atria only
D) Both ventricles only

Answer 56

A) Right atrium and both ventricles *(trans-septal) *

C - *one lead that goes into the right atrium and then you’ll have a lead that goes into each ventricle…it goes through the septum *

Slide 25

Question 57

What is the purpose of BiV pacing in pacemakers?

A) Increase heart rate
B) Improve RV-LV activation time
C) Reduce atrial fibrillation
D) Provide electrical shocks during arrhythmias

Answer 57

B) Improve RV-LV activation time

C - to increase the patient’s cardiac resynchronization (CRT), so the right and left ventricle are working and increasing EF % and improving CO.

Historically these people have bad cardiomyopathy and as a result of that the impulses are delayed as they transmit. They’re pretty dependent on pacemakers…somebody that can’t go without having their pacemaker on. Putting then in non -demand mode is probably fine for them because they’re gonna default to something that’s adequate, but be very cautious about turning these devices off or manipulating them

Slide 25

Question 58

Which of the following methods is NOT used to provide anesthesia for pacemaker placement?

A) Cervical plexus block
B) Sedation
C) Topical
D) Local infiltration
E) Periclavicular block
F) General Anesthesia

Answer 58

C) Topical

C- You can put the patient under general anesthesia… but a lot of times, because they’re so sick, we do sedation and a local. Sometimes we’ll a periclavicular block. Sometimes we’ll do like a cervical plexus block .It really just depends on where they’re putting the device in the surgeon may just infiltrate with local

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Question 59

What is the typical ejection fraction (EF) threshold that may qualify a patient for Bi-V pacing?

A) 40-50%
B) 30-35%
C) 50-60%
D) 20-25%

Answer 59

B) 30-35% - “Moderate/Severe”

C- 30% to 35%, you’ll see is younger athletes that we see that are having out of hospital cardiac arrest with disease early on

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Question 60

Which of the following is a requirement for Bi-V pacing?
(Select 2)

A) Normal heart function
B) EF of 36-40%
C) Intraventricular conduction delays
D) History of cardiomopathy induced cardiac arrest

Answer 60

C) Intraventricular conduction delays
D) History of cardiomopathy induced cardiac arrest

Slide 26

Question 61

What type of pacing does a magnet induce in a pacemaker?

A) Asynchronous pacing with rate modulation
B) Synchronous pacing with no rate modulation
C) Asynchronous pacing with no rate modulation
D) Continuous synchronous pacing

Answer 61

C) Asynchronous pacing with no rate modulation

DOO vs VOO

DOO
Dual paced, with no sensing or inhibition. DOO is used for asynchronous pacing in both the atria and ventricles. It’s often used when a magnet is placed over a pacemaker or when a patient is having surgery. (per google)

VOO
Ventricular paced, with no sensing or inhibition. VOO is used for asynchronous pacing in the ventricle.

Slide 27

Question 62

What might occur when a magnet is placed over a pacemaker?

A) It always switches to asynchronous pacing
B) It always increases the pacing rate
C) It may cause no change in pacing
D) It always decreases the pacing rate

Answer 62

C) It may cause no change in pacing

C - So you may put that small donut magnet over the top of the patient’s pacemaker and nothing happens

Slide 27

Question 63

After a magnet detects battery depletion, follow-up is typically intensified to every ______.
A) 1 week
B) 2 weeks
C) 4 weeks
D) 3 months

Answer 63

C) 4 weeks

Magnet possibly detects decreases pulse amplitude or width…Inadequate capture

Slide 27

Question 64

What is the recommended type of cautery to use during surgery for a patient with an AICD/Bi-V device?
A) Monopolar
B) Bipolar
C) Laser
D) None of the above

Answer 64

B) Bipolar

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Question 65

After surgery, a patient with an AICD/Bi-V device will likely require ________ of the device.
A) Reprogramming
B) Removal
C) Interrogation
D) Testing

Answer 65

C) Interrogation

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Question 66

Which of the following are recommended practices for perioperative care of a patient with an battery powered AICD/Bi-V device? Select 2

A) Optimize patient condition
B) Turn filter ON on cardiac monitor
C) Use monopolar cautery
D) Ensure back-up pacing ability
E) Intaoperative interrogation of the device

Answer 66

A) Optimize patient condition
D) Ensure back-up pacing ability

• Postoperative interrogation of the device*

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Question 67

What is the primary function of an implantable cardioverter-defibrillator (ICD)?
Select 3

A) To assist with heart rate pacing
B) To terminate ventricular fibrillation
C) To defib Supraventricular Tachycardia
D) To monitor atrial fibrillation
E) To terminate ventricular tachycardia

Answer 67

B) To terminate ventricular fibrillation
C) To defib Supraventricular Tachycardia - 10% inappropriate
E) To terminate ventricular tachycardia

Corny - *they’re designed for vFib or VTAC, but you’ll see sometimes the patients will go into SVT and it may have a wide enough complex to meet the pre -programmed specifications for the device, and they’ll wind up defibrillating SVT.
*

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Question 68

Which of the following are criteria ICDs measure when evaluating arrhythmias?
Select 3

A) P-R intervals
B) Onset abrupt or gradual
C) QRS width (normal or wide)
D) Rate of atrial fibrillation
E) Consistency of R-R intervals

Answer 68

B) Onset abrupt or gradual
C) QRS width normal or wide
E) Consistency of R-R intervals or variable

Cornelius - *ICD usually looks at the kind of width of the QRS complex because it is primarily targeting ventricular rhythms, so it’s going to be a wide QRS.

*You may run into trouble if you’ve got kind of an irregular heart rate because it’s looking for that R -to -R interval, so if you’ve had an irregular R -to -R interval, it may not be able to calculate the heart rate appropriately. *

Or maybe you have a whole lot of beats that are close together, and you have a period of tachycardia, but it’s not sustained.

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Question 69

The most common location for inserting a central venous pressure (CVP) line is the ___________, with the catheter positioned at the junction of the vena cava and the right atrium.

A) Left Subclavian Vein
B) Right Internal Jugular Vein
C) Femoral Vein
D) Left External Jugular Vein

Answer 69

B) Right Internal Jugular Vein

Slide 32

Question 70

Which of the following factors significantly influence CVP measurement? Select 3

A) Blood volume
B) Vascular tone
C) Left ventricular ejection fraction
D) Oxygen saturation
E) Respiratory effort

Answer 70

A) Blood volume,
B) Vascular tone,
E) Respiratory effort

Cornelius - *if you have somebody that’s being ventilated by positive pressure ventilation, you may have an artificial increase in the CVP because the intrathoracic pressure is increasing. *

*Whereas if they’re breathing spontaneously, since they have that vacuum of the diaphragm dropping down, it doesn’t tend to alter it quite the same way. *

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Question 71

What is central venous pressure (CVP) primarily used to assess?

A) Left heart function and cardiac output
B) Blood volume and right heart function
C) Pulmonary artery pressure
D) Systemic vascular resistance

Answer 71

B) Blood volume and right heart function

Slide 32

Question 72

True or False

A snapshot of the CVP measurements is a very accurate at calculating of blood volume and RIGHT heart function

Answer 72

FALSE

Cornelius - the big thing you need to take away is that a snapshot with the CVP is not very helpful. It’s more of a trending device.

If I start seeing my CVP increasing, things that could cause it –> fluid overload, pericardial effusions.
If I see my CVP dropping over a long period of time –> I may be volume depleted. But they’re not very good is like one little snapshot.

Slide 32

Question 73

The normal range for CVP in a patient with spontaneous breathing is ________ mmHg.

A) 1-7
B) 7-12
C) 12-16
D) 4-10

Answer 73

A) 1-7

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Question 74

Which of the following is NOT an indication for a CVP line?

A) Temporary hemodialysis
B) Pulmonary artery catheter placement
C) Blood pressure monitoring
D) Rapid infusion of fluids/blood

Answer 74

C) Blood pressure monitoring

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Question 75

Which of the following are valid indications for the placement of a CVP line? Select 4

A) Caustic drug administration
B) Aspiration of air emboli
C) Repeated blood testing
D) Monitoring left heart function
E) Transvenous cardiac pacing
F) Increased coagulopathy

Answer 75

A) Caustic drug administration
B) Aspiration of air emboli
C) Repeated blood testing
E) Transvenous cardiac pacing

Slide 33

Question 76

Label the a, c, & v waveforms on the Wiggers diagram below.

Answer 76

Schmidt PTSD…

Question 77

The “A wave” on a CVP waveform is a result of:

A) Ventricular contraction
B) Atrial contraction
C) Tricuspid valve closure
D) Blood filling the right atrium

Answer 77

B) Atrial contraction

C- you have the atrial depolarization and then you have increased atrial pressure. And this is really the atrial that’s starting to fill from that preload.

So the atrial starts to dilate, dilate, dilate, and then you have that A wave that appears.

Slide 34

Question 78

Which of the following are characteristics of the “A wave” in a CVP waveform? select 3

A) Occurs after the “P” wave
B) Represents ventricular contraction
C) Increases atrial pressure
D) Provides the “atrial kick”
E) Occurs after the “QRS” complex

Answer 78

A) Occurs after the “P” wave
C) Increases atrial pressure
D) Provides the “atrial kick”

Slide 34

Question 79

The “C wave” on a CVP waveform is associated with:

A) Atrial contraction
B) Isovolumetric contraction of the ventricle
C) Tricuspid valve opening
D) Rapid ventricular filling

Answer 79

B) Isovolumetric contraction of the ventricle

• Backward “bowing” of the valves (from ventricular contraction) slightly displacing blood backwards.

Slide 34

Question 80

Which of the following are true about the “C wave” in the CVP waveform? Select 3

A) It follows the “R” wave on the ECG
B) Tricuspid valve closed and ventricle bulges toward the atria
C) It represents the tricuspid valve opening and atria bulges out
D) It interrupts the decreasing atrial pressure
E) It is seen after the “P” wave on the ECG

Answer 80

A) It follows the “R” wave on the ECG
B) Tricuspid valve closed and ventricle bulges toward the atria
D) It interrupts the decreasing atrial pressure

slide 35

Question 81

The “X descent” on the CVP waveform represents:

A) Atrial contraction
B) Isovolumetric relaxation of the ventricle
C) A decrease in atrial pressure during ventricular systole
D) Tricuspid valve opening

Answer 81

C) A decrease in atrial pressure during ventricular systole

Slide 36

Question 82

The “X descent” on the CVP waveform is sometimes referred to as ______.

A) Increase in atrial pressure
B) Systolic collapse
C) Diastolic collapse
D) Ventricular diastole

Answer 82

B) Systolic collapse

Steep drop in pressure as atria relax and start filling.

Slide 36

Question 83

The “V wave” on the CVP waveform represents:

A) Atrial contraction
B) Venous filling of the atrium
C) Tricuspid valve opening
D) Isovolumetric contraction of the ventricle

Answer 83

B) Venous filling of the atrium

Slide 37

Question 84

Which of the following are true about the “V wave” on the CVP waveform? Select 3

A) It is associated with atrial contraction
B) The tricuspid valve remains closed during the V wave
C) It follows the “T” wave on the ECG
D) It occurs during late systole
E) It represents the opening of the tricuspid valve

Answer 84

B) The tricuspid valve remains closed during the V wave
C) It follows the “T” wave on the ECG
D) It occurs during late systole

Slide 37

Question 85

The “Y descent” on the CVP waveform occurs when the ______ valve opens, allowing initial blood flow into the ______.

A) Mitral; left ventricle
B) Tricuspid; right atrium
C) Tricuspid; right ventricle
D) Mitral; left atrium

Answer 85

C) Tricuspid; right ventricle

Slide 38

Question 86

Which of the following are true about the “Y descent” on the CVP waveform? Select 2

A) It occurs when the mitral valve opens
B) It is called diastolic collapse
C) It represents blood flow into the right atrium
D) It follows the “T” wave on the ECG
E) It represents the initial blood flow into the right ventricle
F) It is called the systolic collapse

Answer 86

B) It is called diastolic collapse,
E) It represents the initial blood flow into the right ventricle

Slide 38

Question 87

In atrial fibrillation, what happens to the CVP waveform?

A) There is a tall “a” wave
B) The “c” wave is absent
C) The “a” wave is absent
D) The “v” wave is smaller

Answer 87

C) The “a” wave is absent

Cornelius -* If you have somebody that’s got AFib because you don’t have kind of that consistent atrial filling, you may not have an A wave. *

Likewise you may have a larger C wave because there’s more volume in there when it finally contracts

Slide 39

Question 88

In tricuspid regurgitation, the ___________ is absent because the tricuspid valve is ___________.

A) Y; stenotic
B) X; incompetent
C) A; absent
D) V; open

Answer 88

B) X descent ; incompetent

Slide 39

Question 89

Which of the following are characteristics of tricuspid stenosis on the CVP waveform? Select 2

A) Tall “a” wave
B) Absent “a” wave
C) No “x” descent
D) Changes in the “y” descent
E) Larger “c” wave

Answer 89

A) Tall “a” wave
D) Changes in the “y” descent

Cornelius - *somebody with tricuspid stenosis, you may have a really large A wave because of that back pressure and the inability of it to effectively contract. *

You may also not see the Y descent happen there just because it’s masked by other waveforms, usually that big A wave

Slide 39

Question 90

KRISTA’s START!!!

What is 1 on the photo?

Answer 90

Distal Port

Most distal - Monitors PAP

Cornelius: very distal port that’s coming out beyond that balloon, and that’s what you’re gonna use to monitor your pulmonary artery pressure.

Slide 40-41

Question 91

What is 2 on the photo?

Answer 91

30 cm proximal
Monitors CVP

Slide 40-41

Question 92

What is the preferred site for PA catheter placement in most patients?
A) Left Subclavian
B) Right Internal Jugular
C) Left Internal Jugular
D) Right Subclavian

Answer 92

B) Right Internal Jugular

Slide 42

Question 93

What 3A and 3B on the photo?

Answer 93

3A = 40 cm mark
thin lines = 10 cm

3B = 50 cm mark
thick line = 50 cm

Slide 40-41

Question 94

Where is the PA catheter at based on the waveform below?

Answer 94

Right Atrium

Slide 42

Question 95

What is 4 on the photo?

Answer 95

4th Lumen
Houses temperature thermistor

Lies just proximal to balloon

Slide 40-41

Question 96

Where is the PA catheter at based on the waveform below?

Answer 96

RV

Slide 42

Question 97

What is 5 on the photo?

Answer 97

CVP port

Slide 40-41

Question 98

Where is the PA catheter at based on the waveform below?

Answer 98

Pulmonary Artery

Slide 42

Question 99

What is 6 on the photo?

Answer 99

Lock for Balloon

3rd lumen leads to a balloon near the tip

Slide 40-41

Question 100

Where is the PA catheter at based on the waveform below?

Answer 100

Wedged

Slide 42

Question 101

What is 7 on the photo?

Answer 101

Balloon Syringe

Most of these are gonna be 1/2 to 1 1/2 C’s of air that go into that balloon

Slide 40-41

Question 102

The PA catheter typically used in clinical practice is how many centimeters long?
A) 80 cm
B) 100 cm
C) 110 cm
D) 130 cm

Answer 102

C) 110 cm
marked at 10 cm intervals

Cornelius: You may also see there’s some variation as far as the size of the catheters for length, so some of them are longer than 110 centimeters, some are shorter, especially if you have one that’s more of like a pacing catheter or something like that.

Slide 43

Question 103

What PA catheter complication is associated with very high mortality?

A) Endocarditis
B) Catheter knots
C) Pulmonary artery rupture
D) Dysrhythmias

Answer 103

C) Pulmonary artery rupture

• Hemoptysis (Bright red and copious)
• Hypotension

Slide 44

Question 104

Which of the following characteristics might be observed on a CVP waveform in a patient with mitral regurgitation? Select 3

A) Tall V-wave
B) Prominent A-wave
C) C & V wave fused
D) No X-descent

Answer 104

A) Tall V-wave
C) C & V wave fused
D) No X-descent

No specificity/sensitivity to severity of MR d/t: LA compliance, LA volume

Slide 48

Question 105

Which of the following features might be observed on a CVP waveform in a patient with mitral stenosis?

A) Tall V-wave
B) Prominent A-wave
C) Slurred, early Y-descent
D) Absent C-wave

Answer 105

C) Slurred, early Y-descent

A wave may be absent d/t frequent assoc. with A-fib

Slide 49

Question 106

Which of the following is considered the gold standard for cardiac output measurement?

A) Bolus Thermodilution
B) Doppler Ultrasound
C) Fick Principle
D) Impedance Cardiography

Answer 106

A) Bolus Thermodilution

Slide 55

Question 107

Which of the following characteristics are typically observed in the PA catheter waveform of a patient with an acute LV myocardial infarction?

A) Tall A-waves
B) Decreased LVEDP
C) Increased LVEDV
D) Flattened V-waves
E) Increased LVEDP

Answer 107

A) Tall A-waves
C) Increased LVEDV
E) Increased LVEDP

PAWP increases

Slide 50

Question 108

Which of the following statements about the bolus thermodilution method are correct? (Select 3)

A) It involves injecting cold saline into the pulmonary artery.
B) Cardiac output is directly proportional to the degree of temperature change.
C) Measurements are taken in the pulmonary artery using a thermistor.
D) Three attempts are averaged to obtain the final measurement.

Answer 108

A) It involves injecting 10mL cold saline into the pulmonary artery.

C) Measurements are taken in the pulmonary artery using a thermistor.

D) Three attempts are averaged to obtain the final measurement.

CO inversely proportionate to degree of change

Slide 55

Question 109

What is the typical range for Systemic Vascular Resistance (SVR)?

A) 400 - 800 dynes/sec/cm⁵
B) 800 - 1600 dynes/sec/cm⁵
C) 1000 - 2000 dynes/sec/cm⁵
D) 1200 - 1800 dynes/sec/cm⁵

Answer 109

B) 800 - 1600 dynes/sec/cm⁵

Slide 54

Question 110

At what depth (in cm) should the PAC tip be located when it reaches the right atrium?
A) 10-15 cm
B) 20-25 cm
C) 30-35 cm
D) 40-45 cm

Answer 110

B) 20-25 cm

Slide 43

Question 111

What is the typical range for Pulmonary Vascular Resistance (PVR)?

A) 20 - 100 dynes/sec/cm⁵
B) 40 - 180 dynes/sec/cm⁵
C) 60 - 200 dynes/sec/cm⁵
D) 100 - 300 dynes/sec/cm⁵

Answer 111

B) 40 - 180 dynes/sec/cm⁵

Slide 54

Question 112

Which of the following factors contribute to inaccuracies in thermodilution measurements? (Select 4)

A) Mishandling of the injectate
B) Intracardiac shunts
C) Fluctuations in patient temperature
D) Rapid infusion of warm fluids
E) Tricuspid/pulmonic regurgitation

Answer 112

A) Mishandling of the injectate
B) Intracardiac shunts
C) Fluctuations in patient temperature
E) Tricuspid/pulmonic regurgitation

Rapid fluid infusion of cold fluids

Slide 57

Question 113

What is the typical depth range (in cm) for the PAC to reach the right ventricle?
A) 10-15 cm
B) 20-25 cm
C) 30-35 cm
D) 40-45 cm

Answer 113

C) 30-35 cm

Slide 43

Question 114

Which of the following statements are true about continuous cardiac output monitoring? (Select 4)

A) It is more accurate during positive pressure ventilation.
B) Data is averaged over 3-6 minutes.
C) It involves injecting cold saline for temperature measurement.
D) It provides better reproducibility than bolus thermodilution.
E) It delays updates in unstable patients compared to thermodilution.

Answer 114

A) It is more accurate during positive pressure ventilation.
B) Data is averaged over 3-6 minutes. Updated q 30-60 seconds
D) It provides better reproducibility than bolus thermodilution.
E) It delays updates in unstable patients compared to thermodilution.

Small quantities of heat are released from filament in RV

Slide 58

Question 115

What is the typical range for stroke volume in a healthy adult?

A) 40 - 60 mL
B) 50 - 80 mL
C) 60 - 90 mL
D) 70 - 100 mL

Answer 115

C) 60 - 90 mL

Slide 54

Question 116

Pulse contour devices use the area under the curve (AUC) of arterial pressure tracings to estimate which of the following? Select 2

A) Central venous pressure (CVP)
B) Cardiac output (CO)
C) Stroke volume variation (SVV)
D) PA pressure

Answer 116

B) Cardiac output (CO)
C) Stroke volume variation (SVV)
and pulse pressure

Slide 59

Question 117

At what depth (in cm) should the PAC tip be located when it reaches the pulmonary artery?
A) 20-25 cm
B) 30-35 cm
C) 40-45 cm
D) 50-55 cm

Answer 117

C) 40-45 cm

Slide 43

Question 118

What is the typical range for mixed venous O₂ saturation (SvO₂) in a healthy adult?

A) 50 - 60%
B) 60 - 70%
C) 70 - 80%
D) 80 - 90%

Answer 118

C) 70 - 80%

Slide 54

Question 119

True or False

Pulse contour devices rely on an algorithm that measures from end diastole to end systole to calculate ventricular compliance.

Answer 119

True

+/- 0.5 L/min compared to thermodilution

Slide 59

Question 120

The wedge position of the PAC is typically found at what depth (in cm)?
A) 20-25 cm
B) 30-35 cm
C) 40-45 cm
D) 45-55 cm

Answer 120

D) 45-55 cm

Slide 43

Question 121

Which of the following factors are likely to cause inaccuracies in pulse contour measurements? (Select 3)

A) Atrial fibrillation
B) Bradycardia
C) Site of arterial puncture
D) Vasopressors affecting arterial trace
E) Diuretic use

Answer 121

A) Atrial fibrillation
C) Site of arterial puncture
D) Vasopressors affecting arterial trace
and requires frequent re-calibration

Slide 60

Question 122

What would the following cardiac output thermodilution curve indicate?

Answer 122

Low CO
(Longer time to return to baseline)

Slide 56

Question 123

Echocardiography uses which type of waves to produce images?

A) Radio waves
B) High-frequency ultrasound waves
C) Microwaves
D) Infrared waves

Answer 123

B) High-frequency ultrasound waves

Density x velocity (sound through tissue)

Slide 61

Question 124

Which of the following is/are NOT potential complication(s) associated with a pulmonary artery catheter (PAC)?

A) Dysrhythmias, PVCs/V-tach
B) Transient RBBB or complete heart block
C) Catheter knots
D) Pulmonary edema
E) Pulmonary infarction
F) Pulmonary artery rupture
G) Endocarditis
H) Valve injury

Answer 124

D) Pulmonary edema

Slide 44

Question 125

Which of the following statements are true about echocardiography? (Select 3)

A) It uses low-frequency ultrasound waves.
B) M-mode can measure tissue planes such as ventricular wall mass.
C) Doppler mode shows real-time cardiac motion.
D) 2-D mode is used to shows function and real-time motion.
E) Doppler can determine the speed and direction of blood flow

Answer 125

B) M-mode can measure tissue planes such as ventricular wall mass.

D) 2-D mode is used to shows function and real-time motion.

E) Doppler can determine the speed and direction of blood flow.

Slide 61

Question 126

What would a high cardiac output thermodilution curve look like?

Answer 126

Small curve/area

Slide 56

Question 127

What SVV percentage indicates that a patient with hypotension is likely to respond well to fluid resuscitation when using a pulse contour device?

A) SVV < 5%
B) SVV > 10%
C) SVV = 8%
D) SVV = 3%

Answer 127

B) SVV > 10%

Slide 59

Question 128

In the FoCUS method, where is the parasternal window placed?

A) At the PMI
B) 3-5 intercostal space (ICS)
C) Below the xiphoid process
D) In the subclavian region

Answer 128

B) 3-5 intercostal space (ICS)

Slide 63

Question 129

Which of the following is considered a comprehensive exam using the FoCUS method?

A) 5 views
B) 10 views
C) 15 views
D) 28 views

Answer 129

D) 28 views

Anterior structures closest to transducer…..at the top of image

Slide 63

Question 130

Where is the apical window positioned during a FoCUS examination?

A) Below the xiphoid
B) At the 3-5 ICS
C) At the point of maximal impulse (PMI)
D) At the left clavicle

Answer 130

C) At the point of maximal impulse (PMI)

Slide 63

Question 131

Which of the following pressures are monitored by a Pulmonary Artery Catheter (PAC)? Select 2

A) Pulmonary Artery Pressure (PAP)
B) Central Venous Pressure (CVP)
C) Pulmonary Artery Wedge Pressure (PAWP)
D) Right Atrial Pressure (RAP)

Answer 131

A) Pulmonary Artery Pressure (PAP)

C) Pulmonary Artery Wedge Pressure (PAWP)
* Indirect measurement of left atrial pressure
* PAD pressure often used as alternative

Slide 46

Question 132

The subcostal window in the FoCUS method is found:

A) Just below the xiphoid process
B) At the mid-clavicular line
C) At the left sternal border
D) In the 2nd intercostal space

Answer 132

A) Just below the xiphoid process

Slide 63

Question 133

Which of the following are part of the standard five views in a focused transthoracic echocardiogram (TTE)? (Select all that apply)

A) Parasternal Long Axis
B) Parasternal Short Axis
C) Apical Four Chamber
D) Subcostal Four Chamber
E) Subcostal IVC

Answer 133

ALL OF THE ABOVE

Slide 63

Question 134

For accurate measurement, the tip of the Pulmonary Artery Catheter (PAC) should be in which zone of the lung?

A) Zone 1
B) Zone 2
C) Zone 3
D) Any zone is acceptable

Answer 134

C) Zone 3

Schmidty!

Slide 46

Question 135

Which of the following is primarily assessed using the parasternal long-axis view in a focused TTE? Select 2

A) Overall Function
B) Pulmonary artery
C) Left heart and aortic root
D) Inferior vena cava

Answer 135

A) Overall Function
C) Left heart (Left ventricle, left atrium) and aortic root

Slide 64

Question 136

Which conditions can cause a Pulmonary Artery Catheter (PAC) to provide a poor estimate of Left Ventricular End-Diastolic Pressure (LVEDP)? (Select 5)

A) Compliance
B) Aortic regurgitation
C) PEEP
D) Ventricular Septal Defect (VSD)
E) Mitral stenosis/regurgitation
F) Systemic hypertension

Answer 136

A) Compliance
B) Aortic regurgitation
C) PEEP
D) Ventricular Septal Defect (VSD)
E) Mitral stenosis/regurgitation

Cornelius: It doesn’t provide a good estimate of Compliance. If you have somebody with Aortic regurgigation, it’s gonna artificially increase your numbers. PEEP may affect things because you’re increasing pressure on the heart. If you’ve got a VSD in place, you may have altered flow so it may not provide you with a good estimate, or if you have somebody with a any sort of Mitral problem, you may not get good numbers.

Slide 47

Question 137

The parasternal short-axis view in a TTE is primarily used to assess which of the following?

A) Right atrium and tricuspid valve
B) Pulmonary valve and left atrium
C) Left ventricular function and volume status
D) Inferior vena cava and aortic root

Answer 137

C) Left ventricular function and volume status

Slide 64

Question 138

The apical four-chamber view is primarily used to assess ________ vs ________ size and the function of the ________ and ________ valves.

A) Right atrium (RA); Left atrium (LA); aortic; mitral
B) Right ventricle (RV); Left ventricle (LV); tricuspid; mitral
C) Left ventricle (LV); Right ventricle (RV); aortic; pulmonary
D) Right ventricle (RV); Left ventricle (LV); aortic; tricuspid

Answer 138

B) Right ventricle (RV); Left ventricle (LV); tricuspid; mitral

Slide 64

Question 139

“The subcostal four chamber view is primarily used to assess ________ and the ____ heart chambers”?

A) Right ventricular hypertrophy; two
B) Pericardial effusion; four
C) Aortic stenosis; three
D) Mitral valve function; two

Answer 139

B) Pericardial effusion; four heart chambers

Pericardial effusion often next
to right heart

Slide 65

Question 140

The subcostal IVC view is primarily used to assess the ___ and ___ of the inferior vena cava (IVC), especially during spontaneous respiration. Select 2

A) Diameter
B) Collapsibility
C) Wall motion abnormalities
D) Pulmonary valve function

Answer 140

A) Diameter
B) Collapsibility

Slide 65

Question 141

Which of the following conditions can mixed venous oximetry help assess? (Select 2)

A) Shock
B) Hyperglycemia
C) Cardiac output
D) Liver function

Answer 141

A) Shock
C) Cardiac output

Cornelius: this is kind of falling out of favor…it’s not quite as popular as it was. The mixed venous oximetry is kind of an indirect indicator of cardiac output. The problem we run into and the reason we don’t use it is often is because many times all those factors (Hgb, Arterial saturations, O2 consumption) are changing at the same time.

Slide 51-52

Question 142

Which of the following are the two main contraindications to intraoperative TEE?

A) Aortic stenosis and esophageal varices
B) Esophageal varices and laparoscopic banding
C) Mitral valve prolapse and esophageal stricture
D) Pulmonary hypertension and left atrial enlargement

Answer 142

B) Esophageal varices and laparoscopic banding

Slide 66

Question 143

What is the correct formula for calculating cardiac output?

A) CO = HR / SV
B) CO = SV x HR
C) CO = SV + HR
D) CO = HR - SV

Answer 143

B) CO = SV x HR

Total blood flow generated by heart/minute

Slide 53

Question 144

What is the typical range for cardiac output in a healthy adult?

A) 2.5 - 4.0 L/min
B) 4.0 - 6.5 L/min
C) 5.0 - 7.5 L/min
D) 6.5 - 9.0 L/min

Answer 144

B) 4.0 - 6.5 L/min

Slide 54

Question 145

Intraoperative TEE serves as a ___ , ___ , and ___ tool during surgical procedures.

A) monitor; rescue; research
B) diagnostic; preventative; decision-making
C) monitor; decision-making; rescue
D) therapeutic; diagnostic; monitor

Answer 145

C) monitor; decision-making; rescue

and assessment of valvular function

Slide 66