RCIS 2023 Questions and Answers Graded A

RCIS 2023 Questions and Answers
Graded A
What is the formula for calculating cardiac output?
A. CO= PA-1 SVC
B. CO= AO x PA
C. CO= HR x SV – C. CO= HR x SV
Stroke volume is…
A. Related to preload
B. Related to afterload
C. The same as ejection fraction – A. Related to preload
Preload is most impacted by…
A. Mean arterial pressure
B. Increased filling volumes
C. Ejection fraction – B. Increased filling volumes
A patient with chronic untreated hypertension would demonstrate
A. Increased afterload
B. Decreased afterload
C. Decreased preload – A. Increased afterload
Vascular resistance/pressure is most influenced by…
A. Blood viscosity
B. BMI
C. Length of the vessel
D. Radius of the vessel – D. Radius of the vessel
The formula for BP is…
A. BP= SV x SVR
B. BP= CO x SVR
C. BP= HR x SVR – B. BP= CO x SVR
What component of a PCWP indicates Mitral Insufficiency
A. A wave

B. C wave
C. P wave
D. V wave – D. V wave
An elevated RVEDP is found in which pathology
A. LV infarct
B. Aortic stenosis
C. RV infarct
D. Mitral regurgitation – C. RV infarct
If the RA waveform is 2x the normal value, where would this be demonstrated in the
physical assessment
A. Decreased exercise tolerance
B. Decreased O2 sat
C. Increased O2 sat
D. JVD – D. JVD
What is the most common cause of Pulmonic stenosis
A. Aging
B. Congenital
C. Cardiomyopathy
D. Mitral regurgitation – B. Congenital
The blue proximal port of the swan is located how far from the distal tip of the swan
A. 15cm
B. 30cm
C. 45cm
D. 5cm – B. 30cm
When performing a thermodilution cardiac output, the operator injects 10cc of saline into
the______ and the temperature is measured in the _
A. LA, AO
B. RV, PCWP
C. RA, PA
D. RA, LA – C. RA, PA
Equalization of RVEDP and LVEDP are found in
A. Tamponade
B. Restrictive pericarditis
C. Acute MI

D. LV MI – B. Restrictive pericarditis
Signs of right sided heart failure include
A. Decreased O2 sat
B. SOB
C. JVD
D. Pulmonary embolism – C. JVD
Based on these oxygen saturations, what type of shunt is present?
SVC sat = 67% IVC sat = 71% RA sat = 85%
PA sat = 85% LA sat = 98% LV sat = 98%
RV sat = 85% AO sat = 98%
A. R to L ASD
B. L to R ASD
C. L to R VSD
D. It is all normal, there is not shunt – B. L to R ASD
What type of ASD, located in the middle 1/3 of the atrial septum (the former site of the
fossa ovalis) is called
A. Ostium primium
B. Sinus venosus
C. Ostium secundum – C. Ostium secundum
What is the Flamm’s equation
A. 3(svc) + 1(ivc)/4
B. 6(svc) + 2(ivc)/2
C. 3(pa) + 2(ao)/4 – A. 3(svc) +1(ivc)/4
The formula used to calculate MAP is
A. HR x SV/SVR
B. Mean AO-mean RA
C. 1 (systolic) + 2 (diastolic)/3 – C. 1(systolic) + 2(diastolic)/3
What are the four anomalies associated with Tetralogy of Fallot
A. ASD, VSD, LVH, RVH
B. VVH, PS, Over riding aorta, RVH
C. Over riding aorta, RVH, LVH, ASD
D. Pulmonic stenosis, over riding aorta, RVH, VSD – D. Pulmonic stenosis, over riding
aorta, RVH, VSD

Which fetal anomaly is characterized by a large VSD over which a large single great
vessel arises
A. Transposistion of the great vessels
B. Tricuspid atresia
C. Tetralogy of fallot
D. Truncas arteriosus – D. Truncas arteriosus
Pulsus paradoxus is a sign of
A. Constrictive percarditis
B. Cardiomyopathy
C. Cardiac tamponade
D. COPD – C. Cardiac tamponade
What does RAD stand for
A. Radiation absorbed dose
B. Radiation attenuated date
C. Radiation attributable distance – A. Radiation absorbed dose
Which component of the x-ray system converts light rays to images
A. Image intensifier
B. X-ray tube
C. Photon tube
D. Anode – A. Image intensifier
What is the maximum annual dose of radiation one can receive annually
A. 5 RAD
B. 5 Currie
C. 0.5 REM
D. 5 REM – D. REM
Lead protection should be at least how many millimeters of lead
A. 1.0
B. 0.25
C. 0.5 – C. 0.5
What is the minimum safe distance to position oneself from the x-ray source
A. 3ft
B. 6ft

What is the formula for calculating cardiac output?
a. CO = PA – 1SVC
b. CO = AO x PA
c. CO = HR x SV
c. CO = HR x SV

Stroke Volume is____?
a. Related to preload
b. Related to afterload
c. The same as ejection Fraction?
a. Related to preload

Preload is most impacted by?
a. Mean arterial Pressure
b. Increased filling volumes
c. Ejection Fraction
b. Increased filling volumes

A patient with chronic untreated hypertension would demonstrate
a. increased afterload
b. Decreased afterload
c. Decreased preload
a. increased afterload

Vascular resistance/pressure is most influenced by
a. Blood viscosity
b. BMI
c. Length of the vessel
d. Radius of the vessel
d. Radius of the vessel

The formula for BP is
a. BP = SV x SVR
b. BP = CO x SVR
c. BP = HR x SVR
b. BP = CO x SVR

What component of a Pulmonary Capillary Wedge Pressure indicates mitral insufficiency
a. A Wave
b. C wave
c. P wave
d. V wave
d. V wave

An elevated RVEDP is found in what pathology?
a. LV infract
b. Aortic Stenosis
c. RV infract
d. Mitral regurgitation
c. RV infract

If the RA waveform is 2x the normal value, where would this be demonstrated in the physical assessment?
a. Decreased exercise tolerance
b. Decreased 02 sat
c. Increased 02 sat
d. JVD
d. JVD

What is the most common cause of Pulmonic stenosis?
a. Aging
b. Congenital
c. Cardiomyopathy
d. Mitral regurgitation
b. Congenital

The blue proximal port of the swan is located how far from the distal tip of the swan?
a. 15 cm
b. 30cm
c. 45cm
d. 5cm
b. 30cm

When performing a thermodilution cardiac output, the operator injects 10 cc of saline into the _ and the temperature change is measured in the _
a. LA , AO
b. RV , PCWP
c. RA , PA
d. RA, LA
c. RA , PA

Equalization of the RVEDP and LVEDP are found in
a. Tampanode
b. Restrictive pericarditis
c. Acute MI
d. LV MI
b. Restrictive pericarditis

Signs of Right sided heart failure include
a. Decreased 02 sats
b. SOB
c. JVD
d. Pulmonary embolism
c. JVD

Based on these oxygen saturations, what type of shunt is present?
SVC sat = 67% IVC sat= 71% RA sat = 85% RV sat = 85% PA sat = 85% LA sat = 98% LV sat = 98% AO sat = 98%
a. R to L ASD
b. L to R ASD
c. L to R VSD
d. Normal, no shunt
b. L to R ASD

The type of ASD, located in the middle 1/3 of the atrial septum (the former site of the fossa ovalis is called
a. Ostium Primum
b. Sinus Venosus
c. Ostium Secundum
c. Ostium Secundum

What is Flamms equation?
a. 3 (SVC) + 1 (IVC) / 4
b. 6 (SVC) + 2 (IVC) / 2
c. 3 (PA) + 2 (AO) / 4
a. 3 (SVC) + 1 (IVC) / 4

The formula to calculate MAP is
a. HR x SV / SVR
b. Mean AO – Mean Ra
c. 1 (systolic) + 2 (diastolic) / 3
c. 1 (systolic) + 2 (diastolic) / 3

What are the 4 anomalies associated with Tetrology of Fallot?
a. ASD, VSD, LVH, RVH
b. VVH, PS, Overriding aorta, RVH
c. Overriding aorta, RVH, LVH, ASD
d. Pulmonic stenosis, overriding aorta, RVH, VSD
d. Pulmonic stenosis, overriding aorta, RVH, VSD

Tetralogy of Fallot consists of the combination of four different heart defects: a ventricular septal defect (VSD); obstructed outflow of blood from the right ventricle to the lungs (pulmonary stenosis); a displaced aorta, which causes blood to flow into the aorta from both the right and left ventricles (dextroposition or overriding aorta); and abnormal enlargement of the right ventricle (right ventricular hypertrophy)

Which fetal anomaly is characterized by a large VSD over which large single great vessel arises
a. Transposition of the Great Vessels
b. Tricuspid Atresia
c. Tetralogy of Fallot
d. Trucas Arterosus
d. Trucas Arterosus

Pulsus Paradoxus is a sign of
a. Constructive Pericarditis
b. Cardiomyopathy
c. Cardiac Tamponade
D. COPD
c. Cardiac Tamponade

Pulsus paradoxus refers to a BP drop of at least 10 mm Hg with each breath in.

What does RAD stand for?
a. Radiation Absorbed dose
b. Radiation attenuated date
c. Radiation attributable distance
a. Radiation Absorbed dose

Which component of the X-ray system converts light rays into images
a. Image intensifier
b. X-ray tube
c. Photon Tube
d. Anode
a. Image intensifier

What is the maximum annual dose of radiation one can receive annually
a. 5 RAD
b. 5 currie
c. 0.5 REM
d. 5 REM
D. 5 rem

Lead protection should be at least how many millimeters of lead
a. 1.0
b. .25
c. .5
c. .5

What is the maximum safe distance to position oneself from the X-ray source
a. 3 feet
b. 6 feet
c. 10 feet
d. 15 feet
b. 6 feet

In an x-ray tube
a. Cathode is positive and the anode is negative
b. Cathode is negative and the anode is positive
c. The charges alternate depending on the heat generated
b. Cathode is negative and the anode is positive

What view exposes the operator to the greatest amount of radation
a. AP
b. LAO cranial
c. Lateral
d. RAO with cranial 30
c. Lateral

What converts x-ray into an image
a. Filament
b. Image intensifier
c. x-ray tube
d. KVP
b. Image intensifier

the contrast that is best for a patient is
a. Low osmolarity
b. High osmolarity
c. Renografin
a. Low osmolarity

Radiolucent means
a. X-rays are not permitted to pass through
b. X-rays are partially deflected
c. X-rays are permitted to pass through
c. X-rays are permitted to pass through

Radiopaque means
a. X-rays are permitted to pass through
b. X-rays are not permitted to pass through
c. X-rays are randomly deflected
b. X-rays are not permitted to pass through

ReoPro works on
a. Fibrin
b. Prothrombin
c. Antithrombin
d. IIb/IIIa receptors
d. IIb/IIIa receptors

Heparin potentiates the action of
a. Antithrombin
b. Factor III
c. Factor IX
d. Factor VIII
a. Antithrombin

Fibrinogen is converted to Fibrin by the action of
a. Pro thrombin
b. Tissue Factor
c. Platelets
d. Thrombin
d. Thrombin

There are _ known pathways to imitate the clotting cascade
a. 2
b. 1
c. 3

4
a. 2

(intrinsic: tissue factor, extrinsic: contact pathway)

Aspirin inhibits the action of
a. VWF
b. Factor VII
c. Thrombin
d. Arachidonic Acid
d. Arachidonic Acid

Which agent is not an antiplatelet
a. ASA
b. Heparin
c. Plavix
d. ReaPro
b. Heparin

Is a patient has diabetes and renal failure with a creatinine of 2.0 what would you give?
a. Lasix
b. Fluids to hydrate
c. Ionic contrast
b. Fluids to hydrate

If a patient is taking NPH, which medication should not be given
a. Protamine
b. Lasix
c. Heparin
a. Protamine

Which medication is most commonly given to a patient with SVT
a. NTG
b. Lidocaine
c. Dopamine
d. Adenosine
d. Adenosine

If a patient has a creatinine greater than 1.4 contrast volume should be minimized
a. True
b. False
a. True

Lidocaine converts from 2gm in 500cc to
a. 8gm in 1cc
b. 400mg in 250cc
c. 4mg in 250cc
c. 4mg in 250cc

Dopamine concentration 1600 mcg/ml in 250cc yields a concentration of
a. 200mg in 250cc
b. 400mg in 250cc
c. 100mg in 250cc
b. 400mg in 250cc

(16000/1000) x 250

The best short acting medication / anxietolytic to sedate a patient is
a. Fentanyl
b. Valium
c. Versed / Midazolam
c. Versed / Midazolam

The drug of choice for treating coronary spasm is
a. Verapamil
b. NTG
c. Amiodarone
b. NTG

Amiodarone is used to treat
a. Atrial arrhythmias only
b. Ventricular arrhythmias only
c. Atrial and ventricular arrhythmia’s
c. Atrial and ventricular arrhythmia’s

What medication is used as a preload and afterload reducer
a. Dopamine
b. Dobutamine
c. NTG
d. Lidocaine
c. NTG

Diabetic patients have a greater incidence of developing __ post contrast administration
a. Renal Failure
b. Infract
c. PE
d. Systemic infection
a. Renal Failure

Which rhythm is most likely to become lethal
a. 1st-degree heart block
b. Wenchbach
c. Mobitz 2
c. Mobitz 2

Mobitz type 2 is more serious, because it is usually chronic and tends to progress to third-degree AV block. Moreover, cardiac output may be reduced if many impulses are blocked.

The Impella catheter most closely resembles
a. JR 4
b. Amplatz
c. Pigtail
d. IMA
c. Pigtail

When preforming an LV angiogram with the LV injector, what is the purpose of setting a “rate of rise”
a. It controls the total volume rejected
b. It makes for a smoother injection, less catheter whip, limits ecotpy
c. It adjusts the PSI for the correct catheter size
b. It makes for a smoother injection, less catheter whip, limits ecotpy

An EKG demonstrates ST elevation in leads 11, 111, and AVF. What type of infract would you suspect
a. Inferior wall
b. Lateral wall
c. Apical wall
a. Inferior wall

An EKG demonstrates ST elevation in leads V5, V6, Lead 1, and AVL. Which coronary artery is most likely occluded
a. RCA
b. LAD
c. Cx
c. Cx

How do you test the defibrillator
a. Hold the paddles in the air and discharge
b. Discharge into the defibrillator (dummy load)
c. Never test, call Biomed
b. Discharge into the defibrillator

What happens if you deliver a shock to a patient on the T-wave?
a. They are easily cardioverted to ta sinus rhythum
b. You could put them into v-fib
c. You could make the hypertension
b. You could put them into v-fib

In 1st degree heart block, where is the conduction delay
a. AV node
b. SA node
c. Bundle of HIS
d. In the RA
a. AV node

It is defined by ECG changes that include a PR interval of greater than 0.20 without disruption of atrial to ventricular conduction.

What is the normal PR interval
a. .8-.12
b. >.20
c. .12-.20
c. .12-.20

If a patient is attached to the monitor, v-tach is the rhythm, the patient has no pulse and is not responding, what should you do
a. Synchronized cardioversion
b. UnSynchronized cardioversion
c. Call the MD before taking action
d. Check for a BP
b. UnSynchronized cardioversion

If a patient is on a monitor in SVT, SBP is 70, the patient is diaphoretic, duskey and SOB. What should you do
a. Call the MD before taking action
b. Do immediate unsynchronized cardioversion
c. Do immediate synchronized cardioversion
d. Give adenosine 6mg
c. Do immediate synchronized cardioversion

A common complication of placing a pacing electrode/wire is
a. MI
b. Perforation/ Pericardial Effusion/ Tamponade
c. Cardiac arrest
b. Perforation/ Pericardial Effusion/ Tamponade

A pacing generator that paces in both chambers, senses in the ventricle, and inhibits QRS complexes is a
a. DDI
b. DVI
c. AAI
b. DVI

A pacing generator that paces both chambers, senses in both chambers, and triggers or inhibits is a
a. DDI
b. DDD
c. AAI
b. DDD

A pacing generator that paces in the atria, senses in the artia, and inhibits pacing is a
a. AAI
b. AAO
c. DDD
a. AAI

What is the formula for calculating SVR
a. Mean AO-MeanRA / CO
b. Mean PA-Mean PCWP / CO
c. EDV-ESV / EDV
a. Mean AO-MeanRA / CO

Which CO would be most accurate in a patient with TR
a. Thermals
b. LVMF
c. Fick
c. Fick

Which right heart pressure reflects LV preload
a. PA systolic pressure
b. PCWP
c. RA Pressure
b. PCWP

Which balloon is used for valvuloplasty
a. ICE balloon
b. Trans-septal balloon
c. Inoue
d. Self-expanding
c. Inoue

Aortic stenosis demonstrates a pressure that is elevated in the LV and a pressure that is lower in the____
a. Left atrium
b. Aortic arch
c. Pulmonary artery
d. RV
b. Aortic arch

Calculate CO of a patient with the following data:
Arterial 02 sat= 98% RV 02 sat= 71% PCWP= 12 Constant= 1.36 Mean gradient= 70 Pulmonary artery 02 sat= 74% Hgb= 14.7 02 consumption= 250ml/min RA=5
a. 4.8 L/min
b. 5.2 L/min
c. 6.0 L/min
d. Not enough information collected
b. 5.2 L/min

Fick CO= 02 consumption / (hgb x constant x AO sat)- (hgb x constant x PA sat) x 10
=250/ (14.7 x 1.36 x .98) – (14.7 x 1.36 x .74) x 10
= 250 / (19.59 – 14.79) x 10
= 250 / 48
=5.2

Calculate the stroke volume on this patient:
ESV= 35 EF=40% EDV= 85 HR= 70 BP= 120/74
a. 50cc
b. 45cc
c. 20cc
d. Not enough info collected
a. 50cc

SV = EDV-ESV
SV= 85-35
SV= 50cc

Calculate the Aortic Valve area with the following:
HR= 85 CO= 4.2L/min Sep= .37 Mean gradient= 64 BP= 136/74
a. .52cm2
b. .75cm2
c. .37cm2
d. Not enough info given
c. .37cm2

AVF = CO mL/min / SEP sec/min
AVA = AVF / 44.5 x sqr root mean gradient

1.
= 4.2L/min x 1000= 4200mL/min
2.
=.37sec/beat x 85BPM
Valve open= 31.45sec/beat
3.
=4200 / 31.45
AVF = 133.55
4.
= 133.55 /(44.5 x sqr root 64)
=133.55 / (44.5 x 8)
= 133.55 / 356
= .27 cm^2

Calculate the regurgitant fraction of a patient who has a thermal CO of 4.1L/min and an angiographic CO of 5.4L/min
a. 24%
b. 34%
c. 15%
d. 41%
a. 24%

RF = (CO (angio) – CO (Fick or TDCO)) / CO (angio)
=(5.4 – 4.1) ./ 5.4
=.24

This patient has a CO of 5.1L/min. Calculate SVR of this patient with the following data:
Mean PA= 24 Mean PCWP= 15 Mean RA= 5 Mean AO= 95
a. 1411 dynes/sec/cm-5
b. 800 dynes/sec/cm-5
c. 1010 dynes/sec/cm5
d. Not enough info provided
a. 1411 dynes/sec/cm-5

SVR = (Mean AO – Mean RA) / CO x 80
=(.95 – .5) / 5.1 x80
= .9 / 5.1 x 80
=.17 x 80
=14.11 x1000
=1411

If a patient has a pulsatile mass below the sheath site, and a bruit is present, what would be suspected?
a. Hematoma
b. Aortic Dissection
c. Thrombus
d. Pseudo aneurysm
d. Pseudo aneurysm

An abdominal pulsation greater than 3.0cm can be a finding for what?
a. Normal finding
b. Anomalous renal artery
c. Increased BMI
d. Aortic aneurysm
d. Aortic aneurysm

Back pain not relieved with NTG, morphine, or oxygen and not associated with EKG changes can indicate
a. PVD
b. Renal Failure
c. Aortic dissection
d. Occluded LAD
c. Aortic dissection

Which stent is self-expanding?
a. Cypher
b. Wall stent
c. Vision
b. Wall stent

A catheter has a dimeter of 2.66mm. What french size is it?
a. 7fr
b. 6fr
c. 5fr
d. 8fr
d. 8fr

In relation to a coronary artery lesion where should the wire be placed?
a. As distal as possible
b. In the nearest side branch
c. In the distal side branch
d. Proximal to the lesion
E. All of the above
E. All of the above

Which lesion is best addressed with a Rotoblader?
a. Calcified
b. Soft thrombus
c. New dissection
d. Very small vessels
a. Calcified

Which catheter should be used to cannulate an LAD with a high takeoff?
a. JL4
b. MP
c. Amplatz
c. Amplatz

Landmarks for an internal jugular approach should include the
a. Head of the sternocleidomastoid muscle and the clavicular head
b. Superior and inferior carotid pulsations
c. 2cm proximal to the xyphoid process
a. Head of the sternocleidomastoid muscle and the clavicular head

When preforming a myocardial biopsy where are the tissue samples taken from
a. LV
b. RV
c. LA
d. Left atrial appendage
b. RV

Hypokinetic means
a. No movement at all
b. Decreased movement
c. Hyper or increased movement
d. Disorganized movement
b. Decreased movement

In the formula BP = HR x SV x SVR, dobutamine acts as an , to _ by increasing _.
a. Chronotrope, decrease SV, contractibility
b. Chronotrope, increase SV, contractibility
c. Inotrope, increase SV, contractibility
c.

Which of the following are Angiotensin Receptor Blockers (ARBS) (choose all that apply)
a. Lisiopril
b. Losartan
c. Metoprolol
d. Valsartan
B D

NTG works to decrease preload when given during an MI by dilating
a. Peripheral arteries
b. Arterioles
c. Veins
d. Coronary arteries
c. veins

Low dose dopamine, 1-5mcg/kg/min
a. Improves renal function and urine output
b. Increases HR
c. Increases systolic blood pressure
d. Increases SV
a.

If the patient complains of pain down the leg when attempting to cannulate the right femoral artery, which way do you move the needle?
a. Lateral
b. Medial
c. Anterior
d. Medial and superior
b.

Coronary artery perfuse best during
a. Systole
b. When the systolic blood pressure is less than 140mmHG
c. Diastole
d. Equally during systole and diastole
c.

What is the purpose of the IABP
a. Increase coronary perfusion, decrease afterload
b. Increase coronary perfusion, decrease preload
c. Raise systolic BP
d. Increase renal perfusion
a.

An IMA catheter most nearly resembles a
a. AR1
b. JR4
c. MP
d. Renal catheter
b.

What is the recommended rate of burr rotation when using Rotoblader
a. 50,000-100,000
b. 100,000-150,000
c. 150,000-210,000
d. 100,000-105,000
c.

Over tightening of the Touhy Borst will
a. Impinge the wire
b. Prevent balloon inflation or deflation
c. Crimp the guide
d. Is not an issue
b.

The best advice for management of an acute thrombus in a vessel is
a. Rotoblader
b. Stent
c. Angiojet
d. Laser
c.

Which device employs the use of sterile heparinized saline to evacuate thrombus?
a. Pressure
b. IVUS
c. IABP
d. Angiojet
d.

What are the S/S of a retroperitoneal bleed?
a. Flank pain, elevated BP, bradycardia, drop in Hgb and Hct
b. Back pain, elevated BP, Tachycardia, drop in Hgb and Hct
c. Back or flank pain, drop in BP, bradycardia, drop in Hgb and Hct
d. Back for flank pain, drop in BP, tachycardia, drop in Hgb and Hct
d.

Calcified lesions are best managed with which device
a. Perfusion balloon
b. Stent
c. Cutting/scoring balloon
d. None of the above
c.

When using a temp pacer, where is the lead placed?
a. RA
b. LA
c. SVC
d. RV
d.

When preforming a myocardial biopsy post heart transplant, the biopsy is performed to evaluate
a. EF changes
b. Potential for rejection of the transplanted heart
c. LV muscle thickening
d. Diastolic relaxation time
b.

The drive to breathe in a person with no respiratory diseases is
a. Elevated C02
b. Decreased 02
c. Elevated P02
d. Decreased PC02
a.

The drive to breathe in a person with COPD is
a. Elevated C02
b. Decreased 02
c. Elevated P02
d. Decreased PC02
d.

The greatest risk when preforming a myocardial biopsy is
a. Contamination of the tissue samples
b. Perforation of the RV
c. Perforation of the LV
d. Losing the tissue samples
b

When using Rotoblader, the burr should start rotating
a. On the lesion
b. Mid lesion with following proximal and distal movements
c. Distal to the lesion with rotation as its withdrawn
d. Just proximal to the lesion
d

Akinetic means
a. No movement at all
b. Decreased movement
c. Hyper or increased movements
d. Disorganized movements
a.

Dyskinetic means
a. No movement at all
b. Decreased movement
c. Hyper or increased movements
d. Disorganized movements
d.

An ABI measures
a. The difference between the aortic and pulmonary blood flow
b. The difference between pedal and posterior tibial blood flow
c. The difference between brachial and ankle systemic blood flow
d. The difference between tight and ankle BP
c.

The dorsalis pedal pulse is located
a. Posterior to the knee
b. on the anterior foot
c. Near the lateral malleolus
d. Near the medial malleolus
b.

The posterior tibial pulse is located near
a. Posterior to the knee
b. on the anterior foot
c. Near the lateral malleolus
d. Near the medial malleolus
d.

The site of myxoma is in the
a. RA
b. LA
c. RV
d. Distal to the aortic valve
b

Myxomas are usually located in either the left or right atrium of the heart; about 86 percent occur in the left atrium.

The best catheter to cross a stenotic aortic valve is
a. JR4
b. JL5
c. MP
d. AL2
d.

What medications are commonly given when preforming a radial procedure?
a. NTG, verapamil, Heparin
b. NTG, Lidocaine, Inderal
c. Heparin, Protamine, Lidocaine
d. NTG, Plavix, Heparin
a.

The Allen’s test assesses the flow in the
a. Right internal jugular prior to insertion of a PPM
b. Brachial artery prior or placement of a central catheter
c. Anterior and lateral foot prior to a peripheral stent
d. Blood flow in the radial an ulnar arteries
d.

The IABP catheter should be placed
a. Above the renal arteries and below the right common carotid
b. Above the renal arteries and just distal to the aortic valve
c. Above the renal artery and below the left subclavian
d. Below the renal artery and distal to the left subclavian
c.

Which of the following symptoms after the use of a closure device warrants evaluation?
a. Pain at the procedure site
b. Change in pulses in the foot
c. Loss of pulses in the foot
d. Loss of pulses in the foot on the side the closure device was not placed
c.

If the HR slows, what happens to stroke volume?
a. Decreases
b. Increases
c. Remains the same
d. Results in a paradoxical pulse
b.

What happens to myocardial contractile force (dp/dt) when the HR slows?
a. Increases
b. Decreases
c. Remains the same
d. Results in a paradoxical pulse
a

The Eustachian Valve is located?
a. Between right and left atria
b. Between the right and left ventricles
c. Between the SVC and ICV
d. Between the IVC and the RA
d.

The Amplatzer Septal Occluder device is used
a. to close a PFO
b. as a distal protection devie
c. to increase CO
d. Provides distal perfusion in the LAD when a left main lesion is present
a

The percutaneous Impella
a. Evacuates 5 LPM from the LV, delivers it to the descending aorta, improves CO, increases SV, improves coronary perfusion
b. Evacuates 2.5 LPM from the LV, delivers it to the ascending aorta, improves CO, increases SV, improves coronary perfusion
c. Evacuates 5 LPM from the LV, delivers it to the RV, Improves CO, increases SV, improves coronary perfusion
d. Evacuates 2.5 LPM from the LV, delivers it to the descending aorta, improves CO, increases SV, improves coronary perfusion
b.

The head hunter catheter is used to visualize the
a. Left internal carotid artery
b. Right internal carotid artery
c. Left external carotid artery
d. Left and right ICA and ECA
d.

The fossa ovalis is located
a. Between RV and LV
b. Between the PA and Aorta
c. Between the RA and LA
d. Between the IVC and ra
c.

What is the most common cause of renal artery stenosis?
a. HTN
b. Atherosclerosis
c. Diabetes
d. Obesity
b.

Renal artery stenosis is most commonly found in the
a. Right renal artery
b. Left renal artery
c. Renal-aortic branch
d. Proximal renal artery
d.

FFR measure
a. Pressure proximal to the stenosis
b. Pressure within a stenosis (mid-stenosis)
c. Pressure distal to the stenosis
d. In the branch adjacent to the lesion
c.

When interpreting FFR, an FFR of .80 means that a stenosis causes a 20% drop in blood pressure distal to the lesion
a. True
B. False
a.

FFR expresses the maximal flow down a vessel in the presence of stenosis compared to the maximal flow in the absence of a stenosis
a. True
b. False
a.

When considering FFR, values greater than .75-.80 indicate a non-significant stenosis and lower values indicate a significant stenosis
a. Ture
b. Flase
a.

When considering FFR, significant stenosis (> 70%) may yield an FFR >.80 if there is a significant collateral flow to the vessel with the lesion in it
a. true
b. false
a.

Pulsus alternans is a sign of left sided heart failure
a. Ture
b. False
a.

Prior to mitral valvuloplasty a TEE is needed as atrial thrombus is an absolute contraindication
a. Ture
B. False
a.

How would you monitor heparin therapy if ACT is not available
a. CBC
b. BUN
c. PT/PTT
d. Hgb and Hct
c.

An elevated PCWP, orthopnea, increased LVEDP, and decreased 02 sat are signs of
a. Right sided heart failure
b. PE
c. RCA occlusion
d. Left sided heart failure
d.

What is the NYHA classification of a patient on ventricular assist device
a. I- No limitation of activity, no SOB when walking
b. II- Mild symptoms, mild SOB and or angina, slight limitation of activity
c. III- Marked limitation of activity, comfortable only at rest
d. IV- Severe limitation of activity, symptomatic at rest
d.

A washer that is visualized on fluoroscopy is placed to mark the
a. Proximal vein graft
b. Distal vein graft
c. Mid vein graft
d. None of the above
a.

An ABI measures the difference between the _ and pulses and a reading of __ indicates a flow limiting lesion
a. Left and right brachial, .7
b. Left brachial and right pedal, .8
c. Left popliteal and left pedal, .7
d. Left brachial and left pedal, .7
d.

Cannulation of the femoral artery should be
a. Above the inguinal fold
b. 6cm below the inguinal fold
c. Precisely in the inguinal fold
d. One finger breath below the inguinal fold
d.

Chose the correct answers about a psuedo aneursym (PAS)
a. PSA occurs when an arterial puncture does not seal
b. Pulsatile blood tracks into the perivascular space
c. Blood is contaminated by the perivascular structure
d. Takes on the appearance of a SAC
e. Is a result of cannulating needle penetrating the anterior and posterior vessel walls
f. all of the above
f.

Treatment of a pseudoaneurysm (PSA) includes
a. Thrombin injection into the SAC
b. Ultrasound guided compression
c. Surgical manement
d. all of the above
d.

PSA’s occur most commonly when the puncture site is the (choose all that apply)
a. CFA
b. SFA
c. External iliac artery
d. Given adequate compression time
b c d

Physical sings of a PSA may include (choose all that apply)
a. Palpable pulsatile mass
b. Presence of a systolic bruit
c. Significant site pain
d. Loss of pulse in the opposite leg
a b c

Which of the following are not associated with a retroperitoneal bleed?
a. Cannulation 1 finger breath below the inguinal fold
b. Cannulation of the SFA
c. Cannulation of the profunda
d. Cannulation above the inguinal fold
a.

Which organ system is responsible for metabolic changes in pH?
a. Liver
b. Lungs
c. Kidneys
d. Pancreas
c.

Which of the following organ systems cannot cause changes in the pH? (choose all that apply)
a. GI / Endocrine
b. Liver / pancreas
c. Heart / vascular
d. Kidneys / lungs
A B C

Which of the following are necessary prior to correcting an ASD (choose all that apply)
a. Documentation using ICE catheter
b. Evaluation using a sizing balloon
c. ID the shunt to be in the ostium secundum
d. ID the shunt to be in the ostium premium
a b c

ID all of the following that pertain to the crushing stent technique
a. Created for lesions in a side branch
b. Created for lesions in a bifurcation
c. The first stent is positioned in the side branch with about 1/3 of its length protruding into the main branch
d. A second stent is positioned in the main branch
e. The side branch stent is deployed first
f. The main branch stent is deployed second crushing the portion of the side branch stent from the main branch
a b c d e f

Contraindications for closure devices include (choose all that apply)
a. PVD
b. Diabetes
c. Cannulation above the inguinal fold
d. Cannulation in the profunda
a b c d

The incidence of vascular complications increases when the groin stick is how far below the inguinal fold (choose all that apply)
a. <1 cm b. 2-3 cm c. 3-4 cm d. >4 cm
b c d

The PR interval is .26. The conduction delay is not in the (choose all that apply)
a. SA node
b. AV node
c. Bundle of his
d. Purkinje Fibers
a c d

The laser as an interventional technique eliminates plaque by
a. Crushing
b. Cracking
c. Debulking
d. Vaporizing
d

The impella device evacuates blood from the _ and delivers it to the _
a. RV-RA
b. RV-PA
c. LA-LV
d. LV-AO
d.

Which of the following are not TIMI flow post procedure? (choose all that apply)
a. TIMI 0 (no flow)
b. TIMI 1 (Faint Flow
c. TIMI 2 (Sluggish flow)
d. TIMI 3 (Normal flow)
a b c

Increasing the rate of rise on the power injector results in
(choose all that apply)
a. Decrease in catheter whip
b. Decreased amount of contrast needed
c. Increased amount of contrast needed
d. No change in the amount of contrast needed
e. Decreased change of injuring the LV
a d e

Arteriosclerosis is the thickening/hardening and loss of elasticity of the walls of the arteries
a. true
b. false
a

Arteriosclerosis is the build up of plaque in the arterial wall (string of pearls)
a. true
b. false
a

A properly timed atrial contraction (choose all that apply)
a. Increases SV
b. Decreases SV
c. Increased CO
d. Decreases CO
a c

Symptoms of a RP bleed include (choose all that apply)
a. Back pain
b. Decreased Hgb and Hct
c. Tachy
d. Increased SV
a b c

Which of the following increase the risk of stroke (choose all that apply)
a. A fib
b. V fib
c. V flutter
d. A flutter
a d

Balloon expandable stents are used in the _ and self-expanding stents are used in the_
a. Carotids and peripherals
b. Coronaries >2mm and carotids >3mm
c. Coronaries and peripherals >3mm
d. Coronaries and carotids
d

When HR slows (dp/dt) cardiac muscle fiber contraction
a. decreases
b. stays the same
c. increases
d. Alternates between increasing and decreasing
c

CO is measured using which of the following parameters?(choose all that apply)
a. Pulmonary systolic pressure
b. HR
c. SVC pressure
d. SV
b d

Stroke volume is most affected by
a. EF
b. Afterload
c. RV volume
d. Preload
d.

Preload is impacted by
a. Filling volumes
b. Systolic BP
c. MAP
d. Diastolic pressure
a.

Chronic untreated hypertension demonstrates (choose all that apply)
a. A risk for CAD
b. Decrease preload
c. Increase afterload
d. an indication for Coumadin therapy
a c

Choose from the following all of the correct BP equations
a. BP = SV x SVR
b. BP = CO x SVR
c. BP = HR x SV
d. BP = HR x SV x SVR
b d

mitral insufficiency is evaluated by which of the following components of a waveform?
a. a wave and c wave
b. v wave and c wave
c. p wave
d. v wave
d

In order to determine if a patient has MR which of the following pressures must be recorded?
a. RV systolic
b. PA systolic
c. LVEDP
d. PCW
d

ID which pathologies would increase the RVEDP (choose all that apply)
a. RV infract
b. Systemic hypertension
c. Chronic COPD
d. Chronic pulmonary hypertension
a c b

An elevated RA waveform and elevated RA pressure could be caused by (choose all that apply)
a. TR
b. RV MI
c. Decreased 02 sat
d. ASD
a b d

Pulmonic stenosis (choose all that apply)
a. Results from MR
b. is a congenital anomaly
c. Occurs with cardiomyopathy and pulmonary hypertension
d. is a narrowing of the pulmonic valve
b d

The blue proximal port of the swan (choose all that apply)
a. is located 45 cm from the distal tip of the swan
b. the port used to measure PCW
c. Is located 30 cm from the distal tip of the swan
d. The port used to inject saline for CO
c d

The transducer is zeroed and falls off the table to the floor (choose all that apply)
a. The pressure being read is now reading higher
b. The pressure being read is now lower
c. The transducer dropping to the floor wont affect the pressure readings
d. The transducer should be re-zeroed
a d

Pulsus paradoxus (choose all that apply)
a. is a sign of tamponade
b. Demonstrates abnormal variation in filling pressures during inspiration
c. Can be seen on a PCW tracing
d. is caused by cardiomyopathy
a b c

Signs of LV failure include (choose all that apply)
a. Bilateral peripheral edema
b. Ascites
c. Orthopnea and pulmonary hypertension
d.. Decreased exercise tolerance and decreased EF
c d

Constrictive pericarditis (choose all that apply)
a. causes equalization of RVEDP and LVEDP
b. Decreases SV
c. Increases CO
d. Increased exercise tolerance
a b c

Constrictive pericarditis results in decreased EDV, equalization of EDV, and decreased SV & CO

RHF (choose all that apply)
a. causes decreased 02 sat
b. causes JVD
c. causes unilateral peripheral edema
d. causes bilateral peripheral edema
b d

Choose the views that result in higher dose to the patient (choose all that apply)
a. Lateral
b. LAO 60 with 30 Cranial
c. AP
d. RAO 40
a b d

Choose the practices that would minimize a decease in kidney function post cath (choose all that apply)
a. keeping patient NPO
b. Pre procedure hydration
c. Use a low osmolarity contrast
d. min contrast given to he patient
b c d

ReoPro (choose all that apply)
a. Is a platele inhibitor
b. Thrombin inhibitor
c. IIb/IIIa receptor blocker
d. Increases bleeding time
a c d

Heparin (choose all that apply)
a. Decreases bleeding time
b. increases bleeding time
c. in an antithrombin
c. is an antiplatelet
b c

Which of the following are antiplatelets?
a. ReoPro
b. Plavix
c. ASA
d. Heparin
e. Coumadin
a b c

If a patient has an elevated creatinine and decreased GFR which of the following should not be given?
a. Ionic contrast
b. lasix
c. pre procedural fluids to hydrate
d. fentanyl
b

ACE inhibitors (choose all that apply)
a. Decrease HR
b. Decreases BP
c. Lower BP via the kidneys
d. Lower BP via the SA node
b c

A common adverse effect of ACE inhibitors is
a. Hypotension
b. Hypertension
c. Cough
d. Vertigo
c

Select ACE inhibitors
a. Enalapril
b. Lasix
c. Lisinopril
d. NTG
a c

Which of the following are calcium channel blockers?
a. Amlodipine
b. Metorprolol
c. Felodipine
d. Nifedipine
a c d

Choose all of the following tests used to evaluate kidney function
a. urine output
b. GFR
c. Creatinine
d. Creatine clearance
a b c d

An inferior wall MI (choose all that apply)
a. Demonstrates ST elevation in leads 11,111,AVF
b. Involves LAD
c. Involves RCA
d. Involces LCx
a c

In 1st degree heart block (choose all that apply)
a. The delay is in the SA node
b. The delay is in the AV node
c. the PR interval is >.20
d. The PR interval is <.20
b c

An increased LVEDP (choose all that apply)
a. Increases the LV preload
b. Increases PCWP
c. Increases the LA pressures
d. Causes no change in pressures
a b c

An aortic dissection (choose all that apply)
a. Presents with back pain
b. Presents with abdominal pain and RUQ pain
c. Presents with back pain not relieved with NTG, morphine, 02
d. Presents with back pain not associated with EKG changes
a c d

The patient c/o pain down the leg when attempting to cannulate the RFA (choose all that apply)
a. The attempt was too lateral
b. The attempt was too far above the inguinal fold
c. The cannulating needle needs to be repositioned medially
d. The attempt was too inferior to the inguinal fold
a c

Accurate timing of the IABP (Choose all that apply)
A. decreases preload
B. increases preload
C. Decreases afterload
D. increases afterload
E. improves coronary circulation
F. Does not affect coronary circulation
c e

Calcified lesions are best managed with (choose all that apply)
a. Strepokinase
b. ReoPro and a rotoblader
c. Cutting balloon
d. Rotoblader
c d

A perfusion with chronic COPD (choose all that apply)
a. has marginally normal saturations
b. Has increased CO2 content and a normal 02 sat
c. Has increase C02 and a decreased 02 sat
d. Has an increased respiratory rate
e. The drive to breath is a decreased 02 sat
c d e

A common complication of a Rotoblador is
a. loss of diamond studs distally
b. Distal embolization
c. Entrapment of the burr in the guide catheter
d. Fracture of guidewire
b.

On this Aortic waveform, what is the pulse pressure?
100/70
a. 25
b. 30
c. 80
d. 95
b.

This RV waveform below indicates which pathology?
RV: 35/14
a. RV infarct
b. Pulmonary hypertension or Pulmonic Stenosis
c. Tricuspid stenosis
d. Systemic Hypertension and Aortic Stenosis
b.

This waveform demonstrates what?
a. Tricuspid Regurgitation
b. Pulmonic Stenosis
c. Mitral Stenosis
d. Aortic Stenosis
d.

What is the LVEDP?
a. 9
b. 20
c. 15
d. 2
a.

Match:

Mitral Stenosis
Aortic Stenosis
Mitral Regurgitation
Pulmonic Stenosis
Pulmonary Hypertension

a. High V wave
b. Elevated Pulmonary systolic pressure = to elevated RV systolic pressure
c. LV systolic pressure greater than aortic systolic pressure
d. Elevated RV systolic pressure and normal PA pressure
e. Measured when comparing LVEDP and PCWP

Which of the following do you need to calculate FICK CO (choose all that apply)
a. O2 consumption
b. PA 02 sat
c. Height and Weight (BSA)
d. AO 02 sat
e. Hgb
f. All of the above
F

Calculate the AVA using the Gorlin Formula if the patient has: HR 80, Mean Aortic valve gradient of 25mmHG, SEP of .31 sec/beat, CO of 4.8 L/min
a. 1.01
b. .7
c. .87
d. .75
c.

CO= 4800 mL/min
80x.31- 24.8 beat/min
CO/SEP= 193.55
AVF/44.5 x sqr root mean = 193.55 / 222.5= .87

When evaluating a patient for mitral valve stenosis, the gradient can be measured by comparing which two waveforms?
a. LV & AO
b. PA & PCWP
c. PCWP & LVEDP
d. LVEDP & RVEDP
c.

If a patient has ST elevation in Leads 1, AVL, V5, and V6; which wall of the heart is affected?
a. Anterior
b. Inferior
c. Lateral
d. Posterior
c.

Based on the following oxygen saturations, name the shunt and the direction of the shunt: LV 02 sat 96%, LA 02 sat 95%, AO 02 sat 96%, SVC 02 sat 73%, RA 02 sat 73%, RV 02 sat 83%, PA 02 sat 83%, IVC 02 sat 73%
a. R-L ASD
b. R-L VSD
c. L-R ASD
d. L-R VSD
d.

The patient arrives in the ER having an acute anterior wall MI. Which leads would indicate this?
a. II and III
b. AVR and AVL
c. V6 and Lead 1
d. V3, V4, V5
d.

Calculate a Fick CO using the following information: V02= 250L/min, Constant of 1.36, AO sat of 97%, PA sat of 71%, Hgb 13.4
a. 5.2
b. 4.5
c. 6.8
d. 3.1
a.

250 / (13.4×1.36x.97) – (13.4×1.36..71) x 10

When does the MV close?
a. Immediately following peak to peak of the “a” wave
b. Immediately following the peak of the “v” wave
c. On the dicrotic notch
d. at the peak of ventricular systole
a.

Match:

RVMI
MR
COPD
LVMI
AS
TS
TS
Pulmonary hypertension

a. Increases PA systolic pressure
b. Increases RV systolic pressure
c. Increases RA pressure
d. Increases LV systolic pressure
e. Increases LVEDP
f. High V wave
g. Increases LA pressure
h. Increases RVEDP

Match (each of the following can be used more than once)

Rotoblader
Laser
Cutting Balloon
Angiojet
Filter wire
Inueo balloon
Mitral valve clip
TAVR
Covered Stent

a. Vaportizes the lesion
b. Rotates
c. Creates a controlled dissection
d. Used on vein grafts
e. Used to soften thrombus
f. Used to treat a stenotic Mitral valve
g. Must be calibrated before each use
h. 180,000-220,000 rpm
i. Scores a lesion
j. Used on carotids
k. Used to treat a stenotic aortic valve
l. Used to treat MR
m. Grasps the leaflets of the MV
n. Inflates at 1atm/sec
o. Treats a perfed artery
a. 2
b. 1
c. 3
d. 4, 5
e. 4, 5
f. 6
g. 2
h. 1
i. 3
j. 5
k. 8
l. 7
m. 7
n. 3
o. 9

Which of the following are positive chronotropes?
a. atropine
b. metoprolol
c. propramolol
d. isuprel
e. NTG
a, d

Match:

Verapamil
Metoprolol
NTG
Lisinoipril
Valsartan

a. Calcium channel blocker
b. ACE
c. ARB
d. Beta blocker
e. Preload reducer

There are the steps involved in inserting and testing a temporary pacing wire. Put them in the correct order
a. Insert the pacing wire
b. Connect the pacing wire to the generator
c. Turn up the MA until capture is seen
d. Make sure the generator is off before connecting to the pacing wire.
e. Dial down the MA until acing or capture is lost
f. Turn up the HR on the generator so it is higher than the patients own HR by 5-10bpm
a d b f c e

Which of the following practices will increase the radiation absorbed dose to the patient? ( choose all that apply)
a. using isocenter
b. using collimators
c. acquiring images as far from the PA position as possible
d. panning the tables as much as possible
e. zooming an image as often as possible
f. not using isocenter
g. not using the collimator
c d e f g

Match the following: (A-B-C, may be used more than once) to the lab test they describe

Clotting efficiency
Renal Function
Immune status

a. INR
b. WBCs
c. GFR
d. PT/PTT
e. platelets
f. Creatinine

a d e
c f
b

Why is it important that veins are thin walled?
Veins have much thinner walls than do arteries, largely because the pressure in veins is so much lower. Veins can widen (dilate) as the amount of fluid in them increases.

When the blood is in the RA, what structure provides resistance to the forward flow of the blood to the RV?
Tricuspid valve

Are the walls of the RA thick or thin? Explain
thin walls because they only need to push blood through the TV with 5mmHg.

If chamber A had to generate 33mmHG pressure to move blood across valve B, and chamber C had to generate 60mmHg of pressure to move blood across valve D, Which chamber A or C would have thicker walls?
C

A stenotic valve increases or decreases resistance flow?
The high pressure gradient across the stenotic valve results from increased resistance (related to narrowing of the valve opening)

A stenotic valve would _ the thickness of the chamber walls attempting to move blood across the stenotic valve
a. increase
b. decrease
c. not affect
a. increase over a period of time because the muscle fibers would have to work harder to push blood through the tightened valve

How does COPD increase PCW pressure
COPD is a group of inflammatory lung diseases that block airflow and make it difficult to breathe. It is the main cause of the increase in pulmonary artery pressure and systemic inflammation has a particular role in COPD pathogenesis.

PA systolic and diastolic can only be measured in the
a. Right pulmonary artery
b. Left pulmonary artery
c. Main pulmonary artery
d. all of the above
e. none of the above
d

Physiologically, what is happening to RBCs in the wedge area?
They regain oxygen saturation from 70% up to 98%-100%

RBC saturation (oxygen tanks to RBCs being filled up) occurs in the
a. RA
b. RV
c. Right pulmonary artery
d. left pulmonary artery
e. PCW
f. Main pulmonary artery
g. none of the above
e

An RBC needs to move from the right heart to the left heart. Arrange the following structures in order RBC would move through: LA aorta, TV, Pulmonic valve, MV, RV, LV, PA, Pulmonary veins, PCW, RA
RA, TV, RV, PV, PA, Pulmonary veins, LA, LV, aorta

What does EDP represent?
End-diastolic volume is the measure of blood in the left or right ventricle before the heart contracts. End-diastolic volume refers to the quantity of blood in the left or right ventricle at the end of diastole, just before systole starts.

Why is EDP not 0?
The heart is not a perfect /efficient pump

Relationship between EDP and EF.
EF is the amount of blood push out of the ventricle in systole and the EDP is the amount of blood left after systole.

Why is EF not 100%
The heart is not a perfect pump, and there is resistance in the valves

Resistance flow is related to
a. valve diameter
b. Chamber wall circumference
c. RBC oxygenation
a

An RVMI would immediately affect
RA, RV diastolic

Tricuspid stenosis would immediately affect which pressure? (choose all the apply):
RA, RV systolic, RV diastolic, PCW, LVEDP, Aortic, PA systolic
RA, RV systolic

Tricuspid regurgitation would immediately affect which pressure? (choose all the apply):
RA, RV systolic, RV diastolic, PCW, LVEDP, Aortic, PA systolic
RA, RV systolic

Pulmonic stenosis would immediately affect which pressure? (choose all the apply):
RA, RV systolic, RV diastolic, PCW, LVEDP, Aortic, PA systolic
RV systolic, PA, PCW

Hypertension would immediately affect which pressure? (choose all the apply):
RA, RV systolic, RV diastolic, PCW, LVEDP, Aortic, PA systolic
PCW, rv systolic

COPD would immediately affect which pressure? (choose all the apply):
RA, RV systolic, RV diastolic, PCW, LVEDP, Aortic, PA systolic, PA diastolic
PA diastolic, PCW, RV systolic

Mitral stenosis would immediately affect which pressure? (choose all the apply):
RA, RV systolic, RV diastolic, PCW, LVEDP, Aortic, PA systolic
PCW, LA, LV systolic, LVEDP (untreated)

LVMI would immediately affect which pressure? (choose all the apply):
RA, RV systolic, RV diastolic, PCW, LVEDP, Aortic, PA systolic
LVEDP, PCW (for larger MIs)

aortic stenosis would immediately affect which pressure? (choose all the apply):
a. RA
b. RV systolic
c. RV diastolic
d. PCW
e. LVEDP
f. Aortic
g. PA systolic
h. LV systolic
d (untreated), f, h

Blood can move
a. down a gradient
b. Up a gradient
c. to an area of equal pressure
d. all of the above in specific situations
a

Why are LVEDP and RVEDP not equal?
LV has to push blood through a smaller valve so the muscle fibers work harder, therefore making the LV muscles bigger and allowing less room for EDP than the RV

Describe why COPD decreases the oxygen saturation of a n RBC
COPD causes higher pressure in the lungs not allowing enough time for RBC to fully oxygenate

Describe how ASA inhibits clotting
ASA is an antiplatelet that helps keep platelets slippery to slow down blood from clotting. It inhibits arachidonic acid from joining VWF and Factor 8 to form a plug

Describe how ReoPro inhibits clotting
it inhibits platelet aggregation by preventing the binding of fibrinogen, von Willebrand factor and other adhesive molecules to GPIIb/IIIa receptor sites on activated platelets

Describe how plavix inhibits clotting
Plavix (Clopidogrel) is an anti platelet that inhibits platelets to clump together to form a clot. Plavi binds to the platelet receptors, preventing ADP from activating platelets.

Describe what a Plavix “non-responder” is
Someone who still has a high platelet reactivity (HPR) after taking the drug.

Describe how Brilinta inhibits clotting
Brilinta (ticagrelor) is an anti-platelet that prevents the formation of new blood clots, thus maintaining blood flow in the body to help reduce the risk of another cardiovascular event.

Describe how Effient inhibits clotting
Effient (pasagrul) is a faster and more effective anti-platelet that prevents platelets and fibrin from sticking together

Describe the different between Plavix and Effient
Plavix :
-inhibits platelet aggregation and thus inhibits aspects of blood clotting
-Plavix is supplied as 75 and 300 mg tablets. For acute coronary syndrome with a non-ST elevation MI, the initial recommended dose is 300 mg, followed by a 75 mg dose per day; for ST elevation MIs, the initial and continuing dose is 75 mg per day.

Effient :
-is an antiplatelet drug that prevents the platelets in the bloodstream from aggregating and forming blood clots.
-Effient treatment is started as a single 60-mg oral loading dose and then continued at 10 mg orally once daily. Patients taking Effient should also take aspirin (75 mg to 325 mg) daily.

Describe how heparin inhibits clotting
Heparin is an antithrombin that that stops prothrombin from converting to thrombin.

Describe how Lovenox (Enoxaparin) inhibits clotting
Lovenox is an antithrombin that inhibits coagulation on factors Xa and IIa. By blocking clotting factor Xa, your body breaks down the clot faster than it can build it.

Describe how angiomax (Bivalirudin) inhibits clotting
angiomax is a stronger version of heparin (antithrombin) that has a longer half-life, it directly inhibits thrombin.

Describe how FFR works
A pressure wire is equalized in the health part of the proximal vessel then is placed below a lesion of interest. Adenosine is then turned on to dilate the vessels to see if enough blood flow is making it past the lesion

Describe the impact if any, tamponade has on the ability of the heart to fill in diastole
Cardiac tamponade impairs the ability of the heart to pump blood around the body. tamponade increases pericardial pressure- thus impairs diastolic filling

Define:

EDV
Preload
SV
EDV: the amount of blood that is in the ventricles before the heart contracts
Preload: From the EDV after diastole, preload is the stretching of the walls of the ventricle, priming the heart to pump blood to the lungs and body
SV: the amount/volume of blood that is pumped from the ventricle each time the heart contracts

Describe how tamponade would affect the Frank Starling Law of the heart
-Law: SV increases as a response to an increase in the volume of blood in the ventricles before the heart contracts.
-More blood in the ventricle (EDV) = More stretching of walls ventricular walls (preload) = more forceful contraction (SV)

Another way to think of tamponade is as a rubber band around the cardiac chambers, exerting a constrictive force and preventing adequate expansion. Resultant elevations in intracardiac diastolic pressures impair systemic and pulmonary venous return, leading to venous congestion and reduced cardiac output

Describe how pericarditis affects the filling of the heart is diastole
The increased amount of fluid can cause a rise in pressure within the pericardial sac. The ventricles have difficulty filling with blood because the fluid in the sac prevents them from filling with blood.

Describe how pericarditis impacts each chamber of the heart and the impact on each chamber of the heart
The inflammation of the heart allows for lower filling volumes. This reduces preload and EDP.

Describe the mechanism of respiratory variation and how it effects pressure

Describe how pericarditis affects SV, CO, and HR
The stiff, thickened pericardium markedly impairs ventricular filling, decreasing stroke volume and cardiac output

Equalization of the RVEDP and LVEDP are demonstrated in _, explain the ration for the answer
a. tamponade
b. pericarditis
c. all of the above
d. none of the above
a. Tamponade limits cardiac filling. Under these conditions, the intrapericardial pressure and mean diastolic pressure in the cardiac chambers equalize.

Restrictive pericarditis also causes equalization of EDPs

What is the definition of preload
How much the ventricle stretches due to blood volume before systole

What is the definition of afterload
The amount of blood left in the ventricle after systole

How is vessel diameter related to pressure?
The smaller the diameter of a vessel the more pressure required to move blood through it

Describe how carotid baroecptor work
is a receptor that reads to make sure the vessel can stretch far enough to hold the mount of blood volume that comes through it

What enzyme in the body does an ACE inhibitor work?
Angiogentsin 1

Which of the following block ACE enzymes?
a. Losartan
b. Metoprolol
c. Verpamil
d. Capopril
e. Inderal
f. Lisinopril
d f

Catopril and Lisonpril block the formation of which chemicals in the bod?
Angiotensin

Describe the action Angiotension II has on the body
It tells the kidneys to hold onto sodium so it can then retain more fluid, thus increasing BP. It also is a vasoconstrictor

The acronym ACE stands for what?
Angiotensin-converting-enzyme

The acronym ARB stands for what
Angiotensin-Recptor-Blockers

which chemical produced in the body does losartan block?
Angiotensin II

What is the action of a positive chronotrope?
Increases HR

What is the action of a negitive chronotrope?
Decreases HR

Describe how nipride affects BP
Nipride is a vasodilator that helps reduce BP (also known as a preload reducer)

Describe how negative chronotrope would affect the equation:
CO = SV x HR
A negative chronotope would lower HR, so SV would then increase to maintain CO

Describe how NTG would affect the equation:
CO = HR x SV
NTG is a vasodilator that would lower the expansion is diastole, lowering SV, so HR would increase to maintain CO

Where does nipride exert its affect in the equation:
BP = HR x SV x SVR
SVR

Nipride lowers BP by dilating the vessels

If amiodarone is used for atrial and ventricular arrhythmias where in the conduction system does it work (choose all that apply)
a. SA node
b. AV node
c. Bundle of HIS
d. Purkinje Fibers
a b

Match (can be used more than once):

Verapamil
Procardia (Nifedipine)
Metoprolol
NTG
Lisinopril
Valsartan
Atropine

a. Calcium channel blockers
b. ACE
c. ARB
d. Beta Blocker
e. Afterload reducer
f. Preload reducer
g. Positive inotrope
h. Negative inotrope
a. 1, 2
b. 5
c. 6
d. 3
e. 4
f. 4
g. 4,7
h. 2, 3

How does dobutamine affect the equation CO = HR x SV
selectively augmenting SV, which increases HR and CO

Match the following: (may be used more than once)

Versed
Fentanyl
Demerol
Morphine
Valium
Naloxone reverses _
Romazicon reverses _

a. Opioid
b. Anxoetyolytic

Describe how Lasix affects the equation:BP = HR x SV x SVR
Lasix is a dirutic that has a large fluid shift, causing SV and CO to reduce thus lowering BP

The amount of energy/electricity needed to create a systole is called _ and is measured in or _
, L/min or mL/min

The amount of energy/electricity needed to create a systole is __ and does or does not (choose one) change as cardiac muscle fibers are damaged

If a patient has a HR of 75 bpm, and an asynchronous pacer is set at 70 bpm, how many times per minuet will the asynchronous pacer deliver energy to pace the heart?

Put the component of the conduction system in order of how they apprear in he heart starting with the atrium:
purkinje fibers, bundle of his, AV node, SA node, Right and left bundle branches
SA, AV, R+L bundle, purkinje

A temporary pacing wire can be inserted into which vessel (choose all that apply)
a. pulmonary artery
b. left pulmonic vein
c. left femoral vein
d. right femoral vein,
e. right carotid artery
f. right femoral artery
g. right subclavian vein
h. right brachial artery
c d g

Define:
a. capture
b. threshold
c. synchronous
d. asynchronous
a. Capture: Pacer spike causes the chamber to respond and contract

b. Threshold: a threshold is needed for the detection of the R-wave in an electrocardiogram signal

c. synchronous: pacing only when needed

d. asynchronous: constantly delivers a beat regardless of what the hearts own activity is

Define:
a. Scatter
b. Image noise:
c. Image contrast
d. patient does
a. When x-rays bounce twice and make a nosiy image
b. less defined image
c. an image that has a wide scale of greys, whites and blacks
d. the amount of radiation a patient receives

The contrast agent that would be best for a patient would have high or low osmolarity ?
Low osmolarity, less of a fluid shift

NPH insulin contains protamine particles
a. true
b. false
a

A patient that has been taking NPH insulin has developed antibodies to the protamine in the insulin
a. true
b. false
a

Explain what happens when protamine is given to a patient that has been taking NPH insulin
patients can develop a sensitivity to protamine and can have adverse reactions

A recommended position for a patient in acute pulmonary edema is:
a. Prone position, to encourage maximum rest, thus decreasing respiratory and cardiac rates
b. Sitting up position to facilitate breathing and decrease venous return
c. Trendelenburg position, to drain blood from leg veins into the heart
d. Recovery position, lateral with upper leg flexed and forward, and upper hand across the chest with back of hand held supporting his cheek.
b. Sitting up position to facilitate breathing and decrease venous return.

A patient with dyspnea is usually uncomfortable in a lying supine position (orthopnea). This is because gravity increases fluid in the lungs which increases edema in CHF patients. They often have less difficulty breathing when placed in either a semi- sitting (mid- Fowler’s) position 30o, sitting (high- Fowler’s)

When charting in the medical record you should:
a. Avoid generalizations like “appears, inadvertently, seems to…”
b. Avoid writing with fountain pens with liquid ink
c. Avoid documenting routine safety measures
d. Chart care as you are planning it, not after it is given
a. Avoid generalizations like “appears, inadvertently, seems to…”

Kern says: “Information in the medical record should reflect only accurate facts regarding the particular patient. Avoid generalizations and speculating by charting only what you see, hear, feel, and smell. Do not use words such as inadvertently, unfortunately, appears, resembles, and the like…. Chart after the delivery of care, not before. Never make an entry in anticipation of something to be done…The chart note should identify precautionary or protective measures that have been taken for the safety of the patient, including the use of side rails and restraints.” Charting should always be done with a permanent ink pen, although especially runny ink may smear

Prior to any cardiac invasive procedure the ultimate responsibility for obtaining informed consent lies with the:
a. Patient’s primary care physician (GP)
b. The operating physician (Cardiologist)
c. Circulating nurse assigned to the case
d. Patient and his/her family
b. The operating physician (Cardiologist).

The ultimate responsibility for obtaining permission is the operating physician’s, usually the operating cardiologist. The cath lab staff are responsible for checking that the consent is on the chart, properly signed, and that the information on the form is correct.

To be legally valid, what is the LATEST that the patient should sign the informed consent form?
a. Before administration of preoperative medications (such as demerol)
b. Before administration of conscious sedation (such as Versed)
c. Before any invasive incisions or percutaneous punctures are made
d. Before any interventions are made (PTCA, Stent…)
a. Before administration of preoperative medications.

Consent forms must be signed before the administration of preoperative medications. This is to ensure that the patient fully understands and is informed about the procedure and the risks involved. If his mind is clouded by preoperative medications such as demerol the consent is not legally valid.

A patient’s informed consent:
a. Authorizes all routine hospital procedures
b. Protects patient from high risk procedures
c. Protects the operating physician and the hospital from claims of an unauthorized operation
d. Authorizes the physician to withhold lifesaving measures as he deems appropriate
c. Protects the operating physician and the hospital from claims of an unauthorized operation.

An informed consent (operative permit) protects the operating physician and the hospital from claims of an unauthorized operation. A general consent authorizes the physician and staff to render treatment and perform procedures which are routine duties normally carried out at the hospital. It also protects the patient from procedures they have not been informed about. The physician cannot perform different procedures or withhold lifesaving measures unless it has been approved by the patient.

You have just completed an echocardiogram. Your patient asks you to interpret the results of his diagnostic examination. Your response as a healthcare professional should be to:
a. Say you don’t know how to interpret results
b. Explain that the physician will interpret it and report the results
c. Explain that the final results are inconclusive
d. Honestly interpret it to the best of your ability
b. Explain that the physician will interpret it and report the results.

One of the 10 principles of professional conduct adopted by the ARRT is “Radiologic Technologists shall not diagnose, but in recognition of their responsibility to the patient, they shall provide the physician with all information they have relative to radiologic diagnosis for patient management.” We do not possess all the information or training necessary to diagnose the patient. Diagnosis, pathology and treatment are the physician’s final responsibility. We can often reinforce his comments, clarify things and respond to our patient’s questions, but always with the qualification that the physician has the final say.

Your patient with hypertension has been noncompliant in taking his antihypertensive medications. He should be taught that one relatively common complication of uncontrolled hypertension is:
a. Thrombophlebitis
b. Herniation of the aorta
c. Destruction of valves in the venous system
d. Hemorrhaging of blood vessels in the brain
d. Hemorrhaging of blood vessels in the brain.

“Hemorrhaging and occlusion of blood vessels in the body are relatively common complications of uncontrolled hypertension and occur in various places in the body, but most often in the brain (stroke), the eyes, the heart (myocardial infarction) and the kidneys.” Just as in coronary disease we should encourage patients to beware of the symptoms of MI, we should alert hypertensive patients about the risk of stroke of failing to take their medication.

Your patient is told that he has a poor prognosis, but says he believes there is some mistake. According to Dr. Elisabeth Kubler- Ross, this patient is most probably in what grief stage?
a. Anger
b. Denial
c. Bargaining
d. Depression
b. Denial

Your patient is to receive vein stripping surgery for varicose veins. She asks you how her circulation will be provided in her leg after surgery with the veins gone? You should base your response on knowledge that:
a. Such information should only be provided by the physician
b. New veins develop to replace the removed veins
c. Veins deep in the leg take over the work of the removed veins
d. The end of ligated veins are anastomosed for continuity of veins
c. Veins deep in the leg take over the work of the removed veins

Which of the following is NOT a predisposing factor for acute MI?
a. Diabetes
b. Hypertension
c. Hyperlipidemia
d. High estrogen levels
d. High estrogen levels is incorrect. Estrogen, the female hormone, appears to protect women from heart disease. After menopause, when estrogen levels fall in women, they begin to develop coronary disease akin to men. Diabetes, hypertension, and hyperlipidemia (high cholesterol) are all risk factors for atherosclerosis.

If you suspect that your patient has an organic heart murmur, the cause of such a murmur would probably be a defect in the:
a. Conduction system
b. Coronary arteries
c. Mixing of blood
d. Action of the heart valves
d. Action of the heart valves. An organic heart murmur is caused by a defect in the action of heart valves such as stenosis or leakage (regurgitation or shunt).

A functional heart disorder, in contrast to an organic heart disease, is a disturbance in function only with no organic cause. A functional heart murmur is often caused by anxiety or exercise. Heart murmurs are unrelated to oxygenation of blood, the heart’s ability to pump, or the capacity of coronary arteries.

Your patient reports having had an illnesses which predisposed her to having a heart murmur. What childhood disease was this:
a. Measles
b. Mononucleosis
c. Rheumatic fever
d. Infectious hepatitis
c. Rheumatic fever. Patients who have had rheumatic fever often have heart valve problems, such as mitral stenosis, later in life. Although mostly eliminated in the USA due to the advent of antibiotics, it is common in tropical countries.

Retrosternal chest pain that is associated with sweating, nausea or vomiting, and not relieved by rest and nitroglycerine is most likely due to:
a. Pericarditis
b. Variant angina
c. Aortic dissection
d. Myocardial infarction
d. Myocardial infarction.

Braunwald says about MI: “The pain of AMI is variable in intensity; in most patients it is severe…prolonged. described as constricting, crushing, oppressing,… The pain is usually retrosternal in location, spreading frequently to both sides of the anterior chest, with predilection for the left side. Often the pain radiates….Nausea and vomiting occur in more than 50 percent of patients with transmural MI and severe chest pain,….

One indicator of cardiogenic shock is:
a. Decreased heart rate
b. Increased blood pressure
c. Increased body temperature
d. Decreased urine output
d. Urine output decrease

low BP, weak rapid heart rate, cold clammy skin, cyanosis – are all indicators of shock (cardiogenic or hypovolemic). Braunwald states that “Shock encompasses the syndromes associated with an acute reduction in effective blood flow with failure to maintain the transfer and delivery of essential substrates to sustain the function of vital organ systems.” In shock, blood is shunted to vital organs (such as the brain), and away from less essential tissues (like skin).

Amaurosis Fugax is a symptom that involves the patient’s:
a. Sight
b. Hearing
c. Equilibrium
d. Sensation of pain
a. Sight.

Amaurosis fugax is a condition in which a person cannot see out of one or both eyes due to a lack of blood flow to the eye(s).

A patient’s blood pressure is 80/45 and heart rate of 56. This pressure and HR is:
a. Hypertensive, tachycardia
b. Hypertensive, bradycardia
c. Hypotensive, tachycardia
d. Hypotensive, bradycardia
d. Hypotensive, bradycardia.

Normal blood pressure is 120/80. Below 100 is hypotensive. Normal HR is 60-100. Below 60 is bradycardia. However, in resting athletic young people the rate may normally go as low as 50 bpm.

Which body fluid is LEAST likely to transmit HIV to a health care worker?:
a. Semen
b. Blood
c. Pericardial fluid
d. Saliva
d. Saliva.

The CDC says: “HIV has been isolated from blood, semen, saliva, tears, urine, vaginal secretions, cerebro-spinal fluid, breast milk, and amniotic fluid, but only blood and blood products, semen, vaginal secretions, and possibly breast milk (this needs to be confirmed) have been directly linked to transmission of HIV. Contact with fluids such as saliva and tears has not been shown to result in infection. Although other fluids have not been shown to transmit infection, all body fluids and tissues should be regarded as potentially contaminated by HBV or HIV, and treated as though they were infectious….” HIV may also be transmitted by sexual contact, including semen.

Which body fluid is MOST likely to transmit Hepatitis B virus to a health care worker?
a. Urine
b. Blood
c. Pericardial fluid
d. Vomitus
b. Blood.

The CDC says: “Blood contains the highest HBV titers of all body fluids and is the most important vehicle of transmission in the health- care setting. HBsAg is also found in several other body fluids, including breast milk, bile, cerebrospinal fluid, feces, nasopharyngeal washings, saliva, semen, sweat, and synovial fluid. However, the concentration of HBsAg in body fluids can be 100- 1000- fold higher than the concentration of infectious HBV particles. Therefore, most body fluids are not efficient vehicles of transmission because they contain low quantities of infectious HBV….Feces, nasal secretions, saliva, sputum, sweat, tears, urine and vomitus are not considered potentially infectious unless they contain blood. The risk for transmission of HBV, HCV, or HIV infection from these fluids and materials is extremely low.”

Which of the following exposures pose the greatest risk for bloodborne pathogen infection?
a. A nurse sustains a needle-stick while drawing up insulin to administer to a patient with diabetes
b. A lab worker is splashed in the eye with urine from a patient with HIV
c. A scrub tech who gets blood on his chapped hands while assisting in a surgery on a patient with hepatitis B infection
d. While cleaning the bathroom, a housekeeper’s intact skin has contact with feces
c. A scrub tech who gets blood on his chapped hands while assisting in a surgery on a patient with hepatitis B infection.

Blood is the most infectious body fluid, especially when it gets into an open wound as may be found on chapped hands. The nurse’s needle-stick appears to be from a clean needle. CDC says: “Feces, nasal secretions, saliva, sputum, sweat, tears, urine and vomitus are not considered potentially infectious unless they contain blood.” See: Dept Labor/Dept Health & Humans Services, Joint advisory Notice, “Protection against occupational exposure to HBV and HIV”

Which virus is commonly transmitted by food workers who fail to wash their hands?
a. Hepatitis A
b. Hepatitis B
c. AIDS
d. HIV
a. Hepatitis A is a food borne virus.

HAV is found in the feces of HAV-infected persons. It is commonly spread by food workers who don’t wash their hands after using the toilet. HIV, Hepatitis B and Hepatitis C viruses are found in the body fluids of infected individuals; and can be transmitted to health workers during invasive procedures via needle sticks, skin lesions, or splashing body fluids onto mucous membranes. HIV virus leads to the AIDS syndrome, which occurs in the final stages of the HIV infection

Many health care workers who develop hepatitis B viral infections have not been exposed to HBV infected patients. How were these workers probably infected?
a. Private sexual encounters
b. Tattooing or ear piercing
c. Inhalation of aerosolized nasal secretions
d. Direct contact with dried blood on environmental surfaces
e. Ingestion of contaminated food or drinking water
d. Contact with Dried blood on environmental surfaces.

Such secondary infection is the main reason all blood spills and spatters must be cleaned up and disinfected and why it is so important to wash your hands frequently. The CDC says: “Although percutaneous injuries are among the most efficient modes of HBV trans mission, these exposures probably account for only a minority of HBV infections among health care professionals (HCP). In several investigations of nosocomial hepatitis B outbreaks, most infected health care professionals could not recall an overt percutaneous injury, although in some studies, up to one third of infected HCP recalled caring for a patient who was HBsAg- positive. In addition, HBV has been demonstrated to survive in dried blood at room temperature on environmental surfaces for at least 1 week. Thus, HBV infections that occur in health care professionals with no history of nonoccupational exposure or occupational percutaneous injury might have resulted from direct or indirect blood or body fluid exposures that inoculated HBV into cutaneous scratches, abrasions, burns, other lesions, or on mucosal surfaces…, There is no evidence that HBV or HIV can be transmitted via food, drinking water, or airborne aerosols.”

For which viruses currently are there NO immunizing vaccines?
a. HIV and HBV
b. HIV and HCV
c. HAV and HBV
d. HAV and HCV
b. HIV and HCV have NO immunizing vaccines as of year 2002.

These are the Human Immunodeficiency Virus and the Hepatitis C Virus. Unfortunately both of these virus can be spread by blood or body fluids from infected individuals

After an accidental needle-stick from the needle used on an infected patient, which bloodborne pathogen poses the greatest risk of infection to health care workers?
a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. HIV
b. Hepatitis B is most contagious.

Your ICU patient needs arterial line monitoring. He develops sepsis and tenderness at the insertion site. Besides systemic antibiotics therapy you should:
a. Apply Povidone- Iodine related ointment at puncture site
b. Change the continuous flush, transducer, and pressure tubing
c. Remove the catheter and replace it with a new one at a different access site
d. Exchange the Arterial line and catheter with the Seldinger technique
c. Remove the catheter and replace it with a new one at a different access site.

CDC Guidelines say: “Do not use guide wire assisted catheter exchange whenever catheter-related infection is documented. If the patient requires continued vascular access, remove the implicated catheter, and replace it with another catheter at a different insertion site.”

Which of the following areas of a patient’s body is the LEAST likely place for bloodborne pathogens to enter?
a. The nose
b. The intact skin
c. The genital tract
d. The urinary tract
b. The intact skin.

The CDC says: “Both HBV and HIV appear to be incapable of penetrating intact skin, but infection may result from infections fluids coming into contact with mucous membranes or open wounds (including unapparent lesions) on the skin. If a procedure involves the potential for skin contact with blood or mucous membranes, the appropriate barriers to skin contact should be worn. e.g., gloves.” Organisms enter the nose, the genital tract, and the urinary tract with greater ease than intact skin. Since we commonly touch or eyes, nose and mouth good hand washing is critical. See: Dept Labor/Dept Health & Humans Services, Joint advisory Notice, “Protection against occupational exposure to HBV and HIV”

If a patient acquires an infection in the hospital where he is a patient, it is called:
a. A local infection
b. An enteric infection
c. A primary infection
d. A nosocomial infection
d. A nosocomial infection

Eye-wear, goggles, and/or face-shields need to be worn only:
a. On invasive procedures
b. On interventional procedures
c. On cases who are in isolation
d. On positive HIV or HBV cases
a. On invasive procedures of vascular access.

You are working around a patient with an IV. You are wearing gloves but accidentally get some patient blood on your forearm where you have a small cut. The CDC recommends that your first action should be to:
a. Rinse it off with warm water
b. Wash forearm and the cut with soap and water
c. Wash forearm and rinse your cut with a mild bleach solution
d. Wash your forearm and cut with antiseptic and squeeze to make it bleed
b. Wash it with soap and water

While working to place an IV you accidentally spatter patient blood in your mouth and eye. The CDC recommends that your first action should be to:
a. Flush your mouth and eye with water
b. Flush your mouth and eye with soap and water
c. Flush your mouth and eye with a mild bleach solution
d. Flush your mouth and eye with antiseptic
a. Flush your mouth and eye with water. The CDC says: “mucous membranes should be flushed for several minutes with copious amounts of water. No evidence exists that using antiseptics for wound care or expressing fluid by squeezing the wound further reduces the risk of bloodborne pathogen transmission; however, the use of antiseptics in not contraindicated. The application of caustic agents (e.g. bleach) or the injection of antiseptics or disinfectants into the wound is not recommended.” Many labs contain eye-wash sinks or eye-cups for irrigation.

After a blood spill it is best to disinfect the area of the spill with:
a. Soap and water
b. Betadine 5%
c. One part bleach to 10 parts water
d. One part alcohol to 10 parts water
c. One part bleach to 10 parts water is an excellent disinfectant. If alcohol were used it should be much stronger than 1:10 concentration. Betadine is an antiseptic for skin use, not as a disinfectant. Gloves should be worn, the area mopped up and then disinfected with diluted beach. It will kill all pathogens

What should be done with needles used for patient injection or IV infusion?
a. Bent and then placed in the sharps disposal container
b. Cut in half and then placed in the sharps disposal container
c. Removed from the syringe and then placed in the sharps disposal container
d. Recapped on the syringe and placed in the sharps disposal container
e. Both needle and syringe should be placed together in the sharps disposal container
e. Both needle and syringe should be placed together in the sharps disposal container without bending, shearing, or recapping. OSHA says that: “Contaminated needles and other contaminated sharps shall not be bent, recapped or removed [from the syringe] unless the employer can demonstrate that no alternative is feasible or that such action is required by a specific medical or dental procedure.”

How should laundry contaminated by patient body fluids such as bloody patient drapes be handled?
a. Sort it, bag it in heavy cloth, and remove it at end of the day
b. Wear gloves, sort it, bag it in heavy cloth, and remove it at end of the day
c. Bag it in plastic, and remove it at end of each case
d. Wear gloves, bag it in plastic, and remove it at end of each case
d. Wear gloves, bag it in plastic, and remove it at end of each case.

OSHA says: “Contaminated laundry shall be placed and transported in bags or containers labeled or color-coded….Whenever contaminated laundry is wet and presents a reasonable likelihood of soak-through of or leakage from the bag or container, the laundry shall be placed and transported in bags or containers which prevent soak-through and-or leakage of fluids to the exterior. The employer shall ensure that employees who have contact with contaminated laundry wear protective gloves and other appropriate personal equipment.”

According to “Universal or Standard precautions” in emergency situations which body fluids are to be considered infectious?
a. Blood and certain body fluids of infected patients
b. All body fluids of infected patients c. Blood and certain body fluids of all patients
d. All body fluids of all patients
d. All body fluids of all patients are considered infectious

because in an emergency it is difficult to distinguish one body fluid from another and blood may be mixed within any of them. According to OSHA: “Universal [Standard] precautions must be observed. This method of infection control requires the employer and employee to assume that all human blood and specified human blood fluids are infectious for HIV, HBV, and other bloodborne pathogens. Where differentiating of types of body fluids is difficult or impossible [as in emergency trauma] , all types of body fluids are considered to be potentially infectious.” CDC says that feces, nasal secretions, saliva, sputum, sweat, tears, urine and vomitus are probably not potentially infectious unless they contain blood. And the risk for transmission of HBV, HCV, or HIV infection from these fluids and materials is extremely low. But, who wants to take the chance? For this reason, hospital workers consider ALL body fluids as potentially infectious.

Large sideholes are sometimes cut into the side of PTCA guider catheters in order to:
a. Disperse angiographic contrast more evenly
b. Utilize a second guide wire (Kissing wire technique)
c. Prevent catheter damping (occlusion of the coronary ostium)
d. Reduce guider trauma and dissection at the coronary ostium
c. Prevent catheter damping (occlusion of the coronary ostium).

Cutting sideholes in a guider allows you to monitor the aortic pressure accurately. Since the sidehole will admit aortic pressure, it will not be damped. But, it can be a false sense of security. Now, you are monitoring the aortic pressure, not coronary. The guider can still occlude the ostium. You just won’t see it on the pressure monitor. Another benefit of sideholes is they allow additional blood flow out the tip, to perfuse the artery. You may purchase guiders with side-holes or cut your own. This is done with a special needle with no bevel. It is drilled into the side of the catheter. Do not continue drilling through the other back wall. Two opposing holes would weaken the catheter at that point.

Which type of plastic has the least memory and torque control, and is so soft that it is used in construction of most balloon floatation catheters?
a. Polyurethane (PU)
b. Teflon
c. Polyethylene (PE)
d. Poly Vinyl Chloride (PVC)
d. Polyvinyl Chloride (PVC).

Balloon floatation catheters need to be soft and float with the current. PVC is like a “wet noodle” in the warm blood stream. It has almost no torque control or memory. Some Swan-Ganz catheters will admit a guidewire to stiffen them if necessary. Since, PVC’s busting pressure is much lower than other plastics (250 PSI) they are never pressure injected.

In the USA what type of cardiac catheters (Single Use Devices) may be reserialized by 3rd party reprocessor companies?
a. PTCA balloon catheters
b. Polyurethane (PU) catheters
c. Teflon Guider catheters
d. Diagnostic EP electrodes
d. Diagnostic EP electrodes.

With current concerns over blood transmitted diseases, the only catheters now commonly reused are the diagnostic EP pacing and sensing electrodes. This is a controversial medico-legal issue, because catheter manufacturers place “For Single Use Only” disclaimers on all catheters. Doubtless, this is to protect them from legal repercussions. But, several studies have demonstrated the safety of EP electrode reuse. EP electrodes are a Class II non exempt device temporarily approved by the FDA for reprocessing. Since they have no lumen (technically not a catheter) EP electrodes are much easier to inspect, clean and sterilize. EP ablation catheters and angioplasty balloons are not yet approved. The FDA requires that each item reprocessed and resterilized be tracked, forms submitted, and strict quality control procedures followed. They say: “Despite a lack of clear data that directly link injuries to reuse, FDA has concluded that the practice of reprocessing SUDs merits increased regulatory oversight. . . .Our plan is to phase-in additional oversight based on assessment of current practice and potential risk.”

Catheters with side-holes (e.g., Pigtails) provide better injection dynamics and pressure measurement than single end-hole catheters. The chief DISADVANTAGE of multiple side-holes in angiographic flood catheters is that they:
a. Hang up on guide wires and valves
b. Traumatize the vessel wall
c. Tend to clot unless flushed frequently
d. Cannot be used with a leading guidewire
c. Tend to clot unless flushed frequently.

Pigtail catheters are especially prone to clotting, because of their many holes. A normal hand flush only exits the proximal holes and the distal holes remain full of blood. Judkins said, “A pigtail catheter should have no more than four sideholes…the extra ports serve no purpose and provide sites for accumulation of formed blood elements. Unless flushed frequently and forcefully these side-holes provide an eddy location for blood to stagnate and clot. Then these small clots can embolize during pressure injection and produce a stroke.

If a 1 mm. ID catheter will transmit contrast at a rate of 1 ml/sec at 500 PSI, how much will a 2 mm ID catheter theoretically transmit at the same pressure according to Poiseuille’s law?
a. 2 ml/sec
b. 4 ml/sec
c. 8 ml/sec
d. 16 ml/sec
d. 16 ml/sec.

According to Poiseuille’s law as the radius is doubled the flow increases as the fourth power of this change. 2 to the 4th power is 2 x 2 x 2 x 2 = 16. 16 x 1 ml/sec = 16 ml/sec. Poiseuille’s Law is shown above. Catheter radius is obviously the most important factor in limiting flow though catheters. That is why most flood catheters have a large lumen and selective catheters tend to have a smaller lumen. However, as you see from the formula many other factors come in to play, such as contrast viscosity, pressure, length of catheter, turbulent flow through sideholes, etc.

How is the curve of Judkins Right coronary catheters measured?
a. Across the shortest diameter of the ellipse
b. Across the longest diameter of the ellipse
c. From primary to Secondary curves
d. From secondary to tertiary curves
c. From primary to Secondary curves.

The Judkins coronary catheter bend size is measured between the steepest portions of the primary and secondary curves. Note where the Judkins (JL6 cm) left coronary catheter is measured compared to the Judkins (JR) catheters. Again, The longer bends are for more dilated aortas or more inferiorly directed coronary ostia.

Which type of catheter is necessary for optimal WEDGE pressures?
a. End-hole only
b. 4 Side-holes
c. 4 Side-hole + end-hole
d. 6 side-holes + distal balloon
a. End-hole only catheters are the best wedge catheters.

The one end-hole then looks through the capillary bed and only measures distal pressure (Pulmonary capillary wedge = LA pressure). Side-holes may allow the PA pressure to enter and contaminate the wedge. However, Multipurpose and birds eye 2 side-hole + end-hole catheters can be used to obtain adequate wedge pressures if precautions are taken. This is because the distal sideholes are quite close to the tip and are usually covered by arteriolar tissue. Most wedge pressures are now taken with balloon floatation catheter with the balloon inflated. But a balloon is not necessary. In fact, where an accurate wedge waveform is critical, as in mitral disease, a stiff single-end-hole catheter is much more accurate (most like LA). A single end-hole catheters can be pushed out as far as it will go until it ends “wedged” into the capillary bed. It’s really wedged in small arteries, not capillaries. The resulting wedge pressure gives a better LA pressure.

Which of the following RV/PA flood catheters will recoil the LEAST during a high flow pressure injection?
a. Multipurpose/Gensini
b. Pigtail/Van Tassel Pigtail
c. Lehman/Cornand
d. NIH/Berman
d. The NIH has little kickback because it has no end-hole.

The Berman angiographic catheter is now more commonly used because it has no end-hole, is softer, and has the added balloon floatation feature.

A. MULTIPURPOSE/GENSINI: ANGIOGRAPHIC. MP catheters should not be injected at rates over 10 ml/sec. B. PIGTAIL/VAN-TASSEL PIGTAIL: With up to 12 sideholes a pigtail evenly disperses the contrast within the LV. Although, with high pressure injection the pigtail straightens and may slightly recoil or accidentally inject some aortic vessel.
C. LEHMAN/CORNAND: THESE woven Dacron catheters are for hemodynamic measurements only. They are not designed for angiography. They are single end-hole catheters which may kickback badly with rapid injection.
D. NIH/BERMAN: THE NIH is a “No End-hole” catheter. The absence of an end-hole makes them very stable during pressure injection. The Berman is a PVC balloon floatation catheter with side-holes and is usually the Rt. ht. angiographic catheter of choice in infants and children.

Which of the following is a flow directed, balloon tipped, pediatric flood angiographic catheter?
a. Berman
b. Fogarty
c. Swan Ganz
d. Dotter
a. Berman.

This is a PVC balloon floatation catheter with side-holes proximal to the balloon tip. It is usually the Rt. ht. angiographic catheter of choice in infants and children. Review all the catheter shapes and their uses. See: Tilkian chapter on “Equipment.”

Which catheter is designed to do a complete LV and coronary angiography study from the femoral artery without exchanging catheters?
a. Amplatz
b. Multipurpose
c. Judkins
d. Castillo
b. Multipurpose catheter technique for doing both LV and coronary arteriography using the percutaneous femoral approach.

This uses the standard A-2 Multipurpose catheter. Catheter manipulation is similar to using the Sones catheter. Slight advances of the catheter in the coronary cusps forms a “J” with the catheter and the tip rises to enter the coronary artery. The standard A2 – MP has 2 sideholes and has a 1 ½ inch small diameter unreinforced soft tip. This makes the catheter J very easily. By impinging it on the aortic valve cusps it is “J’d” and then hooked back until the coronary ostium is engaged. The incorrect distractors Amplatz, Judkins, and Castillo are selective end-hole only coronary arteriography catheters unsuitable for LV flood angiography.

Care of indwelling right heart catheters is different from the care of arterial catheters in that right heart catheters:
a. Require pressurized flush bags
b. Require a continuous heparinized saline drip
c. Safely allow injection of small air bubbles
d. Are inserted by the Seldinger technique
R c. Air bubbles are not usually a problem on the right side of the heart.

Small air bubbles will be effectively filtered out by the lungs that then slowly absorb the air. It may take a hundred cc’s of air to cause a critical pulmonary embolism. This is NOT true on the left side where air emboli lodges in peripheral capillaries and obstructs critical flow, leading to tissue infarction or the “bends.” Even so, technologists should get in the habit of keeping bubbles out of all catheter lines. Rt. heart (venous) lines can be dripped continuously with a gravity drip. But a continuous drip on Rt. Ht. catheter is not necessary. Many Rt. Ht. caths are done without heparin. However, frequent hand flushing of these catheters is necessary. Arterial pressure will “back up” an IV because arterial pressure is so great. Pressure bags are necessary. Pressure bags are often used in Swan-Ganz long term monitoring lines as well. This is because the catheter may be in place for a week. Heparin flush is essential to prevent clotting for this long term monitoring

Long term Swan-Ganz and Arterial lines should be connected to a continuous flush device which at 300 mmHg infusion pressure will deliver approximately:
a. 1-2 ml flush/min
b. 5-10 ml flush/min
c. 3-8 ml flush/hour
d. 20-40 ml flush/hour
R c. 3-8 ml flush/hour.

These continuous flush devices have made extended hemodynamic monitoring possible. At this low flow rate catheters can be kept open while simultaneously measuring pressure through the transducer. The pressure increase due to this slow infusion is negligible in most catheters.

Catheters with a closed end CANNOT BE INTRODUCED by the_________ method.
a. Femoral Cutdown
b. Brachial Cutdown
c. Seldinger over-the-wire
d. Femoral Sheath
c. Seldinger over-the-wire method.

Clearly “No End-hole” catheters like the NIH and Berman cannot be introduced percutaneously over a guide wire – since they have no end-hole. They must be introduced by the sheath or cutdown methods. Swan-Ganz catheters are not introduced over the wire, because of their blunt tip and their delicate rubber balloon. They usually require a sheath one Fr. size larger than the catheter Outside Diameter (O.D.) Small diameter guide wires may be placed though the distal lumen after catheter insertion

Hypaque contrast material is and when injected into the heart causes an immediate in cardiac output.
a. Hypertonic, Increase
b. Hypertonic, Decrease
c. Hypotonic, Increase
d. Hypotonic, Decrease
b. Hypertonic, Decrease.

It is hypertonic and high in osmolarity. It is somewhat toxic to the heart and other tissues resulting in a sudden drop in BP and CO. You see this on every coronary angiogram. The hypertonicity of the older contrasts is six times that of blood. When injected it’s high tonicity and osmolarity pull tissue fluids into the vascular space. Within several minutes this leads to increase in preload that can push some patients into CHF. As the vascular volume increases the increased preload usually leads to a mildly increased cardiac output post cath. Osmolarity and osmolality are the same. Both deal with osmotic pressure.

Keywords: hypertonic contrast causes increased preload risking CHF

What chemical element in contrast material makes it radiopaque to X-rays?
a. Calcium
b. Iodine
c. Barium
d. Lead
b. Iodine

Keywords: Iodine in contrast = radiopaque

All vascular contrast media are organic compounds including the chemical element Iodine on the benzene ring. It is a heavy metal which absorbs X-rays. This imparts it’s essential “radiopaque” quality.

Older angiographic contrast agents such as Hypaque or Renografin commonly overload the blood volume of a patient in CHF. New contrast agents such as Ioxaglate (Hexabrix) and Iohexol (Omnipaque) do not increase the preload as much because of their:
a. Low osmolarity
b. Low Na+ and K+ content
c. Higher radio-opacity per cc
d. Increased ionization in solution
a. Low osmolarity.

Keywords: Less volume overload with low osmolar contrast

The reason that these Low Osmolar Contrast Media (LOCM) do not overload the blood volume is due to their low osmolarity (osmolality). Any high volume contrast injection suddenly increases the circulating blood volume. Besides the 30-40 cc of contrast added to the system, the high osmolarity of the contrast suddenly pulls plasma into the vascular space through osmotic action. It is analogous to eating a salty pork dinner. As a result, you retain water. Low Osmolar contrast Media helps maintain normal fluid balance. The sudden increase in blood volume following LVgram dramatically increases preload and LV EDP. This may exacerbate a CHF patient’s pulmonary edema.

A patient’s LV angiogram shows apical hypokinesis during sinus rhythm. But following one PVC the compensatory beat shows significantly improved EF. This post-“PVC potentiation” of LV contractility probably indicates:
a. Reversible apical ischemia
b. Irreversible apical infarcted area
c. Recent LAD occlusion
d. Old LAD occlusion
a. Reversible apical ischemia.

Keywords: post-PVC potentiation = reversible ischemia

Grossman says “Segmental dysfunction of the Left Ventricle can be caused by ischemia or infarction. Segments whose abnormal wall motion is caused by ischemia show improvement in systolic motion, whereas segments whose abnormal wall motion is due to infarction fail to improve. A single ventricular premature beat is introduced during left ventriculography and is followed by a compensatory pause – then a potentiated beat. Segmental wall motion during one of the preceding sinus beats is compared to that of the post-extra-systolic beat. Left ventricles with asynergic wall motion during a preceding sinus beat which improves on the potentiated beat are ischemic, whereas those in which asynergy is similar on the preceding sinus beat and on the post-extra-systolic beat are infarcted.” This PVC may be introduced with a pacemaker or by irritating the ventricle while pulling back a RV catheter. Viable ischemic myocardium may also be evaluated on LVgram post Epinephrine, Dobutamine, or nitroglycerine administration. As with postextra-systolic potentiation, improved contractility indicates reversible ischemia.

The cutoff between normal and abnormal LV function is considered to be an EF of:
a. 10%
b. 30%
c. 50%
d. 70%
c. 50%.

Keywords: normal EF > 50%

EF is the most commonly used indicator of LV function and a good predictor of patient survival. 50% is usually the cutoff for normal. Kennedy found that 94% of normal individuals have an EF between 51% and 83%

Aneurysmal LV walls which bulge in systole are termed:
a. Akinetic
b. Asyneresis
c. Dyskinetic
d. Hypokinetic
c. Dyskinetic.

A weakened LV wall can bulge in systole just like an aortic aneurysm. They are termed dyskinetic (“dys-” prefix means disordered or bad). It is also termed “paradoxical motion” because it moves the wrong way. Dyskinetic LV walls steal stroke volume from the heart and absorb the LV contraction. They are common immediately following myocardial infarction. They usually heal into a stiff akinetic scar which does not steal as much stroke volume. Open heart surgery can be done to excise the dead bulging aneurysm or scar to improve LV function.

You are assisting a new cardiologist do a right heart cath on a cyanotic child. Before inflating the balloon he asks you “What should I use to inflate this balloon?” You should answer______.
a. “Air”
b. “CO2”
c. “Sterile Saline”
d. “50%-50%, contrast and saline”
b. CO2 is 20 times more soluble in blood than air.

Keywords: Cyanotic kid use CO2 in Swan

If the balloon breaks or leaks in the right heart it will be more quickly absorbed. Since cyanotic shunts move across the septum in a R-L direction, some of the gas may pass through the R-L shunt. If it does embolize into the left heart it might lead to a dangerous arterial embolism or stroke. Get the CO2 from a CO2 tank off the table. O2 gas is heavier than air, so let it bleed into a glass or basin through a sterile tube on the table. Then fill the balloon syringe by aspirating CO2 from the bottom of the glass. Use this to inflate the balloon. One problem with CO2 is that it diffuses rapidly through rubber. So you may have to replenish the CO2 frequently. Never inflate a Swan-Ganz balloon with any fluid, especially contrast! Its high viscosity may prevent you from removing it through the tiny catheter lumen.

Which statement regarding the set-up of hemodynamic monitoring equipment is most correct?
a. The system should only be flushed with saline to remove air bubbles at the time of set-up, prior to connection to the patient.
b. The pressure cuff on the IV solution bag must be maintained at 200 mmHg
c. All stopcock side-arm ports must be replaced with closed (dead-ender) caps
d. A properly inflated pressure cuff on the IV solution bag along with an in-line continuous flush device provides a continuous flow rate of 10-20 ml/minute.
c. All stopcock side-arm ports must be replaced with closed (dead-ender) caps.

This prevents accidental opening to air which could allow contamination or blood leakage. Systems should be flushed whenever air bubbles or blood are present. Air bubbles should be vented up and out of the transducer. Blood should be flushed through the catheter back to the patient. pressure cuff on the IV solution bag must be maintained at 300 mmHg not 200. Normal continuous flow rates are 3-5 ml/hr not 10-20 ml/minute

When inserting a Swan-Ganz catheter the balloon should be inflated in the:
a. Sheath
b. Femoral vein
c. IVC-RA
d. RV
e. PA
c. RA.

The balloon should not be inflated until it reaches the large vena-cava or RA. If inflated in the sheath or small vein it may rupture the balloon or damage the vessel. In an average sized adult the RA is usually reached after inserting the catheter 15-20 cm from the Internal Jugular (I.J.) vein or 30 cm. from the femoral vein. The inflated balloon then floats downstream with the RA-RV-PA blood flow.

Keywords: Inflate Swan balloon in RA

The most stable place to leave a Rt. Ht. catheter positioned is with the tip in the:
a. RA
b. RV
c. PA
d. PAW
c. PA.

Most monitoring catheters are left in the PA position because it produces fewer arrhythmias than the RA (PACs) or RV (PVCs). After obtaining a PA wedge the balloon is deflated to prevent obstruction of blood flow, and the catheter is pulled back out of wedge so in cannot damage the lung. Monitoring Swan-Ganz catheters may be left in the PA position long term.

On the second day of pulmonary artery catheter monitoring an RV waveform is observed from the distal catheter port. Which one of the following is the most appropriate action?
a. Advance the catheter 10 cm with the balloon deflated
b. Switch monitoring lines to the proximal port of the catheter
c. Inflate the balloon with 1.5 ml air and withdraw the catheter
d. Inflate the balloon with 1.5 ml air and advance the catheter
e. Leave in RV, you can still get PA systolic pressure from RV
d. Inflate the balloon with 1.5 ml air to make a soft tip.

Then advance the catheter until PA wedge waveform appears, and deflate the balloon. Check the waveform to assure it is in the PA. You do not want to insert the catheter deflated, because the hard catheter tip may lodge in and damage the RV or PA wall (remember the trabeculations in the RV). Neither, do you want to leave the tip in the RV because it causes of PVCs and ventricular arrhythmias.

All of the following statements regarding PA catheter insertion are true EXCEPT:
a. Following vessel puncture, SaO2 analysis of a withdrawn blood sample should be <95%.
b. Use a Paceport Swan in patients with LBBB.
c. The major risk of internal jugular cannulation is carotid artery puncture.
d. Air embolism is of concern at the time of guidewire and catheter insertion.
a. Following vessel puncture, SaO2 analysis of a withdrawn blood sample should be <95% is not true.

The SvO2 (not SaO2) must be less than 85% to be sure you are in the vein. Patients may develop RBBB if the RBB is irritated during catheter passage through the RV. If the patient has pre-existing LBBB, complete heart block may ensue, requiring pacing via a paceport catheter, a pacing Swan or external transcutaneous pacing. The carotid artery is close to the internal jugular. Take precautions against air embolism by placing the patient in the Trandelenburg position.

To help prevent pulmonary artery rupture when wedging a Swan-Ganz catheter:
a. Check the pulmonary artery occlusion pressure frequently
b. Withdraw PAC slightly if a PAOP waveform is obtained with inflation of <1.25 ml air
c. Advance PAC slightly if a PAOP waveform is obtained with inflation of <1.25 ml air
d. Always use 1.5 ml air to inflate the balloon for a PAOP
b. Withdraw PAC slightly if a PAOP waveform is obtained with inflation of <1.25 ml air.

You want the catheter to wedge with <1.5 ml of air. But, if the wedge air volume is <1.25 the hard catheter tip may be exposed. Darovic says: “The following guidelines should prevent damage or rupture of the pulmonary artery:

Do not advance the catheter with the balloon deflated
Slow balloon inflation while continuously observing the PA waveform. Inflation is stopped immediately when the PA trace changes to a wedged pressure trace.
Do not inflate the balloon with fluid…
Keep the wedging time and the number of balloon inflation/deflation cycles to a minimum. If a close pulmonary artery diastolic/wedge pressure relationship exists, pulmonary artery diastolic pressure may be used to assess left atrial pressure.
Position the catheter tip in a central pulmonary vessel so that the full or nearly full recommended inflation volume produces the wedge waveform.
Avoid excessive catheter manipulation
Avoid irrigating the pulmonary artery lumen under high pressure. … The damped tracing may be due to spontaneous wedging, and forced irrigation may produce rupture of the pulmonary artery.”

Which statement regarding thrombus formation on Swan-Ganz catheters is most correct?
a. All intravascular monitoring catheters are thrombogenic.
b. Heparin should be added to the IV solutions of all patients with a PA catheter.
c. Catheters occluded by thrombus should be flushed vigorously with saline to clear the catheter.
d. Thrombus begins to form on catheters only after 3 to 5 days in the vessel
a. All intravascular monitoring catheters are thrombogenic.

Even heparin does not guarantee they will not clot. However, many physicians are not using heparin for right heart cath or PA monitoring. And, if a catheter does become clotted, do NOT flush the catheter into the circulation. That causes an embolus. Darovic says: “Any catheter in the vascular system can promote thrombus formation, particularly in patients who have prolonged circulatory failure. . .. Prevention of catheter thrombus formation requires consideration of anticoagulation I hypercoagulable patients if pulmonary artery pressure monitoring is prolonged or if catheter insertion is known to have been traumatic.”

Prior to pulling back a Swan-Ganz catheter to record PA-RV pressures you should _.
a. Inflate the balloon
b. Deflate the balloon
c. Flush the distal lumen of the catheter
d. Flush the proximal lumen of the catheter
b. Deflate the balloon.

If you pull back an inflated balloon catheter across a valve, you may damage that valve. The balloon should be “up” when inserting and “down” when withdrawing the catheter. It won’t hurt to flush the distal lumen through which your pressures are coming. It will reduce damping. But it is not necessary at this time.

Which one of the following statements about abnormal central venous O2 saturation (SvO2) is most correct?
a. SvO2 values <0.60 indicate threatened tissue oxygenation b. SvO2 values >0.80 indicate adequate or increased tissue oxygenation
c. SvO2 values <0.60 indicate low oxygen consumption d. SvO2 values >0.80 indicate increased oxygen consumption
a. SvO2 values <0.60 indicate threatened tissue oxygenation.

This low venous saturation suggests low cardiac output (wide A-V difference) and poor tissue oxygenation. Darovic says: “SvO2 monitoring is a sensitive indicator of the oxygen supply/demand balance. When the SvO2 values fall to less than 50 percent, the patient should be rapidly assessed for conditions that increase oxygen demand. . . . Acute changes in the patient’s oxygen supply/demand balance may be simply and safely assessed in the clinical setting by two technologies. First, continuous SvO2 monitoring [via Swan-Ganz fibreoptic catheters] … Second, pulse oximetry can be used with cardiac index and hemoglobin values to estimate the amount of oxygen delivered to the body cells.”

Central venous pressure (CVP) can directly assess which 2 of the following? 1. RV function 2. LV function 3. Fluid volume status 4. Myocardial contractility
a. 1 & 2
b. 2 & 3
c. 3 & 4
d. 1 & 3
e. 2 & 4
d. 1 & 3: RV function and Fluid volume status.

To measure CVP, a catheter may be placed in the SVC or a Swan-Ganz catheter may be monitored from the RA port. CVP or RA pressure directly measures right heart preload and RV function. The RV filling pressures will be elevated in right heart failure (assuming no tricuspid disease). Darovic say: “The central venous pressure measurement also can be used to assess and manage intravascular volume status because pressure in the great thoracic veins generally correlates with the volume of venous return. The amount of blood that returns to the heart is normally ejected by the heart. Therefore, in patients with hypovolemia, a decreased CVP measurement is associated with a decreased cardiac output, whereas patients with volume overload typically have increased CVP and cardiac output.” CVP can indirectly monitor LV function, but only in normal young people. The frequent disparity between right and left heart function in critically ill patients requires a Swan-Ganz catheter so that each side of the heart can be evaluated independently.

Which of the following is most likely to be associated with hypovolemia?
a. Increased central venous pressure
b. Decreased RV end-diastolic pressure
c. Increased PA occlusion pressure
d. Decreased heart rate
b. Decreased RV end-diastolic pressure.

Hypovolemia is a decrease in the volume of blood in your body. Darovic says: “Progressive intravascular volume losses produce greater decrements in right atrial pressure and CVP. Patients with acute, profound hemorrhage may have measurements as low as minus 8 to minus 10 mmHg.” In acute decompensated hypovolemic shock vasoconstriction increases to maintain BP, skin is cool & pale, along with signs of tachycardia, lactic acidosis, and hypoxemia.

Which one of the following statements about the pulmonary artery occlusion pressure (wedge) is most correct?
a. The pulmonary artery occlusion pressure is measured through the most proximal catheter port
b. Inflation of the balloon momentarily stops the flow of blood and creates a static column of blood between the tip of the catheter and the left atrium
c. The PAOP waveform always contains 3 positive waves (a, c, v)
d. During inflation of the balloon the pulmonary artery pressure changes to a right ventricular waveform
b. Inflation of the balloon momentarily stops the flow of blood and creates a static column of blood between the tip of the catheter and the left atrium.

This static column transmits the LA pressure back to the catheter tip. Since LA is the filling pressure of the LV, wedge tells us about the LV filling pressure and LV function. The PA occlusion pressure (wedge) is measured through the distal catheter port, as it is directed into the pulmonary capillary bed. The wedge waveform will show a and v waves, but commonly no c wave is visible, because it merges with the a wave

Which one of the following statements about hemodynamic waveforms is most correct?
a. Hemodynamic pressures rise during inspiration in a patient breathing spontaneously
b. Hemodynamic pressures fall during inspiration in a patient receiving positive-pressure mechanical ventilation
c. Hemodynamic pressures should be read at end-expiration in a patient breathing spontaneously
d. Hemodynamic pressures should be read at peak-inspiration in a patient receiving positive-pressure mechanical ventilation
c. Hemodynamic pressures should be read at end-expiration in a patient breathing spontaneously and when the patient is receiving mechanical ventilation. So endexpiration is always correct.

The problem with mechanical ventilation is, end-expiration pressures tends to be at the bottom of the tracing, where it is normally at the top. Normal inspiration makes the pressures go down, while mechanical inspiration makes the pressures go up.

Indications for diagnostic myocardial biopsy include all the following EXCEPT:
a. Cardiac transplant patient follow up
b. LV hypertrophy associated with untreated chronic systemic hypertension
c. Restrictive cardiomyopathy (Amyloidosis, hemochromatosis…)
d. Viral myocarditis and/or Endocardial fibrosis
b. LV hypertrophy associated with untreated chronic systemic hypertension.

Hypertrophy due to pressure overload, and is a major cause of primary myocardial hypertrophy. Whereas, in the other myocardial conditions listed, distinct histologic changes occur in the muscle secondary to infection, tissue deposits, or rejection. Definitive diagnose of many of these conditions can only be made with microscopic tissue analysis. This tissue sample must be taken during an invasive biopsy procedure. Cardiac biopsies are small bites of tissue taken from the Ventricular myocardium with one of the bioptome catheters described below

From what part of the heart are intracardiac myocardial biopsy samples normally taken?
a. RV septum
b. RV outflow tract
c. Inferior RV wall
d. LV free wall
a. The RV septum is the safest area from which to take a sample.

Being part of the LV septum, it is the thickest part of the RV . Overzealous sampling may perforate the RV wall, leading to pericardial tamponade. 4-5 samples should be taken from the RV. It is not usually necessary to sample LV because most of the diseases diagnosed are diffuse and effect both chambers. In addition, Kern states that sampling from the RV outflow tract (near the pulmonic valve) and inferior wall should be avoided.

How much heparin should a patient receive for Right heart myocardial biopsy? How much for Left heart biopsy?
RT. HEART BIOPSY LEFT HEART BIOPSY
a. None, – – – None
b. None, – – – 5000 u
c. 5000 u, – – – None
d. 5000 u, – – – 5000 u
b. None for RV, 5000 u for LV.

Heparinization encourages the bleeding from biopsy sites and pericardial tamponade into perforations. Grossman states “We avoid right ventricular biopsy in any patient with a Prothrombin time greater than 17 sec, any patient who is heparinized or any patient with a clinical coagulopathy. On the other hand, left ventricular biopsies are generally performed with systemic anticoagulation (heparin 5000 u), which is not reversed with protamine at the end of the procedure to minimize the risk of thrombus formation at the biopsy site.”
RT. HEART BIOPSY LEFT HEART BIOPSY None, – – – 5000 u Bleeding from the right side is more serious than emboli (they will be filtered by the lung). Whereas, emboli from the left side are more serious (possibility of stroke).

The main hazard of myocardial biopsy is:
a. Air embolism through the large sheath
b. Bundle branch or complete heart block
c. Coronary artery perforation and fistula
d. Infection at the biopsy site
e. Cardiac perforation
e. RV perforation is the most dreaded complication since it can lead to fatal pericardial tamponade.

The RV is only a few mm thick and with force any stiff catheter can perforate. That is why only septal wall samples are taken and heparin is not given with RV biopsy. Simple pericardial centesis usually cures the tamponade problem. The other complications listed are also possible. This is a very safe procedure with approximately half the mortality of a left heart cath and coronaries (0.10% vs .05%)

A complication of myocardial biopsy is inadvertent puncture through the ventricular free wall. What lifesaving measure should be considered if hypotension develops following this procedure?
a. Thoracentesis
b. Pericardial centesis
c. Coronary Artery Bypass surgery
d. Aortic Valve Replacement surgery
b. Pericardial centesis. If blood build-up in the pericardial sack, causing restriction of ventricular filling, pericardial centesis may be lifesaving.

Myocardial biopsy samples for light microscopic analysis are placed in a solution of:
a. 10% formalin
b. 56% formalin
c. 5.0% Glutaraldehyde
d. 50% Glutaraldehyde
a. 10% formalin (formaldehyde)

preserves the sample. 2.5% Glutaraldehyde solutions are used for electron microscopic analysis.

Histologic signs of cardiac transplant rejection found in myocardial biopsy samples include all the following EXCEPT:
a. Interstitial edema and inflammation
b. Erythrocyte hemolysis
c. Lymphocyte infiltration
d. Myocyte necrosis
b. Erythrocyte hemolysis is rupture of red blood cells.

It may occur in hypertonic solutions or mechanical valve turbulence (hemolytic anemia), but not with transplant rejection. Braunwald says, “The most important feature of posttransplant biopsies is the detection of lymphocyte infiltration and the presence of myocyte necrosis.” That involves white blood cells (lymphocytes) rushing in to remove dying (necrotic) cardiac muscle cells (myocytes). The early stages of rejection also involve inflammation and edema of the transplanted myocardial cells.

The first medication given to all ACLS patients should be:
a. Nitroglycerine
b. Morphine
c. Aspirin
d. Oxygen
d. Oxygen.

Note that the ABCD’s should always be done first. The B includes providing ventilation and oxygen to all ACLS patients where it is available. Aspirin is important too, but it may be given at any time but only to suspected ischemic chest pain patients. The secondary ABCD’s include IV and administration of medications. The ACLS 2000 Manual says: “Oxygen is always appropriate for patients with acute cardiac disease or pulmonary distress….During cardiopulmonary emergencies use supplemental oxygen as soon as it is available….In patients with acute MI, supplemental oxygen reduces both magnitude and extent of ST-segment changes on the ECG.”

During ACLS certain drugs may be given down the ET tube. When most drugs are given by the endotracheal route you should __ followed by several rapid bag inflations to aerosolize the medication.
a. Half the dose and flush in with 20 mL D5W
b. Half the dose and dilute in 10 mL of normal saline
c. Double the dose and flush in with 20 mL D5W
d. Double the dose and dilute in 10 mL of normal saline
d. Double the dose and dilute in 10 mL of normal saline or sterile saline.

“If a tracheal tube has been placed before venous access is achieved, epinephrine, lidocaine, and atropine can be administered via the tracheal tube. Administer all tracheal medications at 2 to 2.5 times the recommended IV dose, diluted in 10 mL of normal saline or distilled water. Tracheal absorption is greater with distilled water as diluent than with normal saline, but distilled water has a greater adverse effect on PaO2. Pass a catheter beyond the tip of the tracheal tube, stop chest compressions, spray the drug solution quickly down the tracheal tube, follow immediately with several quick insufflations to create a rapidly absorbed aerosol, then resume chest compressions.” D5W is not recommended during resuscitation unless the patient is hypoglycemic.

This is the Vaughan Williams classification of antiarrhythmic drugs – Ia, Ib, Ic, II, III, and IV. Match the class with its action: I.
Class I
Class II.
Class III.
Class IV.
a. Calcium channel blockers II.
b. Potassium channel blockers III.
c. Beta-1 channel blockers IV.
d. Sodium channel blockers
I. Class I. = d. Block fast Sodium channel (slow Na from entering cell during phase 0)
II. Class II. = c. Beta-1 channel blockers (block adrenergic sites) – most end in “-olol.”
III. Class III. = b. Potassium channel blockers ( prolong repolarization)
IV. Class IV. = a. Block slow Calcium channel.

Braunwald says: “the Vaughan Williams classification is widely known and provides a useful communication shorthand. It is listed here, but the reader is cautioned that the drug actions are more complex than those depicted by the classification.”

Many drugs have antagonists that can counteract their action. Match the drug to its antagonist.
I. Heparin antagonist_____________
II. Demerol/morphine antagonist_____________
III. Midazolam (Versed) antagonist_____________
IV. tPA antagonist_____________
V. Warfarin (Coumadin) antagonist_____________
a. Narcan
b. Protamine
c. Romazicon
d. Amicar
e. Vitamin K
I. Heparin antagonist = b. Protamine
II. Demerol/morphine antagonist = a. Naloxone (Narcan)
III. Midazolam (Versed)antagonist = c. Romazicon (Mazicon, flumazenil)
IV. Thrombolytic (tPA) antagonist = d. Aminocaproic Acid (Amicar)
V. Warfarin (Coumadin) antagonist = e. Vitamin K

Stimulation of different autonomic receptor sites causes specific hemodynamic effects. Match each receptor site to the hemodynamic effect it causes.
I. Alpha 1 _ II. Beta 1
III. Beta 2
IV. Parasympathetic _
a. Dilate lung bronchioles
b. Stimulate heart muscle & AV node
c. Vasoconstrict vascular smooth muscle (peripheral arteriolar arterioles…)
d. Slow heart rate and AV node conduction
I. Alpha 1 = c Vasoconstrict vascular smooth muscle (peripheral arteriolar vasoconstriction…)
II. Beta 1 = b. Stimulate heart muscle & AV node (catecholamine effect))
III. Beta 2 = a. Dilate lung bronchioles (reverse bronchoconstriction in asthma)
IV. Parasympathetic = d. Slow heart rate and AV node conduction Remember alpha (α) adrenergic as follows: the Greek letter

Vasopressin has several advantages over Epinephrine in VF/pulseless VT. Circle the 3 advantages of vasopressin.
a. Increased alpha and beta stimulation
b. Reduced cardiac ischemia and irritability
c. More effective in Asystole and PEA
d. One-time dose simplifies administration
e. Reduced propensity for VF
f. Shorter half-life
b, d, & e.

b. Reduced cardiac ischemia and irritability (Epi. should be given cautiously in MI because its beta effects makes the heart beat faster and harder, whipping the heart, which may lead to ischemia and irritability)
d. One-time dose simplifies administration (Yes, You can only give it once, whereas epi. must be given every 3-5 minutes)
e. Reduced propensity for VF (High catecholamine state may make the heart return to VF) The 2000 ACLS manual says: “Vasopressin produces the same positive effects as epinephrine in terms of vasoconstriction and increasing the blood flow to the brain and heart during CPR.

Moreover, vasopressin does not have the negative, adverse effects of epinephrine on the heart, such as increased ischemia and irritability and paradoxically, the propensity for VF…. Vasopressin is not recommended for asystole and PEA at this time simply because its value in the treatment of these cardiac arrest rhythms has not yet been documented in human trials. Give vasopressin as a single, 1-time dose (40 u IV) a regimen based on the much longer half-life of vasopressin (10 to 20 minutes) compared with epinephrine (3 to 5 minutes)….higher epinephrine doses may contribute to return of spontaneous circulation, but they have also been associated with greater postresuscitation myocardial dysfunction, and they may create a “toxic hyperadrenergic state.” Many hospitals give the vasopressin 1st and then start epi. and antiarrhythmics after 10 minutes when the vasopressin wears off.

Match the maximum dose of these antiarrhythmic medications.
I. Amiodarone __
II. Lidocaine __
III. Procainamide __
IV. Atropine __
a. 17 mg/Kg
b. 3 mg/Kg
c. 2.2 g/24 hrs
d. 0.03 mg/Kg (~2 mg)
I. Amiodarone = c. 2.2 g/24 hrs
II. Lidocaine = b. 3 mg/Kg
III. Procainamide = a. 17 mg/Kg
IV. Atropine = d. 0.03 mg/Kg (~2 mg) Note: the International consensus recommends a higher max. dose of 0.04 mg/k (~3 mg)

Antiarrhythmic meds have many side effects and special considerations. Match each major side effect/consideration with its medication.
I. Amiodarone __
II. Lidocaine __
III. Procainamide __
IV. MgSO4 __
V. Sodium Bicarbonate __
a. CNS effects (numbness, tingling…)
b. Don’t shake ampule, Pulmonary Fibrosis
c. Muscle paralysis, flush, sweating
d. Do not mix with other meds
e. Bradycardia, widens QRS, vasodilation, Lupus-like effects
I. Amiodarone = b. Don’t shake ampule, Pulmonary Fibrosis
II. Lidocaine = a. CNS effects (numbness, tingling…)
III. Procainamide = e. Bradycardia, widens QRS, vasodilation, Lupus-like effects
IV. MgSO4 = c. Muscle paralysis, flushing, sweating V. Sodium Bicarbonate = d. Do not mix with other meds

In SVT if the initial dose of adenosine is ineffective after 2 minutes administer:
a. DC cardioversion
b. Transcutaneous pacing
c. 6 mg adenosine rapid IV push x2
d. 12 mg adenosine rapid IV push x2
d. 12 mg adenosine rapid IV push x2.

Opie says about adenosine: “The drug is given as an initial rapid intravenous bolus … followed by a saline flush to obtain high concentrations in the heart. If it does not work within 1 to 2 minutes, a 12 mg bolus is given that may be repeated…” twice for a maximum of 30 mg

What concentration of Lidocaine would result from 1 gram being mixed with 250 ml saline?
a. 2.5 mg/ml
b. 4.0 mg/ml
c. 25.0 mg/ml
d. 40.0 mg/ml
b. 4.0 mg/ml.

Here you simply plug in the numbers and change grams into mg. (1000 mg = 1 gm).
1000mg / 250 mL = 4 mg/mL

Side effects of procainamide indicating that it should be discontinued or the dosage reduced include: (Circle 3 answers below)
a. Hypotension
b. Tachycardia
c. QRS widens by > 50%
d. Decreases contractility
e. PVCs
a. hypotension
c. QRS widens by > 50%
d. Decreases contractility.

ACLS 2000 guidelines say: “Procainamide hydrochloride suppresses both atrial and ventricular arrhythmias…. Procainamide hydrochloride may be given in an infusion of 20 mg/min until the arrhythmia is suppressed, hypotension ensues, the QRS complex is prolonged by 50% from its original duration, or a total of 17 mg/kg (1.2 g for a 70-kg patient) of the drug has been given.”

Which vitamin is necessary for the formation of clotting factors?
a. Vitamin A
b. Vitamin C
c. Vitamin D
d. Vitamin K
d. Vitamin K.

Guyton says, ” Vitamin K is required . . . for normal formation of prothrombin as well as four other clotting factors . . . Therefore, the lack of vitamin K can decrease the prothrombin level so low that a bleeding tendency results.” An important long term anticoagulant coumadin functions by inhibiting vitamin K. Administration of vitamin K reverses this anticoagulant effect

At the beginning of a diagnostic coronary arteriogram procedure a patient was given 5000 units of IV heparin. Before you pull the sheath the physician wants you to neutralize 4000 units of heparin. What medication and dosage should be given to reverse 4000 units of heparin?
a. 2 cc of Protamine (100 micrograms/cc) IV push
b. 4 cc of Protamine (10 mg/cc) slowly over 5 minutes
c. 2 cc of Amicar (100 micrograms/cc) IV push
d. 4 cc of Amicar (10 mg/cc) slowly over 5 minutes
b. 4 cc of Protamine 10 mg/cc slowly over 5 minutes.

Grossman recommends 10 mg (1.0 cc) of Protamine to counteract every 1000 units of heparin. It’s easy to remember because they react 1:1 by volume, or 1000µ:10 mg. by dosage. If the concentrations are standard (1000 units heparin = 1 cc and 10 mg. Protamine = 1 cc), then each 1 cc of protamine counteracts each 1 cc of heparin. Grossman says: “If systemic heparinization is used, its effects must be reversed at the termination of the left heart catheterization and associated angiography. This is usually accomplished by the administration of protamine (1 mL = 10 mg of protamine for every 1,000 IU of heparin) . . . . When giving protamine, administer it slowly (over 5 minutes), since more rapid administration can provoke severe back pain of unknown etiology.”

To mix an epinephrine drip at a concentration of 4 micrograms/ml put __ mg. of epinephrine into 250 ml. (Use Concentration = amount/volume)
a. 1
b. 2
c. 4
d. 8
a. 1 mg.

X/250 ml = 4 micro gm/ml X =(250 ml) (4 micro gm/ml) =1000 microgram =1 mg In the unit drug dosing system 1 mg of epi comes in the “unit” vial (E.g.: 1 mg/10 ml syringe). When the entire vial is added to 250 ml a standard concentration results.

What are the four anomalies associated with Tetralogy of Fallot?
a. ASD, VSD, LVH, RVH
b. VVH, PS, Over riding aorta, RVH
c. Pulmonic stenosis, Over riding aorta, RVH, VSD
d. Over riding aorta, RVH, LVD, ASD

Which fetal anomaly is characterized by a large VSD over which a large single great vessel arises?
a. Truncas Arteriosus
b. Tricuspid Atresia
c. Transposition of great vessels
d. Tetralogy of Fallot

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