ANCC Cardiac Vascular Nursing 1 — Questions and Answers
Question 1: A patient presents with sudden tearing chest pain radiating to the back and unequal blood pressures between arms (160/90 right vs 120/70 left). Which diagnosis is most likely?
- ST-elevation myocardial infarction (STEMI)
- Aortic dissection (Correct answer)
- Pulmonary embolism
- Hypertensive emergency
Correct answer: Aortic dissection
Tearing chest/back pain with unequal blood pressures between arms is the classic presentation of aortic dissection — a surgical emergency.
Aortic dissection: intimal tear allows blood into aortic media creating a false lumen. Stanford Type A involves ascending aorta (surgical emergency); Type B involves only descending aorta (medical management targeting HR below 60 bpm and SBP 100-120 mmHg with IV beta-blockers). Diagnosis: CT angiography of chest/abdomen/pelvis. STEMI has crushing chest pain without BP differential; PE has dyspnea and hypoxia.
Question 2: A patient with HFrEF (EF 30%) is being discharged. Which medication combination has the strongest evidence for reducing mortality?
- Digoxin and furosemide
- ACE inhibitor or ARNI, beta-blocker, aldosterone antagonist, and SGLT2 inhibitor (Correct answer)
- Calcium channel blocker and loop diuretic
- Nitrate monotherapy and aspirin
Correct answer: ACE inhibitor or ARNI, beta-blocker, aldosterone antagonist, and SGLT2 inhibitor
The four pillars of HFrEF therapy with mortality benefit are: ACE inhibitor or ARNI (sacubitril/valsartan), beta-blocker, aldosterone antagonist, and SGLT2 inhibitor.
Guideline-directed medical therapy (GDMT) for HFrEF: ARNI (sacubitril/valsartan — PARADIGM-HF showed 20% mortality reduction); beta-blockers (carvedilol, metoprolol succinate, bisoprolol); MRAs (spironolactone/eplerenone); SGLT2 inhibitors (dapagliflozin/empagliflozin, regardless of diabetes status). Diuretics treat symptoms but have no mortality benefit. Digoxin reduces hospitalizations but not mortality. Most calcium channel blockers can worsen HF.
Question 3: A patient with complete heart block shows ventricular rate 32 bpm and hemodynamic instability. What is the immediate treatment?
- Amiodarone 150 mg IV bolus
- Transcutaneous pacing followed by transvenous pacing (Correct answer)
- Metoprolol IV to slow atrial rate
- Synchronized cardioversion at 120 joules
Correct answer: Transcutaneous pacing followed by transvenous pacing
Symptomatic third-degree AV block requires immediate transcutaneous pacing as a bridge to transvenous pacing. Amiodarone and beta-blockers are contraindicated as they worsen bradycardia.
Third-degree AV block: no relationship between P waves and QRS complexes; ventricles beat independently at escape rate. ACLS algorithm: atropine 0.5-1 mg IV (may not work for infranodal block), transcutaneous pacing (immediate bridge), dopamine or epinephrine while preparing for transvenous pacing, then transvenous temporary pacing, ultimately permanent pacemaker. Amiodarone is for tachyarrhythmias. Synchronized cardioversion is for hemodynamically unstable tachyarrhythmias.
Question 4: A patient underwent PCI via the right radial artery. Which complication should the nurse assess for first post-procedure?
- Retroperitoneal hemorrhage
- Radial artery occlusion and hand ischemia (Correct answer)
- Contrast-induced nephropathy only after 72 hours
- Venous thromboembolism at the access site
Correct answer: Radial artery occlusion and hand ischemia
Radial artery occlusion is the most common complication of transradial PCI, occurring in 1-10% of cases. Assessment of radial pulse, capillary refill, and hand perfusion is the priority.
Transradial access has largely replaced femoral access due to lower bleeding complications. Radial-specific complications: radial artery occlusion (1-10%), radial artery spasm (use vasodilator cocktail prophylactically), and radial-to-brachial hematoma. Femoral-specific complications (retroperitoneal hemorrhage, pseudoaneurysm, AV fistula) are less relevant for radial access. Use patent hemostasis technique to maintain radial artery patency during compression.
Question 5: A stable patient with new-onset atrial flutter (rate 150 bpm) has estimated onset greater than 48 hours ago. What is the priority before electrical cardioversion?
- Immediate synchronized cardioversion at 50 joules
- Rate control followed by anticoagulation for at least 3 weeks before cardioversion (Correct answer)
- Adenosine 6 mg IV push to terminate the flutter
- Amiodarone IV infusion for rhythm conversion
Correct answer: Rate control followed by anticoagulation for at least 3 weeks before cardioversion
For AF/flutter with onset greater than 48 hours or unknown duration in a stable patient, at least 3 weeks of therapeutic anticoagulation is required before cardioversion, or a TEE must rule out left atrial thrombus.
When AF or flutter has been present longer than 48 hours or onset is unknown, atrial thrombus may have formed in the LAA. Cardioversion can dislodge this causing stroke. Two approaches: (1) 3 or more weeks of anticoagulation before cardioversion then 4 or more weeks after; (2) TEE-guided to rule out LAA thrombus then immediate cardioversion with anticoagulation. Adenosine terminates re-entrant SVT but does NOT terminate flutter — it may reveal flutter waves. Immediate cardioversion is only for hemodynamically unstable patients.
Question 6: A patient has a mechanical mitral valve replacement and is prescribed warfarin. What is the correct target INR range?
- 1.5-2.0
- 2.0-3.0
- 2.5-3.5 (Correct answer)
- 3.0-4.0
Correct answer: 2.5-3.5
Mechanical mitral valves carry higher thromboembolic risk and require a target INR of 2.5-3.5. Mechanical aortic valves in normal sinus rhythm with low thrombogenic features may have a target of 2.0-3.0.
ACC/AHA guidelines: mechanical aortic valve (bileaflet, low risk) target INR 2.0-3.0; mechanical aortic valve with risk factors or any mechanical mitral valve target INR 2.5-3.5. Mitral position has lower flow velocity and greater blood stasis increasing thrombus risk. DOACs are contraindicated with mechanical valves — the RE-ALIGN trial showed increased TE events and bleeding with dabigatran.
ANCC Cardiac Vascular Nursing 1
A patient presents with sudden tearing chest pain radiating to the back and unequal blood pressures between arms (160/90 right vs 120/70 left).
Which diagnosis is most likely?