Deck 24: Cardiac Surgery

Question 1

During the preoperative assessment of an adult with a previously corrected congenital heart defect,the perioperative nurse should be aware of anatomic anomalies associated with the original defect,or its subsequent repair,that may alter the current surgical plan for a patient who had prior pediatric cardiac surgery.What is an appropriate nursing response when the assessment reveals the adult patient has undergone prior pediatric cardiac surgery? Select all that apply.

A) Prepare for endocardial injury if the heart is retracted or manipulated too forcefully.
B) Prepare to employ the current surgical plan,adding pediatric vascular clamps to the set.
C) Consult with the surgeon for specific alterations to the typical plan for care.
D) Alert the staff to anticipate altered anatomy,special supplies,and potential complications.

Answer 1

C,D
Consultation with the surgeon can alert the staff to anticipate different anatomy (and surgical landmarks),special supplies and prosthetic materials,and potential complications.In addition to age-specific changes,there are a growing number of adults with acquired heart disease who underwent surgery in childhood for repair of congenital cardiac lesions.For example,patients with a previous Blalock-Taussig shunt for tetralogy of Fallot may have altered pulmonary and subclavian artery anatomy;patients with a mechanical closure device inserted for an atrial septal defect may be at risk for endocardial injury if the heart is retracted or otherwise manipulated too forcefully.The nurse should be aware that anatomic anomalies associated with the original congenital defect,or its subsequent repair,may alter the current surgical plan.

Question 2

During Shelbie Wilson's valve repair,the surgeon realized that the torn leaflet was too damaged to be repaired and Shelbie would be better served with a bioprosthetic replacement valve.The perioperative nurse selected the implant from its secure storage area and transferred it in its storage solution to the sterile back table.What is the appropriate risk reduction strategy to prepare the bioprosthetic valve for implantation?

A) Rinse the biovalve in sterile albumin.
B) Rinse according to the biovalve manufacturer's instructions.
C) Rinse the biovalve in 5 baths of sterile saline.
D) Rinse the biovalve in glutaraldehyde.

Answer 2

B
Both the amount of rinsing solution in each rinsing basin and the time for each rinse (total of three rinsing baths)should be followed according to each manufacturer's instructions.Safety considerations include storing prosthetic materials in a clean,protected environment and using them according to manufacturers' instructions.

Question 3

Select the diagnostic test that represents an invasive cardiac study.

A) Resting MUGA
B) Exercise MUGA
C) Cardiac function
D) Electrophysiology studies

Answer 3

D
The following are invasive diagnostic tests commonly performed for cardiovascular disorders:electrophysiology studies,aortography,arteriography,digital subtraction angiography,cardiac catheterization,ventriculography,endomyocardial biopsy.

Question 4

The temporary substitution of a pump oxygenator for the heart and lungs allows the surgeon to stop the heart and perform cardiac procedures under direct vision in a relatively dry,motionless field.It also allows the surgeon to manipulate the heart without the risk of producing ventricular fibrillation and reduced cardiac output that jeopardize perfusion to the myocardial,peripheral,and cerebral tissues.In traditional cardiopulmonary bypass (CPB),systemic venous return to the heart flows by gravity drainage through cannulae placed in the superior and inferior venae cavae or through a single two-stage cannula in the right atrium into tubing connected to the bypass machine.Blood is oxygenated,filtered,warmed or cooled,and pumped back into the systemic circulation through a cannula placed in the:

A) femoral artery.
B) axillary artery.
C) ascending aorta.
D) All of the arteries could be used for return flow.

Question 5

The blood is oxygenated in the lungs and returns to the left atrium through the pulmonary veins.Where does the blood flow after leaving the left atrium?

A) Through the mitral valve into the left ventricle
B) Through the tricuspid valve into the left ventricle
C) Through the aortic valve into the left ventricle
D) Through the aorta into the systemic circulation

Question 6

What statements regarding vascular clamps are true? Select all that apply.

A) Vascular clamps are designed to partially occlude blood flow.
B) Vascular clamps are designed to totally occlude blood flow.
C) All vascular clamps are designed to hold vessels securely without trauma.
D) All vascular clamps have similar angles,box locks,ring handles,and ratchets.

Question 7

Among the treatment options for tricuspid valve disease are suture annuloplasty,ring annuloplasty,and valve replacement with either a biologic or a mechanical prosthesis.Like the mitral valve,the tricuspid annulus is saddle-shaped and techniques to repair the valve should consider this anatomic configuration for optimal repair.Patients with significant tricuspid stenosis,regurgitation,or failed tricuspid (suture or ring)annuloplasty may require insertion of a prosthetic biologic or mechanical valve.Because there are no specific tricuspid prosthetic valves available,what type of prosthetic graft would be created or implanted?

A) An annuloplasty with a felt-pledgetted suture
B) A tricuspid annular permanent dilator
C) A mitral prosthesis
D) An annuloplasty ring

Question 8

The internal mammary arteries are frequently used as grafts during coronary bypass surgery.Where are they located?

A) They diverge from the anterior interventricular branch of the right coronary artery.
B) They diverge from the subclavian arteries behind the sternum.
C) They diverge from the subclavian arteries anterior to the sternum.
D) They diverge from the innominate artery.

Question 9

This retractor is used to elevate the sternal border to expose the:

A) internal mammary artery.
B) aortic arch.
C) superior vena cava and right atrium.
D) anterolateral coronary arteries.

Question 10

Patients with chronic,severe angina who cannot be revascularized with either coronary bypass surgery or PCI may be appropriate candidates for laser transmyocardial revascularization (TMR).Channels are created in the left ventricular wall with laser energy (e.g.,CO₂,holmium:yttrium-aluminum-garnet [Ho:YAG]).What relevant nursing intervention must accompany this procedure?

A) Prep the patient for possible emergency coronary artery bypass.
B) Prepare for insertion of a ventricular assist device.
C) Employ laser safety precautions.
D) Prepare provisions for an endoscopic or robot-assisted approach.

Question 11

In the pulmonary circulatory system,blood is pumped from the right ventricle (RV)through the pulmonary valve into the main pulmonary artery (PA).The PA divides into the right and left pulmonary arteries,which further subdivide into the arterioles and capillaries of the lungs.Where does the blood from the lungs flow next?

A) Into the capillary beds
B) Into the alveoli
C) Through the pulmonary artery to the left atrium
D) Through the pulmonary veins to the left atrium

Question 12

During the preoperative nursing assessment for a patient scheduled for cardiac surgery,the perioperative nurse reviews the patient's medication history with particular attention to medications that can affect the surgery or cause complications.Select the true statement about specific medications that can affect surgery or cause complications.

A) Aspirin may increase platelet levels.
B) Lipid-lowering drugs (statins) may affect coronary artery bypass patency.
C) Herbal products may promote the development of thromboemboli.
D) Angiotensin converting enzyme inhibitors (ACEIs) may cause malignant hypertension.

Question 13

Identify the correct path of the cardiac conduction system.

A) From the area where the superior vena cava meets the right atrium to the atrioventricular junction close to the tricuspid valve to the right side of the interventricular system into a network of fibers by way of the right and left bundle branches
B) From the SA node to the AV node to the bundle of His to the Purkinje system
C) Both from the area where the superior vena cava meets the right atrium to the atrioventricular junction close to the tricuspid valve to the right side of the interventricular system into a network of fibers by way of the right and left bundle branches,and from the SA node to the AV node to the bundle of His to the Purkinje system
D) Neither from the area where the superior vena cava meets the right atrium to the atrioventricular junction close to the tricuspid valve to the right side of the interventricular system into a network of fibers by way of the right and left bundle branches,and from the SA node to the AV node to the bundle of His to the Purkinje system

Question 14

Thoracic aortic aneurysmectomy is excision of an aneurysmal portion of the ascending aorta,aortic arch,or descending thoracic aorta and replacement with a prosthetic graft,valve-graft conduit,or intra-aortic prosthesis.Aneurysms may be caused by atherosclerosis,trauma,infection,or cystic medial degeneration.What presenting conditions will indicate that surgical intervention is necessary?

A) Compromised circulation or danger of rupture
B) Circumferential involvement
C) Spindle-shaped morphology
D) Combined saccular and fusiform morphology without dissection

Question 15

Select the noninvasive diagnostic test that illustrates heart wall motion and blood flow through the heart and quantifies cardiac function.

A) Radionuclide imaging
B) Cardiac catheterization
C) Echocardiography
D) Cardiac function studies

Question 16

Formerly,ventricular assist devices were reserved for those patients who could not be weaned from CPB after open-heart operations,or who had end-stage cardiomyopathy.Current indications and choices have expanded and a variety of active and passive devices are available to support the circulation for short-,intermediate-,and long-term support.Select the statement that best describes a passive method of assisted circulation.

A) The latissimus dorsi muscle is wrapped around the heart and paces the heart with natural electrical stimulation in patients who are not candidates for transplant.
B) The intra-aortic balloon pump counterpulses with diastole to flood the aorta with oxygenated blood in patients who are not candidates for CPB.
C) Ventricular assist devices augment blood flow by diverting blood from the systemic circulation into the ventricles for patients waiting for a suitable donor heart.
D) The Thoratec HeartMate LVAD is an axial flow permanent replacement heart for patients who are not candidates for heart transplant surgery.

Question 17

An aneurysm of the left ventricle (LV)can develop after a severe myocardial infarction.The affected area of the myocardium is replaced by thin scar tissue that can rupture.The LV undergoes remodeling when the scar stretches as a result of the left ventricular pressure and forms an aneurysm.Left ventricular aneurysmectomy (LVA)is the excision of an aneurysmal portion of the left ventricle.LVA is a form of left ventricular reconstruction undertaken to optimize cardiac function.Select the appropriate nursing actions in preparation for LVA surgery.

A) Place the patient in supine position.
B) Prepare for the procedure in the same manner as typical open-heart surgery.
C) Have Teflon felt pledgets,woven Dacron patches,and cardiovascular sutures available.
D) All of the options are appropriate for LVA.

Question 18

Complete heart block and bradydysrhythmias are the most common indications for pacemaker implantation.A permanent pacemaker (pulse generator and electrodes)initiates atrial or ventricular contraction,or both.What therapy might be used for acute forms of heart block and dysrhythmias that occasionally occur during and after cardiac surgery?

A) Transvenous endocardial stimulation
B) A temporary pacemaker
C) Epicardial cardioversion
D) Resynchronization therapy

Question 19

Disturbances of the conduction system affect the rate,rhythm,and effectiveness of the contracting heart.Surgical techniques have been developed to treat a variety of supraventricular dysrhythmias and both ischemic and nonischemic ventricular tachydysrhythmias.Preprocedural electrophysiologic mapping of the patient's conduction pathways identifies and locates aberrant pathways,or ectopic foci.A catheter is inserted percutaneously into the femoral vein or artery and threaded retrograde to the right or left atrium and ventricle.Various areas of the heart are tested in an attempt to reproduce the dysrhythmia;then the area of the heart where the rhythm disturbance originates is ablated.What directed energy source is employed to produce this selective ablation effect?

A) Cryotherapy
B) Ultrasonic energy
C) Radiofrequency energy
D) All three energy sources can produce the desired ablative effect.

Question 20

Surgery for atrial fibrillation (AF)may also be performed through an open sternotomy or right mini-thoracotomy incisions.By creating small areas of scar tissue in the cardiac muscle,electrical impulses are forced to follow an alternative conduction path or "maze." Select all the statements regarding nursing considerations for the maze procedure that are true.

A) Monitor for heart rhythm problems.
B) Infuse cardioplegic solution through the aortic root and into the coronary arteries.
C) Monitor for bleeding,infection,and potential complications related to heart surgery.
D) Strip the chest tubes and test the pacing wires every 4 hours postoperatively.

Question 21

Camilla Armstrong,a 59-year-old woman with multiple prior cardiac procedures for congenital cardiac anomalies at birth,is scheduled for an open approach coronary artery bypass graft.During the preoperative interview and assessment,the perioperative nurse reviewed Camilla's hematologic tests,including a detailed coagulation profile to uncover possible hemorrhagic disorders.During the assessment the nurse learned of Camilla's many varied co-morbid conditions,including prior vascular procedures,fibromyalgia,diabetes,and eczema.The nurse noted one of Camilla's many nursing diagnoses as:Risk for Bleeding related to surgical incision(s),tissue dissection,altered coagulation function,and inadvertent hypothermia.As a result of this diagnosis,the nurse implemented measures to have blood available,measure and report blood loss,assist with the use of the autotransfusion system per protocol,and have topical hemostatic agents available.The patient will be free from excessive bleeding as evidenced by (select all that apply):

A) chest tube drainage less than 100 mL/hr.
B) dressings dry and intact.
C) normal cardiac function studies.
D) normal skin color,temperature,and turgor.

Question 22

Open commissurotomy of the mitral valve,which is performed for mitral stenosis,is the separation of fused,adherent leaflets of the mitral valve.The nurse assists in placing the patient in the supine position for a median sternotomy.The setup is the same as that described for open-heart procedures,with mitral valve instruments.Select two additional nursing actions that are relevant to the patient with open commissurotomy.

A) Have valve replacement instruments available.
B) Have tricuspid prosthetic implants available.
C) Have a transesophageal echocardiogram (TEE) probe and machine available.
D) Have anterolateral positioning devices available if valve replacement is needed.

Question 23

A percutaneous method of instituting femoral vein-femoral artery CPB can be used for minimally invasive (or conventional open)procedures and in emergency situations where the environment is not conducive to traditional CPB methods.Select all the areas where percutaneous CPB would be indicated.

A) Renal dialysis unit and postoperative cardiac transplant unit
B) Neonatal intensive care unit and emergency department
C) Cardiac catheterization unit and intensive care unit
D) Battlefield trauma/triage unit

Question 24

An implantable cardioverter defibrillator (ICD)is an electronic device designed to monitor cardiac electrical activity and deliver prompt defibrillation.These devices are capable of pacing as well as defibrillating,consisting of a generator and sensing and defibrillator electrodes.Myocardial or thoracic subcutaneous patches may be added if the transvenous catheters alone do not adequately defibrillate the heart.Patients with previously implanted defibrillator patches may present for removal of a patch or patches.What nursing action would be appropriate during this procedure? Select all that apply.

A) Be prepared for emergency intervention if there is electrical overdrive.
B) Be prepared for emergency intervention if there is excessive bleeding.
C) Be prepared for emergency intervention if there is a lethal dysrhythmia.
D) Be prepared for emergency intervention if there is a generator failure.