PCCN CERTIFICATION EXAM REVIEW AACN
VERIFIED(DETAILED Q&A 2022/2023)
(QUESTIONS AND ANSWER)
1.Coronary artery perfusion is dependent upon:
A. diastolic pressure
B. systolic pressure
C. afterload
D. systemic vascular resistance (SVR)
(correct answer)A. diastolic pressure
Diastolic pressure in the aortic root is higher than left ventricular end-diastolic pressure (LVEDP), the
pressure exerted on the ventricular muscle at the end of diastole when the ventricle is full. This enables
blood to flow from a higher pressure through open arteries to a lower pressure, a pressure gradient
known as coronary artery prefusion pressure. As diastolic pressure drops, there is a decrease in coronary
artery blood flow. Coronary artery perfusion is not affected by systolic pressure, afterload or SVR, but
they all increase the demand of oxygen in the heart.
2.A post-STEMI (ST elevation myocardial infarction) patient is started on an angiotensin-converting
enzyme (ACE) inhibitor during his hospital stay. Which of the following is the most common serious side
effect that may occur?
A. a nonproductive cough
B. pedal edema
C. swelling of the tongue and face
D. rhinorrhea
(correct answer)C. swelling of the tongue and face
3.Although all of the answers may occur, swelling og the tongue and face is the most serious and may
require intervention. Patients should be instructed to seek medical attention immediately for any signs
of swelling in the tongue or throat.
Which of the following best describes the fourth heart sound (S4):
,A. It occurs after ventricular contraction
B. It is best heard with the diaphragm of the stethoscope
C. It is a normal finding in children
D. It occurs during late diastole when the atria contracts
(correct answer)D. It occurs during late diastole when the atria contracts
The presence of the extra heart sound S4 signifies a poorly compliant (stiff) left ventricle. An S4 is also
called an atrial heart sound since it occurs at the end of diastolic filling when the atria contracts and fully
fills the left ventricle. Known as "atrial kick", this filling is important to cardiac output. The increased
end-diastolic volume in the ventricle improves cardiac output. When the left ventricle is stiff (decreased
compliance with long term hypertension, aortic stenosis or with acute STEMI), the atrium has to pump
harder to move blood from the atrium to the ventricle, causing a turbulent blood flow and extra heart
sound. This heart sound is always pathologic. It occurs before ventricular contraction, is best heard with
the bell of the stethoscope and is never a normal heart sound, even in children.
4.Which pathologic changes found on the 12-lead ECG indicate myocardial ischemia?
A. ST-segment elevation
B. ST-segment depression and T-wave elevation
C. Q-wave formation
D. ST-segment depression and T-wave inversion
(correct answer)D. ST segment depression and T wave inversion
Myocardial ischemia changes the repolarization of the ventricular muscle. That change is seen on the 12
lead ECG as ST-segment depression and T wave inversion, which demonstrate subendocardial ischemia -
- the innermost layer of muscle in the myocardium. ST-segment elevation indicates acute injury or
infarction, ST segment depression and T wave elevation may indicate an electrolyte abnormality, while
Q wave formation indicates total infarction.
5.Positive inotropic agents are used to:
A. improve cardiac output and tissue perfusion
B. decrease water loss through the kidneys
C. increase heart rate
D. vasodilate vessels
(correct answer)A. improve cardiac output and tissue perfusion
,The term "inotropic" refers to affecting the force of myocardial contraction. Improvement of cardiac
muscle contraction leads to improved cardiac output and tissue perfusion.
6.A patient in the ED is now being admitted to telemetry bwith complaint of chest pain and has been
judged to be a possible candidate for therapy with alteplase (Activase). Which of the following is not
considered a contraindication for the use of this medication?
A. current antibiotic use
B. recent abdominal surgery
C. recent gastrointestinal bleed
D. recent intracranial bleed
(correct answer)A. current antibiotic use
Use of antibiotics is not a contraindication for the use of alteplase. All the other answers -- recent
abdominal surgery, recent gastrointestinal bleeding and a recent intracranial bleed -- are
contraindications for the use of any fibrinolytic.
7.The two major components that determine blood pressure are:
A. systemic vascular resistance (SVR) (afterload) and cardiac output
B. contractility and SVR (afterload)
C. preload and SVR (afterload)
D. contractility and SVR (afterload)
(correct answer)A. SVR (afterload) and cardiac output
The equation for BP is: BP = SVR x cardiac output.
BP is determined by resistance of the arterial bed and the cardiac output. If the SVR (afterload) is high
and the cardiac output low, the patient may still have a normal BP. the pulse pressure will be lower, but
this is a compensatory response by the heart to maintain BP. If the SVR (afterload) is low (as in early
septic shock), the cardiac output is very high, thereby trying to support BP.
8.The layer of the arterial vessel wall responsible for changes in the diameter of the artery is the:
A. media
B. intima
C. externa
D. adventitia
, (correct answer)A. media
The media layer of the arterial wall contains vascular smooth muscle cells and is responsible for arterial
tone. Vasoactive substances released in response to the sympathetic nervous system and/or the renin-
angiotensin system determine arterial tone. Intima, externa and adventitia are incorrect.
9.A patient presents in acute distress with rales halfway up bilaterally; cool and clammy extremities;
elevated jugular venous distention (JVD); oxygen saturations at 95%, down from 99%; and complaints of
shortness of breath. Which of the following findings correspond to the patient's cardiac status?
A. no pulmonary congestion, normal perfusion
B. no pulmonary congestion, low perfusion
C. pulmonary congestion, normal perfusion
D. pulmonary congestion, low perfusion
(correct answer)D. pulmonary congestion, low perfusion
Rales indicate fluid in the alveolar sacs, possibly secondary to pulmonary edema, causing pulmonary
congestion. Pneumonia can also cause fluid in the alveolar sacs. The patient is complaining of shortness
of breath, and the oxygen saturations are lowering, also indicating that the patient has pulmonary
congestion. The patient's skin is cool and clammy, indicating that the skin is poorly perfused. Skin does
not require oxygen and shunts blood away in decreased cardiac function; therefore, this patient has
pulmonary congestion and low perfusion state. The other answers are incorrect.
10.When listening to heart sounds, S1 signifies which of the following?
A. the beginning of ventricular systole
B. the beginning of ventricular diastole
C. the propulsion of blood into a non-compliant ventricle
D. the blood going in the wrong direction
(correct answer)A. the beginning of ventricular systole
The heart sound of S1 indicates the opening of the aortic and pulmonic valves and marks the beginning
of ventricular systole or ejection. The beginning of diastole is after S2, propulsion of blood into a
noncompliant chamber is S4, and blood going in the wrong direction will cause a murmur.
11.A patient with pulmonary edema has impaired diffusion due to:
A. increased thickness of the alveolar capillary membrane
B. retaining CO2
VERIFIED(DETAILED Q&A 2022/2023)
(QUESTIONS AND ANSWER)
1.Coronary artery perfusion is dependent upon:
A. diastolic pressure
B. systolic pressure
C. afterload
D. systemic vascular resistance (SVR)
(correct answer)A. diastolic pressure
Diastolic pressure in the aortic root is higher than left ventricular end-diastolic pressure (LVEDP), the
pressure exerted on the ventricular muscle at the end of diastole when the ventricle is full. This enables
blood to flow from a higher pressure through open arteries to a lower pressure, a pressure gradient
known as coronary artery prefusion pressure. As diastolic pressure drops, there is a decrease in coronary
artery blood flow. Coronary artery perfusion is not affected by systolic pressure, afterload or SVR, but
they all increase the demand of oxygen in the heart.
2.A post-STEMI (ST elevation myocardial infarction) patient is started on an angiotensin-converting
enzyme (ACE) inhibitor during his hospital stay. Which of the following is the most common serious side
effect that may occur?
A. a nonproductive cough
B. pedal edema
C. swelling of the tongue and face
D. rhinorrhea
(correct answer)C. swelling of the tongue and face
3.Although all of the answers may occur, swelling og the tongue and face is the most serious and may
require intervention. Patients should be instructed to seek medical attention immediately for any signs
of swelling in the tongue or throat.
Which of the following best describes the fourth heart sound (S4):
,A. It occurs after ventricular contraction
B. It is best heard with the diaphragm of the stethoscope
C. It is a normal finding in children
D. It occurs during late diastole when the atria contracts
(correct answer)D. It occurs during late diastole when the atria contracts
The presence of the extra heart sound S4 signifies a poorly compliant (stiff) left ventricle. An S4 is also
called an atrial heart sound since it occurs at the end of diastolic filling when the atria contracts and fully
fills the left ventricle. Known as "atrial kick", this filling is important to cardiac output. The increased
end-diastolic volume in the ventricle improves cardiac output. When the left ventricle is stiff (decreased
compliance with long term hypertension, aortic stenosis or with acute STEMI), the atrium has to pump
harder to move blood from the atrium to the ventricle, causing a turbulent blood flow and extra heart
sound. This heart sound is always pathologic. It occurs before ventricular contraction, is best heard with
the bell of the stethoscope and is never a normal heart sound, even in children.
4.Which pathologic changes found on the 12-lead ECG indicate myocardial ischemia?
A. ST-segment elevation
B. ST-segment depression and T-wave elevation
C. Q-wave formation
D. ST-segment depression and T-wave inversion
(correct answer)D. ST segment depression and T wave inversion
Myocardial ischemia changes the repolarization of the ventricular muscle. That change is seen on the 12
lead ECG as ST-segment depression and T wave inversion, which demonstrate subendocardial ischemia -
- the innermost layer of muscle in the myocardium. ST-segment elevation indicates acute injury or
infarction, ST segment depression and T wave elevation may indicate an electrolyte abnormality, while
Q wave formation indicates total infarction.
5.Positive inotropic agents are used to:
A. improve cardiac output and tissue perfusion
B. decrease water loss through the kidneys
C. increase heart rate
D. vasodilate vessels
(correct answer)A. improve cardiac output and tissue perfusion
,The term "inotropic" refers to affecting the force of myocardial contraction. Improvement of cardiac
muscle contraction leads to improved cardiac output and tissue perfusion.
6.A patient in the ED is now being admitted to telemetry bwith complaint of chest pain and has been
judged to be a possible candidate for therapy with alteplase (Activase). Which of the following is not
considered a contraindication for the use of this medication?
A. current antibiotic use
B. recent abdominal surgery
C. recent gastrointestinal bleed
D. recent intracranial bleed
(correct answer)A. current antibiotic use
Use of antibiotics is not a contraindication for the use of alteplase. All the other answers -- recent
abdominal surgery, recent gastrointestinal bleeding and a recent intracranial bleed -- are
contraindications for the use of any fibrinolytic.
7.The two major components that determine blood pressure are:
A. systemic vascular resistance (SVR) (afterload) and cardiac output
B. contractility and SVR (afterload)
C. preload and SVR (afterload)
D. contractility and SVR (afterload)
(correct answer)A. SVR (afterload) and cardiac output
The equation for BP is: BP = SVR x cardiac output.
BP is determined by resistance of the arterial bed and the cardiac output. If the SVR (afterload) is high
and the cardiac output low, the patient may still have a normal BP. the pulse pressure will be lower, but
this is a compensatory response by the heart to maintain BP. If the SVR (afterload) is low (as in early
septic shock), the cardiac output is very high, thereby trying to support BP.
8.The layer of the arterial vessel wall responsible for changes in the diameter of the artery is the:
A. media
B. intima
C. externa
D. adventitia
, (correct answer)A. media
The media layer of the arterial wall contains vascular smooth muscle cells and is responsible for arterial
tone. Vasoactive substances released in response to the sympathetic nervous system and/or the renin-
angiotensin system determine arterial tone. Intima, externa and adventitia are incorrect.
9.A patient presents in acute distress with rales halfway up bilaterally; cool and clammy extremities;
elevated jugular venous distention (JVD); oxygen saturations at 95%, down from 99%; and complaints of
shortness of breath. Which of the following findings correspond to the patient's cardiac status?
A. no pulmonary congestion, normal perfusion
B. no pulmonary congestion, low perfusion
C. pulmonary congestion, normal perfusion
D. pulmonary congestion, low perfusion
(correct answer)D. pulmonary congestion, low perfusion
Rales indicate fluid in the alveolar sacs, possibly secondary to pulmonary edema, causing pulmonary
congestion. Pneumonia can also cause fluid in the alveolar sacs. The patient is complaining of shortness
of breath, and the oxygen saturations are lowering, also indicating that the patient has pulmonary
congestion. The patient's skin is cool and clammy, indicating that the skin is poorly perfused. Skin does
not require oxygen and shunts blood away in decreased cardiac function; therefore, this patient has
pulmonary congestion and low perfusion state. The other answers are incorrect.
10.When listening to heart sounds, S1 signifies which of the following?
A. the beginning of ventricular systole
B. the beginning of ventricular diastole
C. the propulsion of blood into a non-compliant ventricle
D. the blood going in the wrong direction
(correct answer)A. the beginning of ventricular systole
The heart sound of S1 indicates the opening of the aortic and pulmonic valves and marks the beginning
of ventricular systole or ejection. The beginning of diastole is after S2, propulsion of blood into a
noncompliant chamber is S4, and blood going in the wrong direction will cause a murmur.
11.A patient with pulmonary edema has impaired diffusion due to:
A. increased thickness of the alveolar capillary membrane
B. retaining CO2
