(Osborn) Chapter 39 Learning Outcomes (Number and Title)

[ Osborn ]chapter 39
Learning Outcomes [Number and Title ]

Learning Outcome 1
Define sensitivity and specificity as they relate to diagnostic
testing.
Learning Outcome 2
Describe the major noninvasive and invasive diagnostic tests to
detect coronary disease.
Learning Outcome 3
Identify the appropriate screening test and associated nursing
management for a given client population.
Learning Outcome 4
Compare and contrast major advantages and limitations for
each test.
Learning Outcome 5
Prioritize the nursing management for clients receiving
percutaneous coronary interventional procedures.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
1. Which of the following statements regarding exercise testing is accurate?

1. High specificity is the real value of exercise testing in diagnosing CAD.
2. The ability of the test to detect individuals with CAD ranges from 20% to
35%.
3. The test will be positive in 77% to 90% of individuals who do not have CAD.
4. A low pretest probability increases the chances of a positive exercise test.
Correct Answer: High specificity is the real value of exercise testing in diagnosing CAD.
Rationale: High specificity is the real value of exercise testing in diagnosing CAD. The
ability of the test to detect individuals with CAD (sensitivity) ranges from 50% to 75%.
The test will be negative in 77% to 90% of individuals who do not have CAD. The most
important factor affecting the results is the estimation of pretest probability; therefore, the
higher the pretest probability for CAD, the greater the chance of positive results.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1
2. If a test standard is valid and the criteria for discriminating a positive from a negative
test remain constant, what else will remain constant?
1.
2.
3.
4.
Sensitivity
Specificity
Reliability
Accuracy
Correct Answer: Sensitivity

Rationale: If the standard is a valid one, and as long as the criteria for discriminating a
positive from a negative test remain constant, sensitivity will be constant. Sensitivity
describes the ability of a test to identify clients with disease. It may be calculated by
dividing the number of true positive tests by the sum of true positives plus false
negatives. Specificity is calculated by dividing the number of true negatives in the
population by the sum of true negatives plus false positives. Thus, specificity describes
the frequency with which the test is normal in subjects who are free of disease. Reliability
and accuracy are measured with different data.
Client Need: Safe, Effective Care Environment
LO: 1
3. To be useful, a positive test should substantially:

1. Increase posttest probability.
2. Decrease posttest probability.
3. Increase pretest probability.
4. Increase pretest probability.
Correct Answer: Increase posttest probability.
Rationale: To be useful, a positive test should substantially increase the posttest
probability (likelihood that disease is present), and a negative test should lower the
posttest probability. What is not always known is the pretest probability, which is the
likelihood that disease is present in the client before testing.
Cognitive Level: Synthesis
LO: 1
4. The nurse anticipates that which of the following noninvasive tests may be ordered for
detection of coronary artery disease (CAD) in a 50-year-old male with recent episodes of
chest pain?
1.
2.
3.
4.
Exercise electrocardiography
Stress echocardiography
Transesophageal electrocardiography (TEE)
Right heart catheterization
Correct Answer: Exercise electrocardiography

Rationale: During exercise electrocardiography, continuous ECG and blood pressure
monitoring are performed while the client uses a treadmill or stationary bicycle. This is
the most common noninvasive test used to evaluate individuals with suspected ischemic
heart disease. Stress echocardiography would be performed over exercise
electrocardiography when study results may be limited, such as in females and those with
left ventricular hypertrophy. Both TEE and right heart catheterization are invasive and do
not evaluate for coronary artery disease.
Cognitive Level: Application
Nursing Process: Planning
LO: 2
5. A client is scheduled for an ECG single-photon emission-computed tomography

(SPECT). She asks why they are doing this test. The nurse explains that:
Select all that apply.
1. SPECT images display three views of the heart instead of on a single plane.
2. SPECT images are high resolution and have better separation of overlapping
myocardial segments, which provides more specific information about cardiac
muscle function.
3. SPECT images can be correlated with the ECG to assess ventricular wall
motion, which assesses the effectiveness of the heart muscle.
4. SPECT is an accurate depiction of the electrical activity of the heart.
5. SPECT gives specific information about percent of coronary artery occlusion.
Correct Answer:
1. SPECT images display three views of the heart instead of on a single plane.
2. SPECT images are high resolution and have better separation of overlapping
myocardial segments, which provides more specific information about cardiac
muscle function.
3. SPECT images can be correlated with the ECG to assess ventricular wall
motion, which assesses the effectiveness of the heart muscle.
Rationale: SPECT images display three views of the heart instead of on a single
plane. SPECT images are obtained with a rotating gamma camera that stops at preset
angles to record images, which results in views of the heart on three different axes instead
of one plane. SPECT images are high resolution and have better separation of
overlapping myocardial segments, which provides more specific information about
cardiac muscle function. SPECT provides high resolution and better separation of
overlapping myocardial segments, which provides more specific information about
cardiac muscle function. SPECT images can be correlated with the ECG to assess
ventricular wall motion, which assesses the effectiveness of the heart muscle. SPECT
images can be used with the gating technique, which allows for more accurate
interpretation because the perfusion image can be correlated with the gated image of
ventricular contraction. SPECT is an accurate depiction of the electrical activity of
the heart. SPECT does not provide information about the electrical activity of the heart.
The ECG provides that information. SPECT gives specific information about percent
of coronary artery occlusion. Heart catheterization provides information about the
percent occlusion of the coronary arteries.
Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
LO: 2
6. Which diagnostic test is most effective for measuring overall heart size?
1.
2.
3.
4.
Echocardiogram
12-lead ECG
CPK-MB
Troponin
Correct Answer: Echocardiogram

Rationale: Echocardiography refers to the noninvasive assessment of the structures and
function of the heart and great vessels utilizing high-frequency (ultrasound) sound waves.
The 12-lead ECG evaluates the cardiac conduction system. CPK-MB and Troponin are
laboratory blood tests that measure the amount of acute cardiac damage when diagnosing
a myocardial infarction.
Nursing Process: Evaluation
LO: 2
7. A 65-year-old male with several risk factors for CAD is scheduled for exercise testing
in 2 days. The clinic nurse calls the client at home to provide instruction prior to testing.
Which of the following statements made by the client indicates a need for further
teaching?
1. I may have a cigarette or two just before the test because Im very nervous
about the results.
2. I wont eat for at least 3 hours prior to the test.
3. I will walk on a treadmill and my heart and blood pressure will be
monitored.
4. I will check with the doctor to see if I should take my heart medications but
will hold my metformin until after the test.
Correct Answer: I may have a cigarette or two just before the test because Im very
nervous about the results.
Rationale: Clients should be instructed not to eat or smoke for 3 hours before the testing.
Because the client indicated that he will smoke up to the time of testing, further teaching
is indicated. The clients understanding of how the test is performed is accurate. Cardiac
medications are typically not held; however, the client should confirm this with the health
care provider. Because the client is NPO for the test, metformin should be held until the
test is completed and a diet can be resumed.
LO: 3
8. What type of stress test is useful for clients who do not have a normal baseline ECG, or
who have physical limitations, and therefore are not suitable candidates for a standard
exercise test?
1. Exercise myocardial perfusion imaging
2. Treadmill stress test
3. Cardiovascular stress test
4. 12-lead ECG
Correct Answer: Exercise myocardial perfusion imaging
Rationale: Exercise myocardial perfusion imaging (MPI) is the most common application
of nuclear imaging techniques. In clients who do not have a normal baseline ECG, or
who for other reasons such as physical limitations are not suitable candidates for a
standard exercise test, imaging techniques combined with a basic stress test improve the
ability to detect significant CAD. Treadmill testing and cardiovascular stress testing refer
to the same thing, and this testing is only used when the client has a normal baseline ECG
and no physical limitations. The 12-lead ECG provides information about the electrical
activity in the heart. It is not a stress test.
LO: 3
9. A client is scheduled for a transesophageal echocardiogram. The client asks why it is

necessary to do this test instead of a regular, noninvasive echocardiogram. The nurse
explains to the client that this test will assist in the diagnosis of:
1. Aortic abnormalities.
2. Myocardial infarction.
3. Pulmonary embolism.
4. Coronary artery disease.
Correct Answer: Aortic abnormalities.
Rationale: During TEE, the miniaturized transducer is advanced down the esophagus.
Because the esophagus passes directly behind the posterior surface of the heart, it affords
excellent views of the posterior structures of the heart and great vessels. TEE is
frequently used to detect and assess endocarditis, aortic dissection, intracardiac masses
such as thrombi or tumors, valvular pathology, and congenital disorders in both children
and adults. TEE is not used to diagnose myocardial infarctions, pulmonary embolism, or
coronary artery disease.
LO: 3
10. The nurse reviews an ECG tracing and determines that it is not a high-quality tracing.
Which of the following factors can negatively influence an ECG tracing?
Select all that apply:
1.
2.
3.
4.
5.
Client movement during recording

History of COPD
Incorrect positioning of leads
Morbid obesity
Leads in firm contact with the skin
Correct Answer:
1. Client movement during recording
2. History of COPD
3. Incorrect positioning of leads
4. Morbid obesity
Rationale: Client movement during recording. Factors that can negatively impact the
quality of an ECG tracing include motion artifact. History of COPD. Factors that can
negatively impact the quality of an ECG tracing include COPD. Incorrect positioning of
leads. Factors that can negatively impact the quality of an ECG tracing include
incorrectly positioned leads. Morbid obesity. Factors that can negatively impact the
quality of an ECG tracing include morbid obesity. Leads in firm contact with the skin.
Leads must be properly positioned and in firm contact with the skin to ensure accuracy of
the test.
Nursing Process: Evaluation
LO: 4
11. When diagnosing an MI on a 12-lead ECG, the nurse knows that the reciprocal leads
may:
1. Reflect a mirror image of the changes or damage seen in the indicative
leads.
2. Be a sign of ischemia in that area.
3. Indicate there is no ischemia in that area.
4. Reflect the same ST segment elevation seen in the indicative leads.
5. Indicate heart failure.
Correct Answer:
1. Reflect a mirror image of the changes or damage seen in the indicative
leads.
2. Be a sign of ischemia in that area.
Rationale: Reflect a mirror image of the changes or damage seen in the indicative
leads. Reciprocal (electrically opposite) leads are distant from the injury and reflect an
upside-down, mirror image of the changes or damage seen in the indicative leads. Be a
sign of ischemia in that area. These reciprocal changes can also be a sign of ischemia in
that areait doesnt have to be a reciprocal change. Indicates there is no ischemia in
that area. Anytime there is a ST segment change, it indicates some level of ischemia.
Reflect the same ST segment elevation seen in the indicative leads. Reciprocal leads
reflect the opposite ST segment changes as the indicative leads. Indicate heart failure.
ST segment changes are not specifically indicative of heart failure.
LO: 4
12. Obtaining a 12-lead ECG before treating ST segment elevation is important because:
1. The abnormality will subside and an important diagnostic indicator is lost.
2. There is no importance; an ECG may be obtained after treatment has been
initiated.
3. It determines the mortality rate for MIs.
4. It is associated with Q wave changes.
Correct Answer: The abnormality will subside and an important diagnostic indicator is
lost.
Rationale: Once the cardiac ischemia has subsided due to treatment, the ST segment
changes disappear. Therefore, it is essential that the 12-lead ECG is obtained prior to
treatment. Q wave changes indicate necrosis and will be with the client for the remainder
of his or her life. ST segment elevation in and of itself does not determine mortality.
LO: 4
13. A client is scheduled for percutaneous coronary intervention in the morning. Which of
the following would warrant a call to the health care provider by the nurse?
1.
2.
3.
4.
Client has an order for metformin each morning.

Clients serum creatinine is 1.0 mg/dL.
Client takes warfarin at home and current INR is 1.
Clients potassium level is 3.8 mEq/L.
Correct Answer: Client has an order for metformin each morning.

Rationale: Metformin has been associated with an increased risk for lactic acidosis after
PCI. The drug should be held on the day of the procedure and for 48 hours after the
procedure. The nurse will need to contact the health care provider for such orders. The
clients creatinine, INR, and potassium level are all within normal limits, so no
intervention is necessary.
LO: 5
14. Your client with unstable angina who is going for a heart catheterization asks you
why the procedure is being done. You explain it will:
1.
2.
3.
4.
5.
Provide information about structural abnormalities in the heart.

Diagnose plaque build-up in the coronary arteries.
Assist in the diagnosis of heart failure.
Diagnose valve disorders.
Assess ventricular septal defects.
Correct Answer:
1. Provide information about structural abnormalities in the heart.
2. Diagnose plaque build-up in the coronary arteries.
3. Assist in the diagnosis of heart failure.
4. Diagnose valve disorders.
Rationale: Provide information about structural abnormalities in the heart. Dye is
injected into the heart chambers to obtain information about chamber size and the
anatomy of the great vessels, which helps determine structural abnormalities. Diagnose
plaque build-up in the coronary arteries. The patency of coronary arteries is evaluated
by injecting dye into the arteries; this provides information about the lumen patency,
which is used to evaluate the extent of coronary artery disease. Assist in the diagnosis of
heart failure. Hemodynamic pressures can be measured and used to evaluate for heart
failure and pulmonary function. Diagnose valve disorders. Pressure gradients across
valves evaluate the extent of stenosis or regurgitation. Assess ventricular septal defects.
Dye is injected into the right ventricle and images are obtained to determine if the dye
follows the normal blood flow pattern or if it goes directly from the right ventricle to the
left ventricle. The right-to-left ventricular flow pattern indicates that there is a hole in the
septum.
LO: 5
15. A client returns to his room following a cardiac catheterization. Which of the
following assessments, if made by the nurse, would justify calling the health care
provider?
1.
2.
3.
4.
Absence of pulse distal to the catheter insertion site

Pain at the site of the catheter insertion
Drainage on the dressing covering the catheter insertion site
Redness at the catheter insertion site
Correct Answer: Absence of pulse distal to the catheter insertion site

Rationale: Absence of a pulse distal to the catheter insertion site indicates clot formation
in the artery. The health care provider needs to be notified so measures can be taken to
remove the clot and restore tissue perfusion. Pain, some drainage, and redness are all
expected following the insertion of a catheter.
Cognitive Level: Evaluation
LO: 5

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[ Osborn ]chapter 39

Learning Outcomes [Number and Title ]

1. Which of the following statements regarding exercise testing is accurate?

Correct Answer: Sensitivity

3. To be useful, a positive test should substantially:

Correct Answer: Exercise electrocardiography

5. A client is scheduled for an ECG single-photon emission-computed tomography

Correct Answer: Echocardiogram

9. A client is scheduled for a transesophageal echocardiogram. The client asks why it is

Client movement during recording

Client has an order for metformin each morning.

Correct Answer: Client has an order for metformin each morning.

Provide information about structural abnormalities in the heart.

Absence of pulse distal to the catheter insertion site

Correct Answer: Absence of pulse distal to the catheter insertion site

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