A 63-year-old patient arrives in the CVICU 1 hour after off-pump CABG (LIMA to LAD, saphenous vein graft to RCA). Chest tube output has been 60 mL/hr for 2 hours, platelet count is 198,000/mm³, and INR is 1.1. Which medication order should the nurse anticipate within the first 6 postoperative hours?

Aspirin 81–325 mg by orogastric tube or rectally

Clopidogrel 600 mg loading dose by orogastric tube

Heparin infusion titrated to an aPTT of 60–80 seconds

Warfarin 5 mg daily titrated to an INR of 2–3

On postoperative day 1 after CABG, after vigorous diuresis, a patient has runs of polymorphic ventricular tachycardia with a twisting QRS axis that terminate spontaneously. The QTc is 540 ms. Potassium is 3.4 mEq/L and magnesium is 1.3 mg/dL. BP is 112/68 mmHg between runs. Which medication should the nurse anticipate FIRST?

Magnesium sulfate 2 g intravenously

Amiodarone 150 mg intravenously over 10 minutes

A 70-year-old woman after aortic valve replacement has a cardiac output of 3.6 L/min, a body surface area of 2.0 m2, MAP 72 mmHg, and HR 88/min. Which statement about her cardiac index is correct?

It is 1.8 L/min/m2, which is below normal

It is 7.2 L/min/m2, which is above normal

It is 1.8 L/min/m2, which is within normal

It is 3.6 L/min/m2, which is within normal

Twenty minutes after the epicardial pacing wires are removed from a 68-year-old patient on postoperative day 4 after CABG, HR rises from 84 to 122/min, BP falls from 128/70 to 86/62 mmHg, and the patient becomes restless and short of breath. The jugular veins are distended. What is the MOST likely cause?

Cardiac tamponade from bleeding at a wire site

Vasovagal reaction to wire removal

Ventricular perforation by a retained wire fragment

Pneumothorax from wire traction

A 69-year-old patient is 2.5 hours after on-pump CABG. Heparin was reversed with protamine in the OR (ACT 122 seconds), and 900 mL of cell-salvaged blood was reinfused near the end of the case. Chest tube output has increased to 220 mL/hr. ACT is now 168 seconds, aPTT 52 seconds, platelets 160,000/mm³, fibrinogen 240 mg/dL, and temperature 36.9 °C. What should the nurse anticipate?

Additional protamine 25–50 mg IV

Platelet transfusion, 1 apheresis unit

A 74-year-old patient was extubated 4 hours ago after 3 days of mechanical ventilation following CABG with intraoperative transesophageal echocardiography. The patient is alert and asks for water. Which nursing action BEST reduces the risk of aspiration?

Perform a bedside swallow screen first

Start a full liquid diet with the head of the bed at 30 degrees

Give small sips of water and observe for coughing

Give ice chips freely until a speech therapy evaluation

A 68-year-old patient with postcardiotomy cardiogenic shock is 30 hours post-CABG on epinephrine and norepinephrine with CI 1.6 L/min/m2. Urine output has fallen to 10 mL/h, AST is 2,400 U/L, platelets have dropped to 70,000/mm3, lactate is 7.2 mmol/L, and the patient is less responsive. Which intervention should the nurse anticipate as MOST likely to halt progression of organ failure?

Intravenous N-acetylcysteine for liver protection

Initiation of continuous renal replacement therapy

Fresh frozen plasma and platelet transfusion

A 69-year-old man who is 3 hours after CABG suddenly develops asystole. He has functioning atrial and ventricular epicardial wires attached to a pacemaker set at DDD 80/min with low outputs. According to the CALS protocol, what should the nurse do FIRST?

Pace at maximum output in DDD mode before beginning compressions

Begin external compressions and give epinephrine 1 mg IV

Give atropine 1 mg IV and begin compressions

Prepare for immediate emergency resternotomy at the bedside within 5 minutes

CSC Cardiac Surgery Certification Exam

Free CSC Cardiac Surgery Practice Questions

10 sample questions for the CSC Cardiac Surgery Certification Exam, with the correct answer and an explanation for each. No account needed. Try each one before you open the answer.

Sections covered on the exam: Patient Problems, Nursing Interventions.

Question 1 · Patient Problems
A 63-year-old patient arrives in the CVICU 1 hour after off-pump CABG (LIMA to LAD, saphenous vein graft to RCA). Chest tube output has been 60 mL/hr for 2 hours, platelet count is 198,000/mm³, and INR is 1.1. Which medication order should the nurse anticipate within the first 6 postoperative hours?
- A.Clopidogrel 600 mg loading dose by orogastric tube
- B.Aspirin 81–325 mg by orogastric tube or rectally
- C.Heparin infusion titrated to an aPTT of 60–80 seconds
- D.Warfarin 5 mg daily titrated to an INR of 2–3
Show answer and explanation
Answer: B. Aspirin 81–325 mg by orogastric tube or rectally
Early aspirin (within about 6 hours of CABG, once bleeding is controlled) improves saphenous vein graft patency and reduces perioperative MI and mortality; this matters after off-pump surgery, where the absence of bypass-related platelet dysfunction leaves the patient relatively hypercoagulable. A clopidogrel loading dose adds bleeding risk and is reserved for selected indications, not routine first-hours care. A therapeutic heparin infusion and warfarin are not indicated for graft patency after isolated CABG.
Question 2 · Patient Problems
A 172 cm (5 ft 8 in) male patient who is 18 hours post-mitral valve repair develops moderate ARDS. He weighs 98 kg. The current volume-control settings are VT 650 mL, RR 16, PEEP 8 cmH2O, and the plateau pressure is 33 cmH2O. Which tidal volume should the nurse anticipate?
- A.About 590 mL
- B.About 650 mL
- C.About 780 mL
- D.About 410 mL
Show answer and explanation
Answer: D. About 410 mL
Lung-protective ventilation uses 6 mL/kg of predicted body weight, not actual weight; PBW for a male is 50 + 0.91 × (172 − 152.4) ≈ 68 kg, so 6 mL/kg ≈ 410 mL, which should also help bring plateau pressure to 30 cmH2O or less. About 590 mL is 6 mL/kg of actual body weight, which overdistends the lungs in an overweight patient. Keeping 650 mL leaves the plateau pressure above the safe limit.
Question 3 · Patient Problems
On postoperative day 1 after CABG, after vigorous diuresis, a patient has runs of polymorphic ventricular tachycardia with a twisting QRS axis that terminate spontaneously. The QTc is 540 ms. Potassium is 3.4 mEq/L and magnesium is 1.3 mg/dL. BP is 112/68 mmHg between runs. Which medication should the nurse anticipate FIRST?
- A.Magnesium sulfate 2 g intravenously
- B.Procainamide infusion
- C.Amiodarone 150 mg intravenously over 10 minutes
- D.Sotalol orally
Show answer and explanation
Answer: A. Magnesium sulfate 2 g intravenously
Recurrent torsades de pointes with a prolonged QTc and low magnesium is treated first with intravenous magnesium sulfate, with potassium repletion to a target near 4.0 mEq/L. Amiodarone, procainamide, and sotalol all prolong the QT interval and can worsen torsades.
Question 4 · Nursing Interventions
A 70-year-old woman after aortic valve replacement has a cardiac output of 3.6 L/min, a body surface area of 2.0 m2, MAP 72 mmHg, and HR 88/min. Which statement about her cardiac index is correct?
- A.It is 7.2 L/min/m2, which is above normal
- B.It is 1.8 L/min/m2, which is within normal
- C.It is 1.8 L/min/m2, which is below normal
- D.It is 3.6 L/min/m2, which is within normal
Show answer and explanation
Answer: C. It is 1.8 L/min/m2, which is below normal
Cardiac index = CO / BSA = 3.6 / 2.0 = 1.8 L/min/m2, below the normal range of about 2.5 to 4.0 and in the range associated with hypoperfusion after cardiac surgery. Multiplying instead of dividing gives 7.2. Calling 1.8 normal ignores the accepted lower limit, and 3.6 is the cardiac output, not the index.
Question 5 · Nursing Interventions
Twenty minutes after the epicardial pacing wires are removed from a 68-year-old patient on postoperative day 4 after CABG, HR rises from 84 to 122/min, BP falls from 128/70 to 86/62 mmHg, and the patient becomes restless and short of breath. The jugular veins are distended. What is the MOST likely cause?
- A.Vasovagal reaction to wire removal
- B.Ventricular perforation by a retained wire fragment
- C.Pneumothorax from wire traction
- D.Cardiac tamponade from bleeding at a wire site
Show answer and explanation
Answer: D. Cardiac tamponade from bleeding at a wire site
Tachycardia, hypotension with a narrowed pulse pressure, and jugular venous distension shortly after wire removal indicate tamponade from epicardial bleeding, which is why patients are monitored closely and kept on bed rest after removal. A vasovagal reaction causes bradycardia with hypotension rather than tachycardia, and a pneumothorax would not typically produce jugular venous distension with a narrowed pulse pressure.
Question 6 · Patient Problems
A 69-year-old patient is 2.5 hours after on-pump CABG. Heparin was reversed with protamine in the OR (ACT 122 seconds), and 900 mL of cell-salvaged blood was reinfused near the end of the case. Chest tube output has increased to 220 mL/hr. ACT is now 168 seconds, aPTT 52 seconds, platelets 160,000/mm³, fibrinogen 240 mg/dL, and temperature 36.9 °C. What should the nurse anticipate?
- A.Fresh frozen plasma, 2 units
- B.Platelet transfusion, 1 apheresis unit
- C.Cryoprecipitate, 10 units
- D.Additional protamine 25–50 mg IV
Show answer and explanation
Answer: D. Additional protamine 25–50 mg IV
A rising ACT and aPTT after initial reversal, with normal platelets and fibrinogen, suggests heparin rebound (heparin released from tissue stores or residual heparin in salvaged blood), which is treated with a small additional dose of protamine. Plasma would add volume and factors that are not deficient. Platelets and cryoprecipitate are not indicated because the platelet count and fibrinogen level are adequate.
Question 7 · Patient Problems
A 74-year-old patient was extubated 4 hours ago after 3 days of mechanical ventilation following CABG with intraoperative transesophageal echocardiography. The patient is alert and asks for water. Which nursing action BEST reduces the risk of aspiration?
- A.Start a full liquid diet with the head of the bed at 30 degrees
- B.Perform a bedside swallow screen first
- C.Give small sips of water and observe for coughing
- D.Give ice chips freely until a speech therapy evaluation
Show answer and explanation
Answer: B. Perform a bedside swallow screen first
Dysphagia is common after cardiac surgery, especially with intubation longer than 48 hours, older age, and TEE use, and much aspiration is silent, so a formal swallow screen before any oral intake is the safest step. Giving sips and watching for coughing misses silent aspiration. A full liquid diet and unrestricted ice chips both expose the patient to aspiration before swallowing safety is known.
Question 8 · Patient Problems
A 68-year-old patient with postcardiotomy cardiogenic shock is 30 hours post-CABG on epinephrine and norepinephrine with CI 1.6 L/min/m2. Urine output has fallen to 10 mL/h, AST is 2,400 U/L, platelets have dropped to 70,000/mm3, lactate is 7.2 mmol/L, and the patient is less responsive. Which intervention should the nurse anticipate as MOST likely to halt progression of organ failure?
- A.Intravenous N-acetylcysteine for liver protection
- B.Initiation of continuous renal replacement therapy
- C.Fresh frozen plasma and platelet transfusion
- D.Mechanical circulatory support
Show answer and explanation
Answer: D. Mechanical circulatory support
Kidney, liver, hematologic, and neurologic failure developing together from persistent low output reflect MODS driven by hypoperfusion, so restoring cardiac output with mechanical circulatory support (such as an Impella or VA-ECMO) treats the cause. CRRT and blood products support individual failing organs but do not reverse the shock. N-acetylcysteine is not a treatment for ischemic hepatitis.
Question 9 · Nursing Interventions
Parameter Value
MAP 58 mmHg
HR 96/min
CVP 8 mmHg
PAOP 11 mmHg
Cardiac output 7.0 L/min
SvO2 80%
A 69-year-old woman is 2 hours after CABG with cardiopulmonary bypass. Based on these values, which condition is MOST likely?
- A.Vasoplegic syndrome
- B.Cardiogenic shock
- C.Hypovolemic shock
- D.Cardiac tamponade
Show answer and explanation
Answer: A. Vasoplegic syndrome
SVR = (58 - 8) x 80 / 7.0, which is about 570 dynes·sec/cm-5, well below normal, with a high cardiac output, adequate filling pressures, and a high SvO2; this is the pattern of vasoplegia after bypass. Cardiogenic shock has a low CO and high SVR. Hypovolemia has low filling pressures, and tamponade has equalized high pressures with a low output.
Question 10 · Nursing Interventions
A 69-year-old man who is 3 hours after CABG suddenly develops asystole. He has functioning atrial and ventricular epicardial wires attached to a pacemaker set at DDD 80/min with low outputs. According to the CALS protocol, what should the nurse do FIRST?
- A.Begin external compressions and give epinephrine 1 mg IV
- B.Give atropine 1 mg IV and begin compressions
- C.Prepare for immediate emergency resternotomy at the bedside within 5 minutes
- D.Pace at maximum output in DDD mode before beginning compressions
Show answer and explanation
Answer: D. Pace at maximum output in DDD mode before beginning compressions
For asystole or severe bradycardia with pacing wires in place, CALS directs pacing at maximum atrial and ventricular output (DDD at 80 to 100/min) within the first minute, before starting compressions. Compressions start if pacing does not restore output, epinephrine boluses are not used routinely early, and resternotomy is reserved for failed initial interventions.

Parameter	Value
MAP	58 mmHg
HR	96/min
CVP	8 mmHg
PAOP	11 mmHg
Cardiac output	7.0 L/min
SvO2	80%

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