Cardiovascular Assessment Practice Questions

30 multiple-choice questions on Cardiovascular assessment for paramedic and EMT students, from Chapter 18 (Cardiovascular Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

30 practice questions

1. In a dyspneic patient with leg edema, you press firmly over the right upper abdomen for 10 seconds, and the neck veins rise and stay up. What does this suggest?

   1. A. Right heart failure or volume overload
   2. B. Acute appendicitis with local peritonitis
   3. C. Normal venous response to pressure
   4. D. Low circulating blood volume
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   Answer: A. Right heart failure or volume overload

   A sustained rise in jugular venous pressure during abdominal pressure (hepatojugular reflux) means the right heart cannot handle the extra venous return, as in right heart failure or volume overload. It is not a test for appendicitis. In a normal person the rise is brief, and a hypovolemic patient has flat neck veins.

2. While assessing the neck veins, which finding helps you tell a jugular venous pulsation from a carotid pulse?

   1. A. It changes with position and is not palpable
   2. B. It is strong and easy to feel with a fingertip
   3. C. It stays the same when the patient sits up
   4. D. It has a single sharp upstroke per beat
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   Answer: A. It changes with position and is not palpable

   The internal jugular pulsation is soft, has two waves per beat, cannot be felt, falls when the patient sits up, and can be stopped with light pressure at the base of the neck. The carotid pulse is strong and easy to feel, has one brisk upstroke and does not change with position, so the other options describe the carotid.

3. Which chest pain description makes acute coronary syndrome least likely, though it does not rule it out?

   1. A. Pressure that spreads down into both arms
   2. B. Heaviness that came on with exertion
   3. C. Sharp pain pointed to with one fingertip
   4. D. Discomfort with sweating and nausea
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   Answer: C. Sharp pain pointed to with one fingertip

   Pain that is sharp and localized to a spot the patient can cover with a fingertip lowers the likelihood of ischemia, although it never fully excludes it. Radiation to both arms, onset with exertion, and associated diaphoresis and nausea all raise the likelihood of ACS.

4. Which feature of chest pain most increases the likelihood that it is caused by acute coronary syndrome?

   1. A. Pain reproduced by pressing on the chest
   2. B. Sharp pain that changes with position
   3. C. Radiation to both arms or shoulders
   4. D. Pain that worsens with each breath in
   Show answer

   Answer: C. Radiation to both arms or shoulders

   Studies of chest pain features find that radiation to both arms or shoulders and pain with exertion raise the likelihood of ACS the most. Pain reproduced by palpation, positional pain and pleuritic pain each lower the likelihood, though none can rule ACS out alone.

5. A patient with a stab wound to the chest has a systolic pressure that falls 18 mm Hg with each inspiration. This finding is most consistent with:

   1. A. Severe aortic stenosis
   2. B. Hypertensive emergency
   3. C. Cardiac tamponade
   4. D. Complete heart block
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   Answer: C. Cardiac tamponade

   Pulsus paradoxus is a classic sign of cardiac tamponade (it can also occur with severe asthma or COPD). Penetrating chest trauma makes tamponade the leading concern.

6. Pulsus alternans, a regular pulse that alternates between strong and weak beats, most often indicates:

   1. A. Cardiac tamponade from effusion
   2. B. Severe hypovolemia from bleeding
   3. C. Rapid atrial fibrillation
   4. D. Severe left ventricular failure
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   Answer: D. Severe left ventricular failure

   Pulsus alternans is associated with a severely failing left ventricle. Tamponade is associated with pulsus paradoxus, and atrial fibrillation produces an irregular pulse.

7. A patient in atrial fibrillation at about 110/min has an irregular pulse. How should you obtain the most reliable blood pressure?

   1. A. Use the first automated reading you get
   2. B. Read the highest of several readings
   3. C. Take several readings and average them
   4. D. Feel the radial pulse to find the systolic
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   Answer: C. Take several readings and average them

   In AF each beat has a different stroke volume, so single readings vary; repeated measurements averaged together (manual or automated) give a better estimate. Relying on the first or the highest reading can mislead treatment decisions, and palpation gives only a rough systolic value, which is even less reliable in AF.

8. An S3 heart sound in a 70-year-old with dyspnea is most often associated with:

   1. A. A stiff ventricle from chronic hypertension
   2. B. Inflammation of the pericardial sac
   3. C. Heart failure with volume overload
   4. D. Narrowing of the aortic valve
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   Answer: C. Heart failure with volume overload

   An S3 (ventricular gallop) after S2 reflects rapid filling of a volume-overloaded ventricle and is a sign of heart failure in older adults. An S4 is associated with a stiff, noncompliant ventricle.

9. A scratchy, high-pitched sound heard over the precordium that varies with the cardiac cycle suggests:

   1. A. Pulmonary edema
   2. B. Mitral stenosis
   3. C. Pericarditis
   4. D. Spontaneous pneumothorax
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   Answer: C. Pericarditis

   A pericardial friction rub is the rubbing of inflamed pericardial layers and is characteristic of pericarditis. It is often louder with the patient leaning forward.

10. A confused 78-year-old cannot give a history. Her medication list includes apixaban and diltiazem. Which condition do these medicines most strongly suggest?

    1. A. Atrial fibrillation
    2. B. Asthma
    3. C. Heart failure with fluid overload
    4. D. Type 2 diabetes
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    Answer: A. Atrial fibrillation

    An oral anticoagulant such as apixaban paired with a rate-control drug such as diltiazem is the typical regimen for atrial fibrillation, which also raises her risk of stroke and bleeding. Neither drug treats asthma or diabetes, and diltiazem is usually avoided in heart failure with reduced ejection fraction.

11. Which history best suggests a reentrant SVT rather than sinus tachycardia as the cause of a patient's palpitations?

    1. A. A gradual speed-up over several minutes while out running
    2. B. A pulse that is faster after a cup of coffee
    3. C. A rapid, regular pounding that starts and stops suddenly
    4. D. Palpitations that build during a fever over a day
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    Answer: C. A rapid, regular pounding that starts and stops suddenly

    Reentrant SVT typically starts and ends abruptly, like a switch, and is regular and fast. Sinus tachycardia speeds up and slows down gradually in response to a cause such as exercise, caffeine (a cup of coffee) or fever, so those histories point to a sinus rhythm.

12. You suspect pulsus paradoxus. How is it measured with a manual BP cuff?

    1. A. Compare the systolic BP measured in the right and left arms
    2. B. Find the gap between first sounds and sounds on every beat
    3. C. Subtract the diastolic BP from the systolic BP
    4. D. Compare the BP lying down with the BP standing
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    Answer: B. Find the gap between first sounds and sounds on every beat

    Deflate slowly and note the pressure where sounds are first heard only during expiration, then the pressure where they are heard with every beat; a difference over 10 mm Hg is pulsus paradoxus. Comparing arms looks for dissection, subtracting diastolic from systolic gives pulse pressure, and lying-to-standing checks are orthostatic vital signs.

13. A STEMI patient has crackles in the lower third of both lungs and an S3, with a normal BP and good perfusion. What is his Killip class?

    1. A. Class I
    2. B. Class III
    3. C. Class IV
    4. D. Class II
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    Answer: D. Class II

    The Killip classification grades heart failure in acute MI: class I has no signs of failure, class II has crackles in the lower lung fields or an S3, class III has frank pulmonary edema, and class IV is cardiogenic shock. Mortality rises with each class, so this patient is higher risk than class I but not yet in pulmonary edema or shock.

14. A heart failure patient is comfortable at rest and walks around her home without trouble, but she gets short of breath climbing two flights of stairs. Which NYHA functional class fits?

    1. A. Class II
    2. B. Class I
    3. C. Class III
    4. D. Class IV
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    Answer: A. Class II

    NYHA class II means slight limitation: comfortable at rest, but ordinary activity such as climbing stairs causes symptoms. Class I has no limitation of ordinary activity, class III has symptoms with less than ordinary activity (such as walking across a room), and class IV has symptoms at rest.

15. An 80-year-old with exertional chest pain has a weak carotid pulse that rises slowly, and a harsh murmur during systole. Which condition do these findings suggest?

    1. A. Acute aortic regurgitation
    2. B. Mitral valve prolapse
    3. C. Severe aortic stenosis
    4. D. Hypertrophic pericarditis
    Show answer

    Answer: C. Severe aortic stenosis

    A slow-rising, weak pulse with a harsh systolic murmur is typical of severe aortic stenosis, which causes angina, exertional syncope and heart failure and makes these patients very sensitive to drops in preload. Acute aortic regurgitation causes a diastolic murmur, mitral valve prolapse a click and late systolic murmur, and 'hypertrophic pericarditis' is not a real condition.

16. A patient with chest pain places a clenched fist over the center of his chest while describing it. This gesture is known as:

    1. A. Levine sign
    2. B. Kehr shoulder sign
    3. C. Homan sign
    4. D. Murphy sign
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    Answer: A. Levine sign

    The Levine sign, a clenched fist over the sternum, is a classic gesture of ischemic chest pressure. Kehr sign is referred left shoulder pain from splenic injury.

17. A heavy drinker has ascites and leg edema. Which finding favors right heart failure over cirrhosis as the cause?

    1. A. Yellow skin and eyes
    2. B. Spider veins on the chest
    3. C. A long history of drinking
    4. D. Distended neck veins
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    Answer: D. Distended neck veins

    Right heart failure raises venous pressure, so the neck veins are distended; in cirrhosis the fluid comes from portal hypertension and low albumin, and the neck veins are usually flat. Jaundice (yellow skin and eyes) and spider veins point toward liver disease, and a drinking history fits either cirrhosis or alcohol-related cardiomyopathy.

18. A 19-year-old with a BP of 172/96 in the right arm has weak, delayed femoral pulses. Which condition should you suspect?

    1. A. Abdominal aortic aneurysm
    2. B. Acute arterial embolus
    3. C. Coarctation of the aorta
    4. D. White coat hypertension
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    Answer: C. Coarctation of the aorta

    A narrowing of the aorta beyond the arch arteries causes high pressure in the arms with weak, delayed pulses in the legs (radio-femoral delay), a classic finding in a young person with hypertension. An abdominal aortic aneurysm is a disease of older adults and does not cause this pattern. An embolus causes a cold, painful limb, and white coat hypertension would not weaken the femoral pulses.

19. In a bedridden patient with fluid overload, where is dependent edema best assessed?

    1. A. Around the ankles
    2. B. Over the sacrum
    3. C. Around the eyelids
    4. D. In the fingertips
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    Answer: B. Over the sacrum

    Edema collects in dependent areas; in a patient lying in bed that is the sacrum and back rather than the ankles. Checking only the feet can miss significant fluid retention.

20. A bedbound heart failure patient has no ankle swelling. Where should you check for dependent edema?

    1. A. Over the backs of the hands and wrists
    2. B. Around the eyes and the face
    3. C. Over the sacrum and lower back
    4. D. Over the front of the shins
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    Answer: C. Over the sacrum and lower back

    Edema collects in the lowest (dependent) parts of the body, so in a patient who lies in bed it gathers over the sacrum and lower back rather than the ankles or shins. Swelling of the hands or the face around the eyes is not the typical dependent site in heart failure, and the front of the shins is not dependent when the patient is lying down.

21. A 55-year-old's chest pain is partly reproducible when you press on the sternum. How should this finding affect your assessment?

    1. A. It does not rule out acute coronary syndrome
    2. B. It confirms a musculoskeletal source of pain
    3. C. It makes a 12-lead ECG unnecessary to obtain
    4. D. It rules out aortic dissection as a cause
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    Answer: A. It does not rule out acute coronary syndrome

    Chest wall tenderness can coexist with ACS and should not be used to exclude it. Patients with risk factors still need a 12-lead and full cardiac evaluation.

22. A patient's rhythm is irregularly irregular. How should you count the pulse rate?

    1. A. Count for 15 seconds and multiply by 4
    2. B. Count for 6 seconds and multiply by 10
    3. C. Count for a full 60 seconds
    4. D. Use the SpO2 monitor's displayed rate
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    Answer: C. Count for a full 60 seconds

    In an irregular rhythm, short counts multiply sampling error, so count the radial (or better, apical) pulse for a full minute and compare with the monitor to detect a pulse deficit. Fifteen- and six-second counts are unreliable here, and the oximeter may miss weak beats and undercount the rate.

23. In early left-sided heart failure, where are crackles usually first heard?

    1. A. In the dependent lung bases
    2. B. In the upper lung apices
    3. C. Over the trachea and bronchi
    4. D. Only over the right upper lobe
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    Answer: A. In the dependent lung bases

    Fluid accumulates first in the dependent portions of the lungs, so early crackles are heard at the bases. As failure worsens, crackles extend upward.

24. A heart failure patient has crackles, orthopnea, cool clammy skin and a narrow pulse pressure. Which hemodynamic profile fits?

    1. A. Cold and wet
    2. B. Warm and wet
    3. C. Cold and dry
    4. D. Warm and dry
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    Answer: A. Cold and wet

    'Wet' means congestion (crackles, orthopnea, JVD, edema), and 'cold' means poor perfusion (cool skin, narrow pulse pressure, confusion). Cold and wet is the highest-risk profile and may be heading toward cardiogenic shock. Warm and wet has congestion with good perfusion, cold and dry has poor perfusion without congestion, and warm and dry is compensated.

25. Where is the point of maximal impulse (PMI) normally palpated in an adult?

    1. A. Left fifth intercostal space, midclavicular line
    2. B. Right second intercostal space, sternal border
    3. C. Left second intercostal space, sternal border
    4. D. Left eighth intercostal space, axillary line
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    Answer: A. Left fifth intercostal space, midclavicular line

    The PMI, produced by the apex of the left ventricle, is normally at the left fifth intercostal space at the midclavicular line. Displacement laterally suggests cardiac enlargement.

26. Which group of associated symptoms is most suggestive of acute coronary syndrome in a patient with chest discomfort?

    1. A. Fever, productive cough, and chills
    2. B. Pleuritic pain with a recent cold
    3. C. Dyspnea, nausea, and diaphoresis
    4. D. Pain worse with deep breaths only
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    Answer: C. Dyspnea, nausea, and diaphoresis

    Shortness of breath, nausea, and sweating are common accompaniments of myocardial ischemia. Fever and productive cough suggest infection, and purely pleuritic pain suggests a pleural cause.

27. A healthy 82-year-old has a BP of 168/72. What best explains the wide pulse pressure?

    1. A. Severe dehydration
    2. B. Stiff, less elastic large arteries
    3. C. Early cardiogenic shock
    4. D. Gradually rising intracranial pressure
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    Answer: B. Stiff, less elastic large arteries

    With age, the aorta and large arteries stiffen, so systolic pressure rises and diastolic pressure falls, widening the pulse pressure (isolated systolic hypertension). Dehydration and early cardiogenic shock narrow the pulse pressure. Rising intracranial pressure can widen it, but in an otherwise well patient arterial stiffness is far more likely.

28. A patient in complete heart block has occasional large pulsations in the neck veins. What causes these cannon waves?

    1. A. The atria contract against closed AV valves
    2. B. The ventricles contract twice for each P wave
    3. C. Blood leaks back through the aortic valve
    4. D. The carotid arteries pulse into the veins
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    Answer: A. The atria contract against closed AV valves

    In AV dissociation, atrial contraction sometimes happens while the ventricles are contracting and the tricuspid valve is closed, sending a large wave up the jugular veins. The ventricles do not contract twice per P wave, aortic leak produces bounding arterial pulses, and carotid pulses do not pass into the veins.

29. A young athlete has a systolic murmur that gets louder when he stands up from squatting. Which condition does this suggest?

    1. A. Innocent flow murmur of youth
    2. B. Aortic stenosis from aging
    3. C. Mitral stenosis from old rheumatic fever
    4. D. Hypertrophic obstructive cardiomyopathy
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    Answer: D. Hypertrophic obstructive cardiomyopathy

    Standing lowers preload, so the thickened septum and mitral valve narrow the outflow tract and the murmur of hypertrophic obstructive cardiomyopathy gets louder; squatting does the opposite. An innocent flow murmur usually softens on standing, age-related aortic stenosis is unlikely in a young athlete and also softens with less preload, and mitral stenosis causes a diastolic murmur.

30. During a secondary assessment you feel a small, firm, rectangular object under the skin below a patient's left clavicle. What should you do?

    1. A. Press on it to see if the patient's pulse changes
    2. B. Avoid the monitor because it may interfere
    3. C. Ask about the device and look for its ID card
    4. D. Assume it is a port and draw blood from it
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    Answer: C. Ask about the device and look for its ID card

    A firm device below the clavicle is usually a pacemaker or ICD (sometimes a port). Patients carry an ID card with the device type and manufacturer, which helps you interpret the ECG, place pads away from it and inform the hospital. Pressing on it does nothing useful, cardiac monitors are safe with these devices, and you cannot assume it is a port or access one without the right equipment and training.