115 PrepU Ch. 21 Assessment of Cardiovascular Function

Age-related changes associated with the cardiac system include which conditions? Select all that apply.

increased size of the left atrium endocardial fibrosis

Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for receiving oxygenated blood from the lungs?

left atrium

Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for pumping blood to all the cells and tissues of the body?

left ventricle

The nurse prepares to apply ECG electrodes to a male client who requires continuous cardiac monitoring. Which action should the nurse complete to optimize skin adherence and conduction of the heart's electrical current?

Clip the client's chest hair prior to applying the electrodes.

A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). The client's blood pressure is 104/68 mm Hg. The client's pulse rate is 76 beats/minute. The nurse detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take?

Contact the health care provider and report the findings.

A critically ill client is admitted to the ICU. The health care provider decides to use intra-arterial pressure monitoring. After this intervention is performed, what assessment should the nurse prioritize?

Perfusion distal to the insertion site

The nurse is educating a patient at risk for atherosclerosis. What nonmodifiable risk factor does the nurse identify for the patient?

Positive family history

The nurse is assessing a patient's blood pressure. What does the nurse document as the difference between the systolic and the diastolic pressure?

Pulse pressure

The clinic nurse is assessing a client's pulse before outpatient diagnostic testing. What should the nurse document when assessing the client's pulse?

Rate, quality, and rhythm

The nurse is assessing a client taking an anticoagulant. What nursing intervention is most appropriate for a client at risk for injury related to side effects of medication enoxaparin?

Report any incident of bloody urine, stools, or both.

It is important for a nurse to understand cardiac hemodynamics. For blood to flow from the right ventricle to the pulmonary artery, the following must occur:

Right ventricular pressure must be higher than pulmonary arterial pressure.

The nurse is assessing heart sounds in a patient with heart failure. An abnormal heart sound is detected early in diastole. How would the nurse document this?

S3

The nurse observes a client during an exercise stress test (bicycle). Which finding indicates a positive test and the need for further diagnostic testing?

ST-segment changes on the ECG

The nurse notes that a client has an elevated homocysteine level. For which reason will the nurse suggest that the blood test be repeated?

The client ate breakfast before the test.

The client is admitted for a scheduled cardiac catheterization. On the morning of the procedure, while assessing the client's morning laboratory values, the nurse notes a blood urea nitrogen (BUN) of 34 mg/dL and a creatinine of 4.2 mg/dL. What priority reason will the nurse notify the healthcare provider?

The client is at risk for renal failure due to the contrast agent that will be given during the procedure.

The patient has a heart rate of 72 bpm with a regular rhythm. Where does the nurse determine the impulse arises from?

The sinoatrial node

The nurse is caring for a patient with a diagnosis of pericarditis. Where does the nurse understand the inflammation is located?

The thin fibrous sac encasing the heart

A patient recently diagnosed with pericarditis asks the nurse to explain what area of the heart is involved. How does the nurse best describe the pericardium to the client?

Thin fibrous sac that encases the heart.

During an initial assessment, the nurse measures the client's apical pulse and compares it to the peripheral pulse. The difference between the two is known as pulse:

deficit

For both outpatients and inpatients scheduled for diagnostic procedures of the cardiovascular system, the nurse performs a thorough initial assessment to establish accurate baseline data. Which data is necessary to collect if the client is experiencing chest pain?

description of the pain

Within the heart, several structures and several layers all play a part in protecting the heart muscle and maintaining cardiac function. The inner layer of the heart is composed of a thin, smooth layer of cells, the folds of which form heart valves. What is the name of this layer of cardiac tissue?

endocardium

Which area of the heart is located at the third intercostal (IC) space to the left of the sternum?

erb point

The nurse is monitoring a client experiencing a decrease in cardiac output. What medical conditions will lead to a decrease in preload?

hemorrhage, sepsis, and anaphylaxis

A 52-year-old female patient is going through menopause and asks the nurse about estrogen replacement for its cardioprotective benefits. What is the best response by the nurse?

"Current evidence indicates that estrogen replacement is not effective at preventing cardiovascular disease and carries some risks."

The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include?

"Do not bend at the waist, strain, or lift heavy objects for the next 24 hours."

You are doing an admission assessment on a client who is having outpatient testing done for cardiac problems. What should you ask this client during your assessment?

"Have you had any episodes of dizziness or fainting?"

A nurse is preparing a client for an exercise stress test the following morning. Which client statement indicates a need for additional teaching?

"I won't eat or drink anything after midnight tonight."

The nurse is administering a stool softener to a client who experienced a myocardial infarction. The client says, "I had a heart attack; I don't have a problem with constipation." What explanation will the nurse use to answer the client's question?

"If you strain to have a bowel movement, you can cause a drop in your heart rate that can be dangerous."

The nurse is assessing vital signs on a client who is 3 months status post myocardial infarction (MI). While the healthcare provider is examining the client, the client's spouse approaches the nurse and states "We are too afraid he will have another heart attack, so we just don't have sex anymore." What is the nurse's best response?

"The physiologic demands are greatest during orgasm and are equivalent to walking 3 to 4 miles per hour on a treadmill."

The nurse is assessing a patient who reports feeling "light-headed." When obtaining orthostatic vital signs, what does the nurse determine is a significant finding?

A heart rate of more than 20 bpm above the resting rate

The nurse is caring for a client on a monitored telemetry unit. During morning assessment, the nurse notes abnormal ECG waves on the telemetry monitor. Which action would the nurse do first?

Assess the client.

A client has undergone cardiac catheterization and will be discharged today. What information should the nurse emphasize during discharge teaching?

Avoid heavy lifting for the next 24 hours.

A nurse is checking laboratory values on a client who has crackles in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which laboratory value does the nurse expect to be abnormal?

B-type natriuretic peptide (BNP)

The nurse is caring for a client with an elevated blood pressure and no previous history of hypertension. At 0900, the blood pressure was 158/90 mm Hg. At 0930, the blood pressure is 142/82 mm Hg. The nurse is most correct when relating the fall in blood pressure to which structure?

Baroreceptors

The nurse is caring for a client with a damaged tricuspid valve. The nurse knows that the tricuspid valve is held in place by which of the following?

Chordae tendineae

The nurse is performing an assessment of the patient's heart. Where would the nurse locate the apical pulse if the heart is in a normal position?

Left 5th intercostal space at the midclavicular line

The nurse cares for a client with clubbing of the fingers and toes. The nurse should complete which action given these findings?

Obtain an oxygen saturation level.

The clinic nurse caring for a client with a cardiovascular disorder is performing an assessment of the client's pulse. Which of the following steps is involved in determining the pulse deficit?

Count the heart rate at the apex.

The nurse is caring for a geriatric client. The client is ordered Lanoxin (digoxin) tablets 0.125mg daily for a cardiac dysrhythmia. Which of the following assessment considerations is essential when caring for this client?

Digoxin level

The client with a diagnosis of heart failure reports frequently awakening during the night with the need to urinate. What explanation will the nurse offer to explain the urination?

Edema is collected in dependent extremities during the day; at night when the client lays down, it is reabsorbed into the circulation and excreted by the kidneys.

You are monitoring the results of laboratory tests performed on a client admitted to the cardiac ICU with a diagnosis of myocardial infarction. Which test would you expect to show elevated levels?

Enzymes

The nurse prepares to auscultate heart sounds. What nursing intervention will be most effective to assist with this procedure?

Explain to the client that the nurse will be listening to different areas of the chest and may listen for a long time, but that does not mean that anything abnormal is heard.

The nurse receives a laboratory report indicating the client's magnesium level is 5.2 mEq/L. What symptoms is the client at risk to experience? Select all that apply.

Headache Hypotension Irregular heartbeat

The nurse is assessing an older adult client's electrocardiogram (ECG). What age related change to the conduction system may the nurse observe?

Heart block

The nurse is reviewing the results of the patient's echocardiogram and observes that the ejection fraction is 35%. The nurse anticipates that the patient will receive treatment for what condition?

Heart failure

A nurse is reviewing laboratory values for a client diagnosed with hyperlipidemia 6 months ago. Which results indicate that the client has been following a therapeutic regimen?

High density lipoproteins (HDL) increase from 25 mg/dl to 40 mg/dl.

The nurse reviews a client's lab results and notes a serum calcium level of 7.9 mg/dL. It is most appropriate for the nurse to monitor the client for what condition?

Impaired myocardial contractility

The nurse is reviewing the morning laboratory test results for a client with cardiac problems. Which finding is a priority to report to the healthcare provider?

K+ 3.1 mEq/L

After a physical examination, the provider diagnosed a patient with a grade 4 heart murmur. During assessment, the nurse expects to hear a murmur that is:

Loud and may be associated with a thrill sound similar to (a purring cat).

While the nurse is preparing a client for a cardiac catheterization, the client states that they have allergies to seafood. Which of the following medications may the nurse give prior to the procedure?

Methylprednisolone

The nurse is administering a beta blocker to a patient in order to decrease automaticity. Which medication will the nurse administer?

Metoprolol

The nurse uses which term for the normal pacemaker of the heart?

Sinoatrial (SA) node

A nurse is aware that the patient's heart rate is influenced by many factors. The nurse understands that the heart rate can be decreased by:

Stimulation of the vagus nerve.

The nurse is admitting an older adult client with heart failure. Which education will the nurse prepare for this client prior to discharge?"

Try to avoid emotional stress and take part in mild physical stress only.

The nurse cares for a client with an intra-arterial blood pressure monitoring device. The nurse recognizes the most preventable complication associated with hemodynamic monitoring includes which condition?

catheter-related bloodstream infections

What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse?

contractility

What does decreased pulse pressure reflect?

reduced stroke volume

During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure?

wheezes with wet lung sounds

Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes no active gag reflex. What nursing action is a priority?

withhold food and fluids.