Assessment of Cardiovascular Function
The nurse admits an adult female client with a medical diagnosis of "rule out MI." The client is very frightened and expresses surprise that a woman would have heart problems. What response by the nurse will be most appropriate? "A woman's heart is smaller and has smaller arteries that become occluded more easily." "A woman's resting heart rate is lower than a man's." "It takes longer for an electrical impulse to travel from the sinoatrial node to the atrioventricular node in a woman." "The stroke volume from a woman's heart is lower than from a man's heart."
"A woman's heart is smaller and has smaller arteries that become occluded more easily."
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? Potassium B-type natriuretic peptide (BNP) C-reactive protein (CRP) Platelet count
B-type natriuretic peptide (BNP) he client's symptoms suggest heart failure. BNP is a neurohormone that's released from the ventricles when the ventricles experience increased pressure and stretch, such as in heart failure. A BNP level greater than 51 pg/ml is commonly associated with mild heart failure. As the BNP level increases, the severity of heart failure increases. Potassium levels aren't affected by heart failure. CRP is an indicator of inflammation. It's used to help predict the risk of coronary artery disease. There is no indication that the client has an increased CRP. There is no indication that the client is experiencing bleeding abnormalities, such as those seen with an abnormal platelet count.
A nurse is caring for a client with a central venous pressure (CVP) of 4 mm Hg. Which nursing intervention is appropriate? Call the health care provider and obtain an order for a fluid bolus. Re-zero the equipment and take another reading. Call the physician and obtain an order for a diuretic. Continue to monitor the client as ordered.
Continue to monitor the client as ordered.
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 Cardiac output Activity level Dyspnea
Digoxin level
Which area of the heart that is located at the third intercostal space to the left of the sternum? aortic area pulmonic area Erb point epigastric area
Erb point
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?\ Na+ 140 mEq/L Ca++ 9 mg/dL K+ 3.1 mEq/L Mg++ 2 mEq/L
K+ 3.1 mEq/L
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: The atrioventricular valves must open. The pulmonic valve must be closed. Right ventricular pressure must be higher than pulmonary arterial pressure. Right ventricular pressure must decrease with systole.
Right ventricular pressure must be higher than pulmonary arterial pressure.
The cardiologist has scheduled a client for drug-induced stress testing. What instructions should the nurse provide to prepare the client for this test? You will receive medication via IV administration. You will need to wear comfortable shoes to the test. You will begin exercising at a slow speed. You may experience an onset of dizziness during the test.
You will receive medication via IV administration. Drugs such as adenosine (Adenocard), dipyridamole (Persantine), or dobutamine (Dobutrex) may be administered singularly or in combination by the IV route. Drugs may be used to stress the heart for clients with sedentary lifestyles or those with a physical disability, such as severe arthritis, that interferes with exercise testing. Drug-induced stress testing does not require the client to exercise. Instead, drugs are used to stress the heart. Clients performing exercise electrocardiography should report chest pain, dizziness, leg cramps, or weakness if they experience them during the test.
The nurse is teaching a client about the functionality of heart muscle. What factor may decrease a client's myocardial contractility? acidosis alkalosis sympathetic activity administration of digoxin
acidosis Contractility is depressed by hypoxemia, acidosis, and certain medications, such as beta-adrenergic blocking medications. Contractility is enhanced by sympathetic neuronal activity and specific medications like digoxin.
What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse? contractility depolarization repolarization diastole
contractility
The nurse is preparing a client for transesophageal echocardiography (TEE). This procedure is used for which indication? determination of atrial thrombi determination of electrical activity of the heart evaluation of the response of the cardiovascular system to increased oxygen demands evaluation of myocardial perfusion at rest and after exercise
determination of atrial thrombi
Age-related changes associated with the cardiac system include decreased size of the left atrium. endocardial fibrosis. increase in the number of SA node cells. myocardial thinning.
endocardial fibrosis.
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 myocardium pericardium epicardium
endocardium
Which symptom is an early warning sign of acute coronary syndrome (ACS) and heart failure (HF)? hypotension fatigue change in level of consciousness weight gain
fatigue Fatigue is an early warning symptom of ACS, heart failure, and valvular disease. Other signs and symptoms of cardiovascular disease are hypotension, change in level of consciousness, and weight gain.
The nurse auscultates the apex beat at which anatomical location? midsternum 5 cm to the left of the lower end of the sternum 2.5 cm to the left of the xiphoid process fifth intercostal space, midclavicular line
fifth intercostal space, midclavicular line
The nurse auscultates the PMI (point of maximal impulse) at which anatomic location? 3 cm to the right of the sternum 5 cm to the left of the lower end of the sternum 2.5 cm to the left of the xiphoid process left midclavicular line, fifth intercostal space
left midclavicular line, fifth intercostal space
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 left atrium right ventricle right atrium
left ventricle
During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure? wheezes with wet lung sounds stridor high-pitched sounds laborious breathing
wheezes with wet lung sounds If the left side of the heart fails to pump efficiently, blood backs up into the pulmonary veins and lung tissue. For abnormal and normal breath sounds, the nurse auscultates the lungs. With left-sided congestive heart failure, auscultation reveals a crackling sound, wheezes, and gurgles. Wet lung sounds are accompanied by dyspnea and an effort to sit up to breathe. With left-sided congestive heart failure, auscultation does not reveal a high pitched sound.
The client states, "My doctor says that because I am now taking this water pill, I need to eat more foods that contain potassium. Can you give me some ideas about what foods would be good for this?" What is the appropriate response by the nurse? Apricots, dried peas and beans, dates Asparagus, blueberries, green beans Cranberries, apples, popcorn Bok choy, cooked leeks, alfalfa sprouts
Apricots, dried peas and beans, dates
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 Atrioventricular tendons Semilunar tendineae Papillary tendons
Chordae tendineae
The nurse is caring for an elderly client with left-sided heart failure. When auscultating lung sounds, which adventitious sound is expected? Whistling Rhonchi Crackles Coarseness
Crackles When the heart is pumping inefficiently, blood backs up into the pulmonary veins and lung tissue. Auscultation reveals a crackling sound. Possible wheezes and gurgles are also possibilities.
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? "That's a great idea. You don't want to have a heart attack." "Current research determines that the replacement of estrogen will protect a woman after she goes into menopause." "Current evidence indicates that estrogen is ineffective as a cardioprotectant; estrogen is actually potentially harmful and is no longer a recommended therapy." "You need to research it and determine what you want to do."
"Current evidence indicates that estrogen is ineffective as a cardioprotectant; estrogen is actually potentially harmful and is no longer a recommended therapy."
The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include? "You can take a tub bath or a shower when you get home." "Contact your primary care provider if you develop a temperature above 102°F." "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." "If any discharge occurs at the puncture site, call 911 immediately."
"Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." The nurse should instruct the client to follow these guidelines: For the next 24 hours, do not bend at the waist, strain, or lift heavy objects if the artery of the groin was used; contact the primary provider if swelling, new bruising or pain from the procedure puncture site, or a temperature of 101°F or more occur. If bleeding occurs, lie down (groin approach) and apply firm pressure to the puncture site for 10 minutes. Notify the primary provider as soon as possible and follow instructions. If there is a large amount of bleeding, call 911. The client should not drive to the hospital.
The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include? "You can take a tub bath or a shower when you get home." "Contact your primary care provider if you develop a temperature above 102°F." "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." "If any discharge occurs at the puncture site, call 911 immediately."
"Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." The nurse should instruct the client to follow these guidelines: For the next 24 hours, do not bend at the waist, strain, or lift heavy objects if the artery of the groin was used; contact the primary provider if swelling, new bruising or pain from the procedure puncture site, or a temperature of 101°F or more occur. If bleeding occurs, lie down (groin approach) and apply firm pressure to the puncture site for 10 minutes. Notify the primary provider as soon as possible and follow instructions. If there is a large amount of bleeding, call 911. The client should not drive to the hospital.
Your client is being prepared for echocardiography when they ask you why they need to have this test. What would be your best response? "This test will find any congenital heart defects." "This test can tell us a lot about your heart." "Echocardiography is a way of determining the functioning of the left ventricle of your heart." "Echocardiography will tell your doctor if you have cancer of the heart."
"Echocardiography is a way of determining the functioning of the left ventricle of your heart."
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?" "Have you had any episodes when you are to nauseous?" "Have you had any episodes of mottling in your hands?" "Have you had any episodes of pain radiating into your lower extremities?"
"Have you had any episodes of dizziness or fainting?"
What does decreased pulse pressure reflect? tachycardia reduced distensibility of the arteries reduced stroke volume elevated stroke volume
reduced stroke volume Decreased pulse pressure reflects reduced stroke volume and ejection velocity or obstruction to blood flow during systole. Increased pulse pressure would indicate reduced distensibility of the arteries, along with bradycardia.
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 heart attack sets you up for limited activity, so constipation is often a problem for clients after a heart attack." "Please talk this over with your healthcare provider for further information." "The prescribed stool softener will decrease stress with a bowel movement and protect your heart from further injury."
"If you strain to have a bowel movement, you can cause a drop in your heart rate that can be dangerous."
The following clients are in need of exercise electrocardiography. Which client would the nurse indicate as most appropriate for a drug-induced stress test? A 48-year-old policemen with history of knee replacement 4 years ago A 68-year-old housewife with history of osteoporosis A 72-year-old retired janitor obtaining a cardiac baseline A 55-year-old recovering from a fall and broken femur
A 55-year-old recovering from a fall and broken femur An exercise electrocardiography or stress test monitors the electrical activity of the heart while the client walks on a treadmill. If a client has a sedentary lifestyle or physical disability, cardiac medications may be administered to stress the heart similar to activity. Even though the client is middle aged at 55 years old, the client is recovering from a broken femur thus would be unable to have vigorous exercise. None of the other clients have a history which precludes them from exercise electrocardiography.
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 An unchanged systolic pressure An increase of 10 mm Hg blood pressure reading An increase of 5 mm Hg in diastolic pressure
A heart rate of more than 20 bpm above the resting rate
A client is experiencing an irregular heartbeat. The client asks the nurse how a heartbeat occurs. The nurse explains the conduction system of the heart beginning with the sinoatrial node (SA node). Place the conduction sequence of the heart in order beginning with the SA node. Use all options.
Atrial cell stimulation AV node Bundle of His Bundle branches Purkinje fibers
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? Chemoreceptors Sympathetic nerve fibers Baroreceptors Vagus nerve
Baroreceptors Baroreceptor sense pressure in nerve endings in the walls of the atria and major blood vessels. The baroreceptors respond accordingly to raise or lower the pressure. Chemoreceptors are sensitive to pH, CO2, and O2 in the blood. Sympathetic nerve fibers increase the heart rate. The vagus nerve slows the heart rate.
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 Atrioventricular tendons Semilunar tendineae Papillary tendons
Chordae tendineae Attached to the mitral and tricuspid valves are cordlike structures known as chordae tendineae, which in turn attach to papillary muscles, two major muscular projections from the ventricles. Options B, C, and D are distractors for the question.
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. Apply baby powder to the client's chest prior to placing the electrodes. Clean the client's chest with alcohol prior to application of the electrodes. Once the electrodes are applied, change them every 72 hours.
Clip the client's chest hair prior to applying the electrodes. The nurse should complete the following actions when applying cardiac electrodes: (1) Clip (do not shave) hair from around the electrode site, if needed; (2) if the client is diaphoretic (sweaty), apply a small amount of benzoin to the skin, avoiding the area under the center of the electrode; (3) debride the skin surface of dead cells with soap and water and dry well (or as recommended by the manufacturer); (4) change the electrodes every 24 to 48 hours (or as recommended by the manufacturer); (5) examine the skin for irritation and apply the electrodes to different locations.
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? Document findings and check the client again in 1 hour. Slow the I.V. fluid to prevent any more swelling at the puncture site. Contact the health care provider and report the findings. Encourage the client to perform isometric leg exercise to improve circulation in the legs.
Contact the health care provider and report the findings. The client is probably developing a hematoma at the puncture site. The decreased pulses, swelling, and cool temperature in the leg are all classic signs that blood flow to that extremity is compromised. The nurse should notify the health care provider immediately to preserve the blood flow in the client's leg. Documenting findings and checking the client again in 1 hour, slowing the I.V. fluid, and encouraging the client to perform isometric leg exercises aren't appropriate actions for the nurse to take at this time.
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 radial pulse for 20 to 25 seconds. Calculate the palpated volume. Count the heart rate at the apex. Calculate the pauses between pulsations.
Count the heart rate at the apex.
The nurse is performing an assessment of a clients peripheral pulses and indicates that the pulse quality is +1 on a scale of 0-4. What does this documented finding indicate? Diminished, but cannot be obliterated with pressure. Full, easy to palpate, and cannot be obliterated with pressure. Difficult to palpate and is obliterated with pressure. Strong and bounding and may be abnormal.
Difficult to palpate and is obliterated with pressure.
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 Cardiac output Activity level Dyspnea
Digoxin level The action of Digoxin slows and strengthens the heart rate. Assessment of the pulse rate is essential prior to administration in all clients. Due to decreased perfusion common in geriatric clients, toxicity may occur more often. The nurse must monitor Digoxin levels in the body. Monitoring symptoms reflecting cardiac output, activity level, and dyspnea are also important assessment considerations for all clients.
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. Ask the client to sit on the edge of the bed and hold breath while the nurse listens. Insist that the family members leave the room if they must speak to each other while the nurse is auscultating heart sounds. Ask the client to take deep breaths through the mouth while the nurse auscultates heart sounds.
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 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. Ask the client to sit on the edge of the bed and hold breath while the nurse listens. Insist that the family members leave the room if they must speak to each other while the nurse is auscultating heart sounds. Ask the client to take deep breaths through the mouth while the nurse auscultates heart sounds.
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 instructor is teaching a group of nursing students about adventitious heart sounds. The instructor explains that auscultation of the heart requires familiarization with normal and abnormal heart sounds. What would the instructor tell these students a ventricular gallop indicates in an adult? Heart failure Hypertensive heart disease Normal functioning Pericarditis
Heart failure
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 Enhanced sensitivity to digitalis Increased risk of heart block Inclination to ventricular fibrillation
Impaired myocardial contractility Normal serum calcium is 8.9 to 10.3 mg/dL. A reading of 7.9 is below normal. Hypocalcemia is associated with slow nodal functioning and impaired myocardial contractility, which can increase the risk of heart failure.
After a physical examination, the provider diagnosed a patient with a grade 4 heart murmur. When auscultating a murmur, what does the nurse expect to hear? Easily heard with no palpable thrill. Quiet but readily heard. Loud and may be associated with a thrill sound similar to (a purring cat). Very loud; can be heard with the stethoscope half-way off the chest.
Loud and may be associated with a thrill sound similar to (a purring cat). Heart murmurs are characterized by location, timing, and intensity. A grading system is used to describe the intensity or loudness of a murmur. A grade 1 is very faint and difficult to describe, whereas a grade 6 is extremely loud. Refer to Box 12-3 in the text for a description of grades 1 to 6.
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: Easily heard with no palpable thrill. Quiet but readily heard. Loud and may be associated with a thrill sound similar to (a purring cat). Very loud; can be heard with the stethoscope half-way off the chest.
Loud and may be associated with a thrill sound similar to (a purring cat). Heart murmurs are characterized by location, timing, and intensity. A grading system is used to describe the intensity or loudness of a murmur. A grade 1 is very faint and difficult to describe, whereas a grade 6 is extremely loud. Refer to Box 12-3 in the text for a description of grades 1 to 6.
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 Furosemide Lorazepam Phenytoin
Methylprednisolone Prior to cardiac catheterization, the patient is assessed for previous reactions to contrast agents or allergies to iodine-containing substances, as some contrast agents contain iodine. If allergic reactions are of concern, antihistamines or methylprednisolone (Solu-Medrol) may be administered to the patient before angiography is performed. Furosemide, Lorazepam, and Phenytoin do not counteract allergic reactions.
The nurse is administering a beta blocker to a patient in order to decrease automaticity. Which medication will the nurse administer? Diltiazem Metoprolol Amiodarone Propafenone
Metoprolol Patients may receive beta-blockers prior to the scan to control heart rate and rhythm.
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 Auscultatory gap Pulse deficit Korotkoff sound
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 Pressure, rate, and rhythm Rate, rhythm, and volume Quality, volume, and rate
Rate, quality, and rhythm
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: An excess level of thyroid hormone. Stimulation of the vagus nerve. An increased level of catecholamines. Sympathetic nervous system stimulation.
Stimulation of the vagus nerve. Parasympathetic impulses, which travel to the heart through the vagus nerve, can slow the cardiac rate. The other choices cause an increase in heart rate.
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? S1 S2 S3 S4
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? Dizziness and leg cramping BP changes; 148/80 mm Hg to 166/90 mm Hg ST-segment changes on the ECG Heart rate changes; 78 bpm to 112 bpm
ST-segment changes on the ECG
A client reports recent onset of chest pain that occurs sporadically with exertion. The client also has fatigue and mild ankle swelling, which is most pronounced at the end of the day. The nurse suspects a cardiovascular disorder. What other client report increases the likelihood of a cardiovascular disorder? Shortness of breath Insomnia Irritability Lower substernal abdominal pain
Shortness of breath
What is considered the pacemaker of the heart? The AV node The bundle of HIS The Purkinje fibers The SA node
The SA node
The nurse is discussing the cardiac system with a client admitted with heart failure. The client asks "What determines the heart rate?" What is the nurse's best response? The autonomic nervous system controls the heart rate. Preload controls the heart rate. Stroke volume controls the heart rate. Force of contractility controls the heart rate.
The autonomic nervous system controls the heart rate.
A nurse is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which action would pose a threat to the client? The client lies still. The client asks questions. The client hears thumping sounds. The client wears a watch.
The client wears a watch. During an MRI, the client should wear no metal objects, such as jewelry, because the strong magnetic field can pull on them, causing injury to the client and (if they fly off) to others. The client must lie still during the MRI, but can talk to those performing the test by way of the microphone inside the scanner tunnel. The client should hear thumping sounds, which are caused by the sound waves thumping on the magnetic field.
The patient has a heart rate of 72 bpm with a regular rhythm. Where does the nurse determine the impulse arises from? The AV node The Purkinje fibers The sinoatrial node The ventricles
The sinoatrial node The sinoatrial node, the primary pacemaker of the heart, in a normal resting adult heart has an inherent firing rate of 60 to 100 impulses per minute; however, the rate changes in response to the metabolic demands of the body (Weber & Kelley, 2010).
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 The inner lining of the heart and valves The heart's muscle fibers The exterior layer of the heart
The thin fibrous sac encasing the heart The heart is encased in a thin, fibrous sac called the pericardium, which is composed of two layers. Inflammation of this sac is known as pericarditis.
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? hemorrhage catheter-related bloodstream infections air embolism pneumothorax
catheter-related bloodstream infections Catheter-related bloodstream infections (CRBSIs) are the most common preventable complication associated with hemodynamic monitoring systems. Comprehensive guidelines for the prevention of these infections have been published by Centers for Disease Control and Prevention (CDC). Complications from use of hemodynamic monitoring systems are uncommon and can include pneumothorax, infection, and air embolism. A pneumothorax may occur during the insertion of catheters using a central venous approach (CVP and pulmonary artery catheters). Air emboli can be introduced into the vascular system if the stopcocks attached to the pressure transducers are mishandled during blood drawing, administration of medications, or other procedures that require opening the system to air.
What is a harsh grating sound caused by abrasion of the pericardial surfaces during the cardiac cycle? murmur opening snap ejection click friction rub
friction rub During pericarditis, a harsh, grating sound that can be heard in both systole and diastole is called a friction rub. A murmur is created by the turbulent flow of blood. A cause of the turbulence may be a critically narrowed valve. An opening snap is caused by high pressure in the left atrium with abrupt displacement of a rigid mitral valve. An ejection click is caused by very high pressure within the ventricle, displacing a rigid and calcified aortic valve.
The nurse cares for a client in the emergency department who has a B-type natriuretic peptide (BNP) level of 115 pg/mL. The nurse recognizes that this finding is most indicative of which condition? heart failure ventricular hypertrophy pulmonary edema myocardial infarction
heart failure
The nurse is performing an assessment for an older adult client and auscultates an S3 heart sound. What condition does the nurse determine may correlate with this finding? congenital heart disease heart failure aortic stenosis coronary artery disease
heart failure
The nurse cares for a client in the ICU who is being monitored with a central venous pressure (CVP) catheter. The nurse records the client's CVP as 8 mm Hg and recognizes that this finding indicates the client is experiencing which condition? hypervolemia excessive blood loss overdiuresis left-sided heart failure
hypervolemia
The nurse cares for a client prescribed warfarin orally. The nurse reviews the client's prothrombin time (PT) level to evaluate the effectiveness of the medication. Which laboratory values should the nurse also evaluate? international normalized ratio (INR) partial thromboplastic time (PTT) complete blood count (CBC) Sodium
international normalized ratio (INR)
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 left ventricle right atrium right ventricle
left atrium
What does decreased pulse pressure reflect? tachycardia reduced distensibility of the arteries reduced stroke volume elevated stroke volume
reduced stroke volume
Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for pumping blood to the lungs to be oxygenated? right ventricle left ventricle right atrium left atrium
right ventricle
Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for pumping blood to the lungs to be oxygenated? right ventricle left ventricle right atrium left atrium
right ventricle
The nurse correctly identifies which data as an example of blood pressure and heart rate measurements in a client with postural hypotension? supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm supine: BP 130/70 mm Hg, HR 80 bpm; sitting: BP 128/70 mm Hg, HR 80 bpm; standing: BP 130/68 mm Hg, HR 82 bpm supine: BP 140/78 mm Hg, HR 72 bpm; sitting: BP 145/78 mm Hg, HR 74 bpm; standing: BP 144/78 mm Hg, HR 74 bpm supine: BP 114/82 mm Hg, HR 90 bpm; sitting: BP 110/76 mm Hg, HR 95 bpm; standing: BP 108/74 mm Hg, HR 98 bpm
supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm Postural (orthostatic) hypotension is a sustained decrease of at least 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP within 3 minutes of moving from a lying or sitting position to a standing position. The following is an example of BP and HR measurements in a client with postural hypotension: supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm. Normal postural responses that occur when a person moves from a lying to a standing position include (1) a HR increase of 5 to 20 bpm above the resting rate; (2) an unchanged systolic pressure, or a slight decrease of up to 10 mm Hg; and (3) a slight increase of 5 mm Hg in diastolic pressure.