Ch. 25: Assessment of Cardiovascular Function
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
Correct response: A 55-year-old recovering from a fall and broken femur Explanation: 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 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."
Correct response: "A woman's heart is smaller and has smaller arteries that become occluded more easily." Explanation: Because the coronary arteries of a woman are smaller, they become occluded from atherosclerosis more easily. The resting rate, stroke volume, and ejection fraction of a woman's heart are higher than those of a man. The electrical impulses from the sinoatrial node to the atrioventricular node are not different in the genders.
The nurse is assessing an older adult client's electrocardiogram (ECG). What age related change to the conduction system may the nurse observe? Tachycardia Thrills Murmur Heart block
Correct response: Heart block Explanation: Age-related changes to the conduction system may include bradycardia and heart block. Age-related changes to the heart valves include the presence of a murmur or thrill.
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
Correct response: wheezes with wet lung sounds Explanation: 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 nurse is assessing a patient's blood pressure. What does the nurse document as the difference between the systolic and the diastolic pressure? Pulse deficit Korotkoff sound Pulse pressure Auscultatory gap
Correct response: Pulse pressure Explanation: The difference between the systolic and the diastolic pressures is called the pulse pressure.
The nurse is caring for an elderly client with left-sided heart failure. When auscultating lung sounds, which adventitious sound is expected? Wheezes Rhonchi Crackles Coarseness
Correct response: Crackles Explanation: 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.
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? Pulmonary embolism Myocardial infarction Pericarditis Heart failure
Correct response: Heart failure Explanation: An ejection fraction of less than 40% indicates that the patient has decreased left ventricular function and likely requires treatment for heart failure.
The nurse cares for a client with diabetes who is scheduled for a cardiac catheterization. Prior to the procedure, it is most important for the nurse to ask which question? "Are you allergic to shellfish?" "Are you having chest pain?" "When was the last time you ate or drank?" "What was your morning blood sugar reading?"
Correct response: "Are you allergic to shellfish?" Explanation: Radiopaque contrast agents are used to visualize the coronary arteries. Some contrast agents contain iodine, and the client is assessed before the procedure for previous reactions to contrast agents or allergies to iodine-containing substances (e.g., seafood). If the client has a suspected or known allergy to the substance, antihistamines or methylprednisolone may be administered before the procedure. Although the other questions are important to ask the client, it is most important to ascertain if the client has an allergy to shellfish.
The nurse cares for a client with diabetes who is scheduled for a cardiac catheterization. Prior to the procedure, it is most important for the nurse to ask which question? "When was the last time you ate or drank?" "Are you allergic to shellfish?" "What was your morning blood sugar reading?" "Are you having chest pain?"
Correct response: "Are you allergic to shellfish?" Explanation: Radiopaque contrast agents are used to visualize the coronary arteries. Some contrast agents contain iodine, and the client is assessed before the procedure for previous reactions to contrast agents or allergies to iodine-containing substances (e.g., seafood). If the client has a suspected or known allergy to the substance, antihistamines or methylprednisolone may be administered before the procedure. Although the other questions are important to ask the client, it is most important to ascertain if the client has an allergy to shellfish.
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."
Correct response: "Current evidence indicates that estrogen is ineffective as a cardioprotectant; estrogen is actually potentially harmful and is no longer a recommended therapy." Explanation: In the past hormone therapy was routinely prescribed for postmenopausal women with the belief that it would deter the onset and progression of coronary artery disease (CAD). However, based on results from the multisite, prospective, longitudinal Women's Health Initiative study, the American Heart Association (AHA) no longer recommends the use of hormone therapy as a prevention strategy for women. In the most recently published AHA guidelines for primary prevention of CAD in women, the use of hormone therapy (estrogen) is noted to be ineffective and potentially harmful (Mosca, Benjamin, Berra, et al., 2011).
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."
Correct response: "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." Explanation: 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 can tell us a lot about your heart." "Echocardiography is a way of determining the functioning of the left ventricle of your heart." "This test will find any congenital heart defects." "Echocardiography will tell your doctor if you have cancer of the heart."
Correct response: "Echocardiography is a way of determining the functioning of the left ventricle of your heart." Explanation: Echocardiography uses ultrasound waves to determine the functioning of the left ventricle and to detect cardiac tumors, congenital defects, and changes in the tissue layers of the heart. All answers are correct. C is the best answer as it addresses the client's question without making them anxious or minimizing their question.
The client is being prepared for echocardiography when he asks the nurse why he needs to have this test. What would be the nurse's best response? "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." "This test will find any congenital heart defects." "Echocardiography will tell your doctor if you have cancer of the heart."
Correct response: "Echocardiography is a way of determining the functioning of the left ventricle of your heart." Explanation: Echocardiography uses ultrasound waves to determine the functioning of the left ventricle and to detect cardiac tumors, congenital defects, and changes in the tissue layers of the heart. All answers are correct. Option C is the best answer because it addresses the client's question without making him anxious or minimizing the question.
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?"
Correct response: "Have you had any episodes of dizziness or fainting?" Explanation: Ask if the client has episodes of dyspnea, dizziness, or fainting. Options B, C, and D are incorrect. Being nauseous, mottling of the hands, and pain radiating into the lower extremities are not indications of cardiac problems.
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.
Correct response: Stimulation of the vagus nerve. Explanation: 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.
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 smoke for 2 to 3 hours before the test." "I'll have to sign a consent form before the test." "I won't eat or drink anything after midnight tonight." "I'll likely be able to take my regular medications before the test."
Correct response: "I won't eat or drink anything after midnight tonight." Explanation: The client requires additional teaching if he states that he'll fast from midnight until the test. Clients need to abstain from eating and drinking for only 4 hours before the test. The client should refrain from smoking for several hours before the test. Although the physician may direct the client to avoid certain medications, it's more likely that the physician will direct the client to take all his normal medications. The client must sign a consent form before the test.
A student nurse is to perform a cardiac assessment for a client and asks the instructor why the aortic valve closure is best heard on the right side of the sternum. What is the best response by the nurse? "The aortic arch causes the closure of the aortic valve to be heard best on the right side of the sternum." "The aortic valve is located near the base of the heart on the right side." "The aortic valve is located on the right side of the heart." "The aortic valve is located near the apex of the heart, which is on the right side."
Correct response: "The aortic arch causes the closure of the aortic valve to be heard best on the right side of the sternum." Explanation: The location of the aortic arch causes the sound of the aortic valve closure to be best heard at the 2nd intercostal space on the right sternal border.
The nurse assesses a client with increasing shortness of breath and peripheral edema. The healthcare provider inserts a triple lumen catheter and orders a transduced central venous pressure (CVP). What CVP reading does the nurse suspect will correlate with the client's symptoms? 0 mmHg 2 mmHg 6 mmHg 8 mmHg
Correct response: 8 mmHg Explanation: The normal CVP reading is 2-6 mmHg. A reading of 0 mmHg indicates hypovolemia. A reading of 8 mmHg, which is high, correlates with hypervolemia and the client's symptoms of fluid overload with increasing shortness of breath and edema.
The nurse is assisting the client to manage the cardiovascular risk factors of hyperlipidemia and hypertension. The client asks the nurse what type of a diet would be best to follow. What is the best response by the nurse? A diet with restricted fruits and fluids A diet high in transfats and potassium A diet low in sodium, fat, cholesterol A diet with high sodium, fruits, vegetables
Correct response: A diet low in sodium, fat, cholesterol Explanation: Diets that are restricted in sodium, fat, and cholesterol are commonly prescribed to manage the cardiovascular risk factors of hypertension and hyperlipidemia. The lowered sodium, fat, and cholesterol diets aid with decreasing water retention and fatty substances. Cardiovascular risk factors do not involve potassium levels and limiting fruits and fluids. Cardiovascular risks factors are lowered by eating fruits and vegetables to lower cholestrol levels.
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? An unchanged systolic pressure An increase of 5 mm Hg in diastolic pressure An increase of 10 mm Hg blood pressure reading A heart rate of more than 20 bpm above the resting rate
Correct response: A heart rate of more than 20 bpm above the resting rate Explanation: Normal postural responses that occur when a person moves from a lying to a standing position include (1) a heart rate 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. 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 to a standing position (Freeman et al., 2011). It is usually accompanied by dizziness, lightheadedness, or syncope.
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? Asparagus, blueberries, green beans Cranberries, apples, popcorn Apricots, dried peas and beans, dates Bok choy, cooked leeks, alfalfa sprouts
Correct response: Apricots, dried peas and beans, dates Explanation: Apricots, dried peas and beans, dates, and kiwi contain high amounts of potassium. The other foods listed contain minimal amounts.
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? Call the physician with a report. Assess the client. Assess for mechanical dysfunction. Reposition the client.
Correct response: Assess the client. Explanation: When a nurse notes an abnormal rhythm on a telemetry monitor, the first action is to assess the client. After client assessment, the nurse is able to make an informed decision on the next nursing action.
A patient had a cardiac catheterization and is now in the recovery area. What nursing interventions should be included in the plan of care? (Select all that apply.) Checking the insertion site for hematoma formation Assisting the patient to the bathroom after the procedure Assessing the peripheral pulses in the affected extremity Assessing vital signs every 8 hours Evaluating temperature and color in the affected extremity
Correct response: Assessing the peripheral pulses in the affected extremity Checking the insertion site for hematoma formation Evaluating temperature and color in the affected extremity Explanation: The nurse should observe the catheter access site for bleeding or hematoma formation and assess peripheral pulses in the affected extremity (dorsalis pedis and posterior tibial pulses in the lower extremity, radial pulse in the upper extremity) every 15 minutes for 1 hour, every 30 minutes for 1 hour, and hourly for 4 hours or until discharge. Blood pressure and heart rate should also be assessed during these same time intervals, not every 8 hours. The nurse should evaluate temperature, color, and capillary refill of the affected extremity during these same time intervals. The patient should maintain bed rest for 2 to 6 hours after the procedure.
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. Take a tub bath, rather than a shower. New bruising at the puncture site is normal. Bend only at the waist.
Correct response: Avoid heavy lifting for the next 24 hours. Explanation: For the next 24 hours, the patient should not bend at the waist, strain, or lift heavy objects. The patient should avoid tub baths, but can shower as desired. The patient should call the healthcare provider if she has any bleeding, swelling, new bruising, or pain from her procedure puncture site, or a temperature of 101.5 degrees Fahrenheit (38.6 degrees C) or higher.
The nurse is providing discharge education for a client going home after cardiac catheterization. What information is a priority to include when providing discharge education? Returning to work immediately is okay. Avoid tub baths, but shower as desired. Do not ambulate until the healthcare provider indicates it is appropriate. Expect increased bruising to appear at the site over the next several days.
Correct response: Avoid tub baths, but shower as desired. Explanation: Guidelines for self-care after hospital discharge following a cardiac catheterization include showering as desired (no tub baths) and avoiding bending at the waist and lifting heavy objects. The healthcare provider will indicate when it is okay to return to work. The client should notify the healthcare provider right away if bleeding, new bruising, swelling, or pain are noted at the puncture site. The client will be able to ambulate after the puncture site has clotted.
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 Platelet count B-type natriuretic peptide (BNP) C-reactive protein (CRP)
Correct response: B-type natriuretic peptide (BNP) Explanation: The 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.
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
Correct response: Baroreceptors Explanation: 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
Correct response: Chordae tendineae Explanation: 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.
Correct response: Clip the client's chest hair prior to applying the electrodes. Explanation: 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.
Correct response: Contact the health care provider and report the findings. Explanation: 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.
Correct response: Count the heart rate at the apex. Explanation: The nurse determines the pulse deficit by counting the heart rate through auscultation at the apex while a second nurse simultaneously palpates and counts the radial pulse for a full minute. The difference, if any, is the pulse deficit. The pulse quality refers to its palpated volume. Pulse rhythm is the pattern of the pulsations and the pauses between them.
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? Full, easy to palpate, and cannot be obliterated with pressure. Strong and bounding and may be abnormal. Difficult to palpate and is obliterated with pressure. Diminished, but cannot be obliterated with pressure.
Correct response: Difficult to palpate and is obliterated with pressure. Explanation: The quality of pulses is reported using descriptors and a scale of 0 to 4. The lower the number, the weaker the pulse and the easier it is to obliterate it. A +1 pulse is weak and thready and easily obliterated with pressure.
A patient has been diagnosed with congestive heart failure (CHF). The health care provider has ordered a medication to enhance contractility. The nurse would expect which medication to be prescribed for the patient? Digoxin Clopidogrel Enoxaparin Heparin
Correct response: Digoxin Explanation: Contractility is enhanced by circulating catecholamines, sympathetic neuronal activity, and certain medications, such as Lanoxin. Increased contractility results in increased stroke volume. The other medications are classified as platelet-inhibiting medications.
The nurse is caring for a geriatric client. The client is ordered Lanoxin (digoxin) tablets 0.125mg daily for a cardiac dysrhythmias. Which of the following assessment considerations is essential when caring for this age-group? Digoxin level Cardiac output Activity level Dyspnea
Correct response: Digoxin level Explanation: 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.
A client is being scheduled for a stress test. The client is unable to exercise during the test. The nurse would include information about which medication used for pharmacologic stress testing? Dipyridamole Lanoxin Thallium 201 Cardiolite
Correct response: Dipyridamole Explanation: If the patient is unable to exercise, a pharmacologic stress test is performed by injecting a vasodilating agent, dipyridamole or adenosine, to mimic the physiologic effects of exercise. The stress test may be combined with an echocardiogram or radionuclide imaging techniques to examine myocardial function during exercise and rest. Digoxin would not be used for stress testing. Thallium 201 and Cardiolite are radioisotopes used in myocardial perfusion scanning.
The nurse caring for a client who is suspected of having cardiovascular disease has a stress test ordered. The client has a co-morbidity of multiple sclerosis, so the nurse knows the stress test will be drug-induced. What drug will be used to dilate the coronary arteries? Thallium Ativan Diazepam Dobutamine
Correct response: Dobutamine Explanation: Drugs such as adenosine (Adenocard), dipyridamole (Persantine), or dobutamine (Dobutrex) may be administered singularly or in combination by the IV route. The drugs dilate the coronary arteries, similar to the vasodilation that occurs when a person exercises to increase the heart muscle's blood supply. Options A, B, and C would not dilate the coronary arteries.
When caring for a client with dysfunction in the conduction system, at which period would the nurse note that cells are resistant to stimulation? During the refractory period During polarization During depolarization During repolarization
Correct response: During the refractory period Explanation: The refractory period is the time when cells are resistant to electrical stimulation. Repolarization is when the ions realign themselves to wait for an electrical signal. Depolarization occurs during muscle contraction when positive ions move inside the myocardial cell membrane and negative ions move outside. Before an impulse is generated, the cells are in a polarized state.
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? RBC Platelets Enzymes WBC
Correct response: Enzymes Explanation: When tissues and cells break down, are damaged, or die, great quantities of certain enzymes are released into the bloodstream. Enzymes can be elevated in response to cardiac or other organ damage. After an MI, RBCs and platelets should not be elevated. WBCs would only be elevated if there was a bacterial infection present.
Which area of the heart that is located at the third intercostal space to the left of the sternum? epigastric area Erb point pulmonic area aortic area
Correct response: Erb point Explanation: Erb point is located at the third intercostal space to the left of the sternum. The aortic area is located at the second intercostal space to the right of the sternum. The pulmonic area is at the second intercostal space to the left of the sternum. The epigastric area is located below the xiphoid process.
A nurse is completing a head to toe assessment on a client diagnosed with right-sided heart failure. To assess peripheral edema, which of the following areas should be examined? Feet and ankles Under the sacrum Lips and earlobes Shoulders and elbows
Correct response: Feet and ankles Explanation: When right-sided heart failure occurs, blood accumulates in the vessels and backs up in peripheral veins, and the extra fluid enters the tissues. Particular areas for examination are the dependent parts of the body, such as the feet and ankles. Other prominent areas prone to edema are the fingers, hands, and over the sacrum. Cyanosis can be detected by noting color changes in the lips and earlobes.
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? Hypertensive heart disease Heart failure Pericarditis Normal functioning
Correct response: Heart failure Explanation: A sound that follows S1 and S2 is called an S3 heart sound or a ventricular gallop. An S3, normal in children, often is an indication of heart failure in an adult. An extra sound before S1 is an S4 heart sound, or atrial gallop. An S4 sound often is associated with hypertensive heart disease. A friction rub may cause a rough, grating, or scratchy sound that is an indication of pericarditis or inflammation of the pericardium.
A client is admitted to the hospital with weakness. What nursing assessment indicates postural hypotension? Heart rate increased from 85 to 110 bpm. Heart rate decreased from 85 to 75 bpm at the same time that the systolic pressure increased from 120 to 135 mm Hg. Diastolic pressure went from 80 to 110 mm Hg. Systolic pressure did not change with the change in position.
Correct response: Heart rate increased from 85 to 110 bpm. Explanation: A sign of postural hypotension is the increase in the heart rate from 5 to 20 bpm with the change in position from lying, sitting and standing. Therefore, an increase of 25 bpm is indicative of hypotension. With postural hypotension, the systolic and diastolic blood pressure will decrease with standing and heart rate will increase.
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? Total cholesterol level increases from 250 mg/dl to 275 mg/dl. Low density lipoproteins (LDL) increase from 180 mg/dl to 190 mg/dl. High density lipoproteins (HDL) increase from 25 mg/dl to 40 mg/dl. Triglycerides increase from 225 mg/dl to 250 mg/dl.
Correct response: High density lipoproteins (HDL) increase from 25 mg/dl to 40 mg/dl. Explanation: The goal of treating hyperlipidemia is to decrease total cholesterol and LDL levels while increasing HDL levels. HDL levels should be greater than 35 mg/dl. This client's increased HDL levels indicate that a therapeutic regimen has been followed. Recommended total cholesterol levels are below 200 mg/dl. LDL levels should be less than 160 mg/dl, or, in clients with known coronary artery disease (CAD) or diabetes mellitus, less than 70 mg/dl. Triglyceride levels should be between 100 and 200 mg/d.
The nurse reviews a client's lab results and notes a serum calcium level of 7.9 mg/dL. It is mostappropriate 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
Correct response: Impaired myocardial contractility Explanation: 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.
The critical care nurse is caring for clients in an emergency department. When caring for a variety of clients, when is the presence of a third heart sound normal? In geriatric clients In clients with an indwelling pacemaker In pediatric clients In clients with heart valve replacement
Correct response: In pediatric clients Explanation: When caring for a variety of clients, it is important to consider that a third heart sound is normal in children. In adults, a third heart sound may signify heart failure. There is no correlation between third heart sounds with heart valve replacement and an indwelling pacemaker.
The nurse is caring for a client who is diagnosed with an infarction of the posterior wall of the right atrium. Which assessment finding would the nurse anticipate relating to the infarction location? Irregular heart rate Respiratory compromise Cyanosis Chronic chest pain
Correct response: Irregular heart rate Explanation: The posterior wall of the right atrium is the location of the sinoatrial node (SA node), which is the pacemaker of the heart. Damage to this location may result in an irregular heart rate due to a disturbance of electrical pulse initiation. Depending on muscle damage, the client may have respiratory compromise, chest pain, and/or cyanosis.
A nurse is performing a cardiac assessment on an elderly client. Which finding warrants further investigation? Fourth heart sound (S4) Increased PR interval Irregularly irregular heart rate Orthostatic hypotension
Correct response: Irregularly irregular heart rate Explanation: An irregularly irregular heart rate indicates atrial fibrillation and should be investigated further. It's normal for an elderly client to have a prolonged systole, which causes an S4 heart sound. It's also normal for an elderly client to have slowed conduction, causing an increased PR interval. As a person ages, it's normal for baroreceptors in the body to decrease their response to changes in body position, which can cause orthostatic hypotension.
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 mE/L
Correct response: K+ 3.1 mEq/L Explanation: All laboratory levels are within normal limits except for the K+, which is low. A low K+ level can cause ventricular tachycardia or fibrillation.
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 2nd intercostal space at the midclavicular line Right 2nd intercostal space at the midclavicular line Right 3rd intercostal space at the midclavicular line Left 5th intercostal space at the midclavicular line
Correct response: Left 5th intercostal space at the midclavicular line Explanation: As a result of this close proximity to the chest wall, the pulsation created during normal ventricular contraction, called the apical impulse (also called the point of maximal impulse [PMI]), is easily detected. In the normal heart, the PMI is located at the intersection of the midclavicular line of the left chest wall and the fifth intercostal space
After a physical examination, the provider diagnosed a patient with a grade 4 heart murmur. When ausculatating 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.
Correct response: Loud and may be associated with a thrill sound similar to (a purring cat). Explanation: 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.
Correct response: Loud and may be associated with a thrill sound similar to (a purring cat). Explanation: 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
Correct response: Methylprednisolone Explanation: 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 caring for a client in the cardiac intensive care unit (CICU) after a myocardial infarction (MI). Which drug will the nurse administer that will decrease contractility? Digoxin Dobutamine Dopamine Metoprolol
Correct response: Metoprolol Explanation: Contractility is depressed by beta-adrenergic blocking medications. The other choices all enhance contractility.
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
Correct response: Metoprolol Explanation: Patients may receive beta-blockers prior to the scan to control heart rate and rhythm.
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. Assess the client's capillary refill. Assess the client for pitting edema. Obtain a 12-lead ECG tracing.
Correct response: Obtain an oxygen saturation level. Explanation: Clubbing of the fingers and toes indicates chronic hemoglobin desaturation (decreased oxygen supply) and is associated with congenital heart disease. The nurse should assess the client's O2saturation level and intervene as directed. The other assessments are not indicated.
You are working on a telemetry unit. Your client was admitted with a cardiac event and is now on a cardiac monitor. You know a cardiac monitor reveals the heart's electrical but not its mechanical activity. How would you assess the mechanical activity of the client's heart? Auscultate the carotid artery. Take the blood pressure in both arms. Palpate a peripheral pulse. Percuss the perimeter of the heart.
Correct response: Palpate a peripheral pulse. Explanation: A cardiac monitor reveals the heart's electrical but not its mechanical activity. The healthcare provider must palpate a peripheral pulse or auscultate the apical heart rate to obtain this information. You cannot obtain information on the mechanical activity of the heart by taking the client's blood pressure, auscultating the carotid artery, or attempting to percuss the perimeter of the heart.
You are the clinic nurse doing assessments on your clients before they have outpatient diagnostic testing done. What would you document when assessing the client's pulse? Rate, quality, and rhythm Pressure, rate, and rhythm Rate, rhythm, and volume Quality, volume, and rate
Correct response: Rate, quality, and rhythm Explanation: Assess apical and radial pulses, noting rate, quality, and rhythm. Pulse quality and volume are not assessed in this instance.
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. Administer calcium supplements. Assess for hypokalemia. Assess for clubbing of the fingers.
Correct response: Report any incident of bloody urine, stools, or both. Explanation: The client who takes an anticoagulant, such as a low-molecular-weight heparin, is routinely screened for bloody urine, stools, or both. Clients taking enoxaparin will not need to take caclium supplements or have potassium imbalances related to the medication. The clubbing of fingers may occur with chronic pulmonary diseases.
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.
Correct response: Right ventricular pressure must be higher than pulmonary arterial pressure. Explanation: For the right ventricle to pump blood in need of oxygenation into the lungs via the pulmonary artery, right ventricular pressure must be higher than pulmonary arterial pressure.
One of the students asks what the consequences of uncorrected, left-sided heart failure would be. What would be the nursing instructor's best response? Blood congestion in neck veins Right-sided heart failure Distention of the jugular vein Effort to lie down to breathe
Correct response: Right-sided heart failure Explanation: If uncorrected, left-sided heart failure is followed by right-sided heart failure because the circulatory system is a continuous loop. 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. If the right side of the heart fails to pump efficiently, blood becomes congested in the neck veins, and the nurse may inspect the distention of external jugular vein.
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
Correct response: S3 Explanation: An S3 ("DUB") is heard early in diastole during the period of rapid ventricular filling as blood flows from the atrium into a noncompliant ventricle. It is heard immediately after S2. "Lub-dub-DUB" is used to imitate the abnormal sound of a beating heart when an S3 is present.
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
Correct response: ST-segment changes on the ECG Explanation: During the test, the following are monitored: two or more ECG leads for heart rate, rhythm, and ischemic changes; blood pressure; skin temperature; physical appearance; perceived exertion; and symptoms, including chest pain, dyspnea, dizziness, leg cramping, and fatigue. The test is terminated when the target heart rate is achieved or if the client experiences signs of myocardial ischemia. Further diagnostic testing, such as a cardiac catheterization, may be warranted if the client develops chest pain, extreme fatigue, a decrease in blood pressure or pulse rate, serious dysrhythmias or ST-segment changes on the ECG during the stress test. The other findings would not warrant stopping the test.
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? Force of contractility controls the heart rate. The autonomic nervous system controls the heart rate. Preload controls the heart rate. Stroke volume controls the heart rate.
Correct response: The autonomic nervous system controls the heart rate. Explanation: The autonomic nervous system primarily controls the heart rate. When the sympathetic branch is stimulated, heart rate increases. When the parasympathetic branch is stimulated, heart rate decreases. Stroke volume is the amount of blood pumped out of the ventricle with each contraction and depends on three factors: preload, afterload, and contractility.
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. These values show a risk for dysrhythmias. The client is overhydrated, which puts him at risk for heart failure during the procedure. The client is at risk for bleeding.
Correct response: The client is at risk for renal failure due to the contrast agent that will be given during the procedure. Explanation: The contrast medium must be excreted by the kidneys. If there is already a degree of renal impairment, indicated by the increased BUN and creatinine, the risk for contrast agent-induced nephropathy and renal failure is high. Renal impairment is not usually associated with dysrhythmias. The increased BUN and creatinine do not indicate overhydration, but decreased kidney function. The BUN and creatinine levels do not interfere with coagulability or bleeding.
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 wears a watch. The client hears thumping sounds. The client asks questions.
Correct response: The client wears a watch. Explanation: 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.
A patient tells the nurse, "I was straining to have a bowel movement and felt like I was going to faint. I took my pulse and it was so slow." What does the nurse understand occurred with this patient? The patient may have had a myocardial infarction. The patient had a vagal response. The patient was anxious about being constipated. The patient may have an abdominal aortic aneurysm.
Correct response: The patient had a vagal response. Explanation: When straining during defecation, the patient bears down (the Valsalva maneuver), which momentarily increases pressure on the baroreceptors. This triggers a vagal response, causing the heart rate to slow and resulting in syncope in some patients. Straining during urination can produce the same response. Myocardial infarction is damage to the heart and clients will experience pain or shortness of breath. Anxiety causes the heart rate to increase. The client with an abdominal aortic aneurysm will experience back or abdominal pain, not a decrease in heart rate.
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
Correct response: The sinoatrial node Explanation: 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).
A nurse is caring for a dying client following myocardial infarction. The client is experiencing apnea with a falling blood pressure of 60 per palpation. Which documentation of pulse quality does the nurse anticipate? A pulse deficit Bounding pulse Weak pulse Thready pulse
Correct response: Thready pulse Explanation: The nurse is most correct to anticipate a thready (barely palpable) pulse quality. A bounding pulse indicates a strong cardiac output. A weak pulse indicates a lower pulse quality. A pulse deficit occurs when the pulses between the apex of the heart differs from the radial pulse.
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.
Correct response: You will receive medication via IV administration. Explanation: 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.
Which term describes the ability of the heart to initiate an electrical impulse? conductivity automaticity contractility excitability
Correct response: automaticity Explanation: Automaticity is the ability of specialized electrical cells of the cardiac conduction system to initiate an electrical impulse. Contractility refers to the ability of the specialized electrical cells of the cardiac conduction system to contract in response to an electrical impulse. Conductivity refers to the ability of the specialized electrical cells of the cardiac conduction system to transmit an electrical impulse from one cell to another. Excitability refers to the ability of the specialized electrical cells of the cardiac conduction system to respond to an electrical impulse.
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
Correct response: catheter-related bloodstream infections Explanation: 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.
For a client who has undergone peripheral arteriography, how should the nurse assess the adequacy of peripheral circulation? hemodynamic monitoring checking for cardiac dysrhythmias observing the client for bleeding checking peripheral pulses
Correct response: checking peripheral pulses Explanation: Peripheral arteriography is used to diagnose occlusive arterial disease in smaller arteries. The nurse observes the client for bleeding and cardiac dysrhythmias and assesses the adequacy of peripheral circulation by frequently checking the peripheral pulses. Hemodynamic monitoring is used to assess the volume and pressure of blood in the heart and vascular system.
What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse? contractility depolarization repolarization diastole
Correct response: contractility Explanation: Contractility is the ability of the cardiac muscle to shorten in response to an electrical impulse. Depolarization is the electrical activation of a cell caused by the influx of sodium into the cell while potassium exits the cell. Repolarization is the return of the cell to the resting state, caused by reentry of potassium into the cell while sodium exits the cell. Diastole is the period of ventricular relaxation resulting in ventricular filling.
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. quality. volume. rhythm.
Correct response: deficit. Explanation: To determine the pulse deficit, one nurse counts the heart rate through auscultation at the apex while a second nurse simultaneously palpates and counts the radial pulse for a full minute. The difference, if any, is the pulse deficit. Pulse rhythm is the pattern of the pulsations and the pauses between them. Pulse volume is described as feeling full, weak, or thready, meaning barely palpable. The pulse quality refers to its palpated volume.
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. rhythm. volume. quality.
Correct response: deficit. Explanation: To determine the pulse deficit, one nurse counts the heart rate through auscultation at the apex while a second nurse simultaneously palpates and counts the radial pulse for a full minute. The difference, if any, is the pulse deficit. Pulse rhythm is the pattern of the pulsations and the pauses between them. Pulse volume is described as feeling full, weak, or thready, meaning barely palpable. The pulse quality refers to its palpated volume.
The nurse cares for a client in the ICU diagnosed with coronary artery disease (CAD). Which assessment data indicates the client is experiencing a decrease in cardiac output? BP 108/60 mm Hg, ascites, and crackles disorientation, 20 mL of urine over the last 2 hours reduced pulse pressure and heart murmur elevated jugular venous distention and postural changes in BP
Correct response: disorientation, 20 mL of urine over the last 2 hours Explanation: Assessment findings associated with reduced cardiac output include reduced pulse pressure, hypotension, tachycardia, reduced urine output, lethargy, or disorientation.
Age-related changes associated with the cardiac system include myocardial thinning. decreased size of the left atrium. endocardial fibrosis. increase in the number of SA node cells.
Correct response: endocardial fibrosis. Explanation: Age-related changes associated with the cardiac system include: endocardial fibrosis, increased size of the left atrium, a decreasing number of SA node cells, and myocardial thickening.
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
Correct response: endocardium Explanation: The inner layer, the endocardium, is composed of a thin, smooth layer of endothelial cells. Folds of endocardium form the heart valves. The middle layer, the myocardium, consists of muscle tissue and is the force behind the heart's pumping action. The pericardium is a saclike structure that surrounds and supports the heart. The outer layer, the epicardium, is composed of fibrous and loose connective tissue.
Which area of the heart is located at the third intercostal (IC) space to the left of the sternum? aortic area pulmonic area erb point epigastric area
Correct response: erb point Explanation: Erb point is located at the third IC space to the left of the sternum. The aortic area is located at the second IC space to the right of the sternum. The pulmonic area is at the second IC space to the left of the sternum. The epigastric area is located below the xiphoid process.
Which symptom is an early warning sign of acute coronary syndrome (ACS) and heart failure (HF)? weight gain change in level of consciousness fatigue hypotension
Correct response: fatigue Explanation: 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 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
Correct response: heart failure Explanation: A BNP level greater than 100 pg/mL is suggestive of heart failure. Because this serum laboratory test can be quickly obtained, BNP levels are useful for prompt diagnosis of heart failure in settings such as the emergency department. Elevations in BNP can occur from a number of other conditions such as pulmonary embolus, myocardial infarction (MI), and ventricular hypertrophy. Therefore, the healthcare provider correlates BNP levels with abnormal physical assessment findings and other diagnostic tests before making a definitive diagnosis of 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? heart failure aortic stenosis congenital heart disease coronary artery disease
Correct response: heart failure Explanation: The S3 heart sound is heard immediately after the S2 sound, early in diastole, as blood flows from the atrium into a noncompliant ventricle. The S3 heart sound is normal in children and young adults, but it is a significant finding suggestive of heart failure in older adults. A client with aortic stenosis commonly may have a murmur. A client with congenital heart disease may have more that one abnormal heart sound. Clients with coronary artery disease do not have S3 heart sounds.
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 myocardial infarction, fluid overload, and diuresis fluid overload, sepsis, and vasodilation third spacing, heart failure, and diuresis
Correct response: hemorrhage, sepsis, and anaphylaxis Explanation: Preload is the volume in the left ventricle at the end of diastole. It's also referred to as end-diastolic volume. Preload is reduced by any condition that reduces circulating volume, such as hemorrhage, sepsis, and anaphylaxis. Hemorrhage reduces circulating volume by the loss of volume from the intravascular space. Sepsis and anaphylaxis reduce circulating volume by increased capillary permeability. Diuresis, vasodilation, and third spacing also reduce preload. Preload increases with fluid overload and heart failure.
During the auscultation of a client's heart sounds, the nurse notes an S4. The nurse recognizes that an S4 is associated with which condition? heart failure hypertensive heart disease turbulent blood flow diseased heart valves
Correct response: hypertensive heart disease Explanation: Auscultation of the heart requires familiarization with normal and abnormal heart sounds. An extra sound just before S1 is an S4 heart sound or atrial gallop. An S4 sound often is associated with hypertensive heart disease. A sound that follows S1 and S2 is called an S3 heart sound or a ventricular gallop. An S3 heart sound is often an indication of heart failure in an adult. In addition to heart sounds, auscultation may reveal other abnormal sounds, such as murmurs and clicks, caused by turbulent blood flow through diseased heart valves.
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? excessive blood loss overdiuresis hypervolemia left-sided heart failure
Correct response: hypervolemia Explanation: The normal CVP is 2 to 6 mm Hg. A CVP greater than 6 mm Hg indicates an elevated right ventricular preload. Many problems can cause an elevated CVP, but the most common is hypervolemia (excessive fluid circulating in the body) or right-sided HF. In contrast, a low CVP (<2 mm Hg) indicates reduced right-ventricular preload, which is most often from hypovolemia.
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
Correct response: international normalized ratio (INR) Explanation: The INR, reported with the PT, provides a standard method for reporting PT levels and eliminates the variation of PT results from different laboratories. The INR, rather than the PT alone, is used to monitor the effectiveness of warfarin. The therapeutic range for INR is 2 to 3.5, although specific ranges vary based on diagnosis. The other laboratory values are not used to evaluate the effectiveness of warfarin.
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
Correct response: left atrium Explanation: The left atrium receives oxygenated blood from the lungs. The left ventricle pumps that blood to all the cells and tissues of the body. The right atrium receives deoxygenated blood from the venous system. The right ventricle pumps that blood to the lungs to be oxygenated.
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
Correct response: left ventricle Explanation: The left ventricle pumps blood to all the cells and tissues of the body. The left atrium receives oxygenated blood from the lungs. The right ventricle pumps blood to the lungs to be oxygenated. The right atrium receives deoxygenated blood from the venous system.
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? right ventricle left ventricle left atrium right atrium
Correct response: left ventricle Explanation: The left ventricle pumps blood to all the cells and tissues of the body. The left atrium receives oxygenated blood from the lungs. The right ventricle pumps blood to the lungs to be oxygenated. The right atrium receives deoxygenated blood from the venous system.
A nurse is assessing a client with heart failure. When assessing hepatojugular reflux, what is the appropriate action for the nurse to take? press the right upper abdomen. press the left upper abdomen. lay the client flat in bed. elevate the client's head to 90 degrees.
Correct response: press the right upper abdomen. Explanation: As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a client has positive hepatojugular reflux. Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree, not 90-degree, angle.
The balloon on the distal tip of a pulmonary artery catheter is inflated and the pressure is measured. What is the term for the measurement obtained? central venous pressure pulmonary artery wedge pressure cardiac output pulmonary artery pressure
Correct response: pulmonary artery wedge pressure Explanation: When the balloon is inflated, the tip of the catheter floats into smaller branches of the pulmonary artery until it can no longer be passed. The pressure is recorded, reflecting left-atrial pressure and left-ventricular end-diastolic pressure. Central venous pressure is measured in the right atrium. Pulmonary artery pressure is measured when the balloon tip is not inflated. Cardiac output is determined through thermodilution, which involves injection of fluid into the pulmonary artery catheter.
When the balloon on the distal tip of a pulmonary artery catheter is inflated and the pressure is measured, the measurement obtained is referred to as the pulmonary artery wedge pressure. cardiac output. central venous pressure. pulmonary artery pressure.
Correct response: pulmonary artery wedge pressure. Explanation: When the balloon is inflated, the tip of the catheter floats into smaller branches of the pulmonary artery until it can no longer be passed. The pressure is recorded, reflecting left-atrial pressure and left-ventricular end-diastolic pressure. Central venous pressure is measured in the right atrium. Pulmonary artery pressure is measured when the balloon tip is not inflated. Cardiac output is determined through thermodilution, which involves injection of fluid into the pulmonary artery catheter.
The physician orders medication to treat a client's cardiac ischemia. What is causing the client's condition? reduced blood supply to the heart pain on exertion high blood pressure indigestion
Correct response: reduced blood supply to the heart Explanation: Ischemia is reduced blood supply to body organs. Cardiac ischemia is caused by reduced blood supply to the heart muscle. It may lead to a myocardial infarction. Chest pain is a symptom of ischemia.
What does decreased pulse pressure reflect? tachycardia reduced distensibility of the arteries reduced stroke volume elevated stroke volume
Correct response: reduced stroke volume Explanation: 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.
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? left atrium right ventricle left ventricle right atrium
Correct response: right ventricle Explanation: The right ventricle pumps blood to the lungs to be oxygenated. The left ventricle pumps that blood to all the cells and tissues of the body. The right atrium receives deoxygenated blood from the venous system. The left atrium receives oxygenated blood from the lungs.
The electrical conduction system of the heart has several components, all of which are instrumental in maintaining polarization, depolarization, and repolarization of cardiac tissue. Which of the conductive structures is known as the pacemaker of the heart? sinoatrial node atrioventricular node bundle of His bundle branches
Correct response: sinoatrial node Explanation: The SA node is an area of nerve tissue located in the posterior wall of the right atrium. The SA node is called the pacemaker of the heart because it initiates the electrical impulses that cause the atria and ventricles to contract. When the impulse from the SA node reaches the AV node, it is delayed a few hundredths of a second. While the ventricles fill with blood, the impulse travels from the AV node to the bundle of His, to the right and left bundle branches, and eventually to the Purkinje fibers. Then, both ventricles contract. While the ventricles fill with blood, the impulse travels from the AV node to the bundle of His, to the right and left bundle branches, and eventually to the Purkinje fibers. Then, both ventricles contract.
The nurse is reviewing the laboratory results for a client with heart failure. Which laboratory value will the nurse report to the healthcare provider? sodium 148 mEq/L potassium 3.4 mEq/L calcium 9.8 mg/d magnesium 1.5 mEq/L
Correct response: sodium 148 mEq/L Explanation: Normal sodium levels are between 135 and 145 mEq/L, so the sodium value is abnormal. The remaining values are normal. Normal potassium levels range from 3.3 to 4.9 mEq/L. The normal range for calcium level is 8.9 to 10.3 mg/dL. Normal magnesium levels range from 1.3 to 2.2 mEq/L.
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
Correct response: 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 Explanation: 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.
A nurse is conducting procedures to determine the extent of a client's left-sided heart failure. What adventitious lung sounds would the nurse expect to hear during auscultation of the lungs to support the diagnosis? Select all that apply. labor stridor wheezes wet lung sounds
Correct response: wheezes wet lung sounds Explanation: With left-sided heart failure, auscultation reveals a crackling sound and possibly wheezes and gurgles. Wet lung sounds are accompanied by dyspnea and an effort to sit up to breathe.
