Chapt 25 Cardiovascular Function Med Surg
The nurse admits a 52-year-old woman with a medical diagnosis of "rule out MI." The client is very frightened and expresses surprise that a woman would have heart problems. Which of the following responses by the nurse would be most appropriate? a) "A woman's heart is smaller and has smaller arteries that become occluded more easily." b) "A woman's resting heart rate is lower than a man's." c) "The stroke volume from a woman's heart is lower than from a man's heart." d) "It takes longer for an electrical impulse to travel from the sinoatrial node to the atrioventricular node."
"A woman's heart is smaller and has smaller arteries that become occluded more easily." Because the coronary arteries of a woman are smaller, they become occluded from atherosclerosis more easily. In addition, the resting rate, stroke volume, and ejection fraction of a woman's heart are higher than those of a man.
The nurse is reviewing discharge instructions with a patient who underwent a left groin cardiac catheterization 8 hours ago. Which of the following instructions should the nurse include? a) "You can take a tub bath or a shower when you get home." b) "Contact your primary care provider if you develop a temperature above 102°F." c) "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." d) "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 patient to complete the following: If the artery of the groin was used, for the next 24 hours, do not bend at the waist, strain, or lift heavy objects; the primary provider should be contacted if any of the following occur: swelling, new bruising or pain from your procedure puncture site, temperature of 101°F or more. 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 patient should not drive to the hospital.
Your client is being prepared for echocardiography when he asks you why he needs to have this test. What would be your best response? a) "Echocardiography is a way of determining the functioning of the left ventricle of your heart." b) "This test will find any congenital heart defects." c) "Echocardiography will tell your doctor if you have cancer of the heart." d) "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 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? a) "Have you had any episodes of dizziness or fainting?" b) "Have you had any episodes when you are to nauseous?" c) "Have you had any episodes of mottling in your hands?" d) "Have you had any episodes of pain radiating into your lower extremities?"
"Have you had any episodes of dizziness or fainting?" 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.
The nurse is assessing the client's cardiovascular system. The client asks the nurse why she presses on his toenails. Which is the best reply by the nurse? a) "Pressing on your toenail gives me an idea about how well you have been eating." b) "I can learn things about your blood coagulation by pressing on your toenail." c) "I can see how quickly the blood returns when I press and release your toenail. This tells me how well your peripheral blood is flowing." d) "I can tell a lot about your respiratory rate from pressing on your toes."
"I can see how quickly the blood returns when I press and release your toenail. This tells me how well your peripheral blood is flowing." Decreased capillary refill time indicates a slower peripheral blood flow.
A nurse is preparing a client for an exercise stress test the following morning. Which client statement indicates a need for additional teaching? a) "I'll have to sign a consent form before the test." b) "I won't eat or drink anything after midnight tonight." c) "I'll likely be able to take my regular medications before the test." d) "I won't smoke for 2 to 3 hours before the test."
"I won't eat or drink anything after midnight tonight." 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.
The nurse is caring for a client anticipating further testing related to cardiac blood flow. Which statement, made by the client, would lead the nurse to provide additional teaching? a) "The first test I am getting is an echocardiography. I am glad that it is not painful." b) "My niece thought that I would be ordered a magnetic resonance imaging even though I have a pacemaker." c) "I had an ECG already. It provided information on my heart rhythm. d) "I am able to have a nuclide study because I do not have any allergies."
"My niece thought that I would be ordered a magnetic resonance imaging even though I have a pacemaker." A magnetic resonance imaging (MRI) test is prohibited on clients with various metal devices within their body. External metal objects must be removed. All other options are correct statements not needing clarification.
The nurse is assisting the client to manage the cardiovascular risk factors of hyperlipidemia and hypertension. The client asks what kind of a diet would be best. The nurse's correct response is which of the following? a) A diet with restricted fruits and fluids b) A diet high in transfats and potassium c) A diet low in sodium, fat, cholesterol d) A diet with high sodium, fruits, vegetables
A diet low in sodium, fat, cholesterol Diets that are restricted in sodium, fat, and cholesterol are commonly prescribed to manage the cardiovascular risk factors of hypertension and hyperlipidemia.
A client is seen in the emergency department and reports left arm pain, fatigue, palpitations, and shortness of breath. Which of the following conditions would the nurse suspect? a) Diabetes insipidus b) Diabetes mellitus c) Renal failure d) Acute coronary syndrome
Acute coronary syndrome Some of the more common signs and symptoms of acute coronary syndrome are chest or arm discomfort, palpitations, fatigue, and shortness of breath.
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?" The nurse's appropriate response is which of the following? a) Apricots, dried peas and beans, dates b) Bok choy, cooked leeks, alfalfa sprouts c) Asparagus, blueberries, green beans d) Cranberries, apples, popcorn
Apricots, dried peas and beans, dates 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? a) Assess for mechanical dysfunction. b) Call the physician with a report. c) Reposition the client. d) Assess the client.
Assess the client. 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 nurse is preparing a client for cardiac catheterization. The nurse knows that she must provide which nursing intervention when the client returns to his room after the procedure? a) Withhold analgesics for at least 6 hours after the procedure. b) Assess the puncture site frequently for hematoma formation or bleeding. c) Restrict fluids for 6 hours after the procedure. d) Inform the client that he may experience numbness or pain in his leg.
Assess the puncture site frequently for hematoma formation or bleeding. Because the diameter of the catheter used for cardiac catheterization is large, the puncture site must be checked frequently for hematoma formation and bleeding. The nurse should administer analgesics as ordered and needed. If the femoral artery was accessed during the procedure, the client should be instructed to report any leg pain or numbness, which may indicate arterial insufficiency. Fluids should be encouraged to eliminate dye from the client's system.
Which of the following terms is used to describe the ability of the heart to initiate an electrical impulse? a) Contractility b) Excitability c) Conductivity d) Automaticity
Automaticity 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 is providing discharge education for the client going home after a cardiac catheterization. Which of the following would be important information to give this client? a) Returning to work immediately is okay. b) Avoid tub baths, but shower as desired. c) Expect bruising to appear at the site. d) Do not ambulate until the physician indicates it is appropriate.
Avoid tub baths, but shower as desired. Guidelines for self-care after hospital discharge following a cardiac catheterization include shower as desired (no tub baths), avoid bending at the waist and lifting heavy objects, the physician will indicate when it is okay to return to work, and notify the physician right away if you have bleeding, new bruising, swelling, or pain at the puncture site.
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? a) Potassium b) C-reactive protein (CRP) c) B-type natriuretic peptide (BNP) d) Platelet count
B-type natriuretic peptide (BNP) 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? a) Baroreceptors b) Vagus nerve c) Chemoreceptors d) Sympathetic nerve fibers
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 accompanies a client to an exercise stress test. The client can achieve the "target heart rate," but the ECG leads show an ST-segment elevation. The nurse recognizes this as a "positive" stress test, and will begin to prepare the client for which of the following procedures? a) Cardiac catheterization b) Telemetry monitoring c) Pharmacologic stress test d) Transesophageal echocardiogram
Cardiac catheterization An elevated ST-segment means an evolving myocardial infarction. A cardiac catheterization would be the logical next step.
The nurse is caring for a patient with an intra-arterial BP monitoring device. The nurse recognizes the most preventable complication associated with hemodynamic monitoring includes which of the following? a) Air embolism b) Pneumothorax c) Hemorrhage d) Catheter-related bloodstream infections (CRBSI)
Catheter-related bloodstream infections (CRBSI) 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.
The nurse is taking a health history from a client admitted with the medical diagnosis of cardiovascular disease (CVD). Identify which of the following symptoms indicate CVD. a) Chest pain, weight gain, fatigue b) Petechiae, ascites, constipation c) Dizziness, rash, extra-ocular eye movements d) Fatigue, ecchymosis, confusion
Chest pain, weight gain, fatigue Chest pain, weight gain, fatigue, dizziness, ascites, and confusion are all symptoms of CVD. Rash, extra-ocular eye movements, ecchymosis, and petechiae are not usually indicative of CVD.
You are caring for a client with a damaged tricuspid valve. You know that the tricuspid valve is held in place by which of the following? a) Papillary tendons b) Atrioventricular tendons c) Semilunar tendineae d) Chordae tendineae
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 is preparing to apply ECG electrodes to a male patient who requires continuous cardiac monitoring. Which of the following should the nurse complete to optimize skin adherence and conduction of the heart's electrical current? a) Apply baby powder to the patient's chest prior to placing the electrodes. b) Clean the patient's chest with alcohol prior to application of the electrodes. c) Clip the patient's chest hair prior to applying the electrodes. d) Once the electrodes are applied, change them every 72 hours.
Clip the patient's chest hair prior to applying the electrodes. The nurse should complete the following actions when applying cardiac electrodes: Clip (do not shave) hair from around the electrode site, if needed; if the patient is diaphoretic (sweaty), apply a small amount of benzoin to the skin, avoiding the area under the center of the electrode; debride the skin surface of dead cells with soap and water and dry well (or as recommended by the manufacturer). Change the electrodes every 24 to 48 hours (or as recommended by the manufacturer); 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. His temperature is 99.8° F (37.7° C). His blood pressure is 104/68 mm Hg. His pulse rate is 76 beats/minute. She 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? a) Slow the I.V. fluid to prevent any more swelling at the puncture site. b) Encourage the client to perform isometric leg exercise to improve circulation in his legs. c) Contact the physician and report her findings. d) Document her findings and recheck the client in 1 hour.
Contact the physician and report her 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 physician 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
A nurse is caring for a client with a central venous pressure (CVP) of 4 mm Hg. Which nursing intervention is appropriate? a) Rezero the equipment and take another reading. b) Continue to monitor the client as ordered. c) Call the physician and obtain an order for a fluid bolus. d) Call the physician and obtain an order for a diuretic.
Continue to monitor the client as ordered. Normal CVP ranges from 3 to 7 mm Hg. The nurse doesn't need to take any action other than to monitor the client. It isn't necessary to rezero the equipment. Calling a physician and obtaining an order for a fluid bolus would be an appropriate intervention if the client has a CVP less than 3 mm Hg. Administering a diuretic would be appropriate if the client had excess fluid, as demonstrated by a CVP greater than 7 mm Hg.
The ability of the cardiac muscle to shorten in response to an electrical impulse is termed which of the following? a) Repolarization b) Contractility c) Diastole d) Depolarization
Contractility 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.
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? a) Count the heart rate at the apex. b) Count the radial pulse for 20 to 25 seconds. c) Calculate the pauses between pulsations. d) Calculate the palpated volume.
Count the heart rate at the apex. 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 caring for an elderly client with left-sided heart failure. When auscultating lung sounds, which adventitious sound is expected? a) Wheezes b) Coarseness c) Rhonchi d) Crackles
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.
The nurse is caring for an elderly client with left-sided heart failure. When auscultating lung sounds, which adventitious sound is expected? a) Coarseness b) Rhonchi c) Crackles d) Wheezes
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
A patient has a high magnesium level. Identify how hypermagnesemia affects cardiac function. a) Causes ventricular tachycardia b) Increases myocardial contractility c) Causes atrial tachycardia d) Decreases myocardial contractility
Decreases myocardial contractility Hypermagnesemia can cause depression of myocardial contractility and excitability heart block and asystole. Hypomagnesemia predisposes patient to atrial or ventricular tachycardias.
For both outpatients and inpatients scheduled for diagnostic procedures of the cardiovascular system, the nurse performs a thorough initial assessment to establish accurate baseline data. Which of the following data is necessary to collect if the patient is experiencing chest pain? a) Description of the pain b) Blood pressure in the left arm c) Pulse rate in upper extremities d) Sound of the apical pulses
Description of the pain If the patient is experiencing chest pain, a history of its location, frequency, and duration is necessary, as is a description of the pain, if it radiates to a particular area, what precipitates its onset, and what brings relief. The nurse weighs the patient and measures vital signs. The nurse may measure BP in both arms and compare findings. The nurse assesses apical and radial pulses, noting rate, quality, and rhythm. The nurse also checks peripheral pulses in the lower extremities
For both outpatients and inpatients scheduled for diagnostic procedures of the cardiovascular system, the nurse performs a thorough initial assessment to establish accurate baseline data. Which of the following data is necessary to collect if the patient is experiencing chest pain? a) Sound of the apical pulses b) Blood pressure in the left arm c) Description of the pain d) Pulse rate in upper extremities
Description of the pain If the patient is experiencing chest pain, a history of its location, frequency, and duration is necessary, as is a description of the pain, if it radiates to a particular area, what precipitates its onset, and what brings relief. The nurse weighs the patient and measures vital signs. The nurse may measure BP in both arms and compare findings. The nurse assesses apical and radial pulses, noting rate, quality, and rhythm. The nurse also checks peripheral pulses in the lower extremities.
Which of the following would be an indication for a transesophageal echocardiography (TEE)? a) Determination of electrical activity of the heart. b) Evaluation of myocardial perfusion at rest and after exercise. c) Evaluation of the response of the cardiovascular system to increased oxygen demands. d) Determination of atrial thrombi
Determination of atrial thrombi The TEE is an important diagnostic tool for determining if atrial or ventricular thrombi are present in patients with heart failure, valvular heart disease, and arrhythmias. The electrocardiogram (ECG) is a graphic recording of the electrical activity of the heart. Stress testing is used to evaluate the response of the cardiovascular system to increased demands for oxygen and nutrients. Thallium is used with exercise or pharmacologic stress testing to assess changes in myocardial perfusion at rest and after exercise.
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? a) Dyspnea b) Cardiac output c) Activity level d) Digoxin level
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 client with a diagnosis of heart failure reports frequently awakening during the night with the need to urinate. The nurse offers which explanation? a) When the client is in the recumbent position, more pressure is put on the bladder with the result of increased need to urinate. b) Edema is collected in dependent extremities during the day; at night when the client lays down, it is reabsorbed into the circulation and excreted by the kidneys. c) The blood pressure is lower when the client is recumbent and this causes the kidneys to work harder; therefore, more urine is produced. d) Fluid that is held in the lungs during the day becomes part of the circulation at night and the kidneys produce an increased amount of urine.
Edema is collected in dependent extremities during the day; at night when the client lays down, it is reabsorbed into the circulation and excreted by the kidneys. Nocturia is common in patients with heart failure. Fluid collected in dependent areas during the day is reabsorbed into the circulation at night when the client is recumbent. The kidneys excrete more urine with the increased circulating volume.
Decreased pulse pressure reflects a) reduced distensibility of the arteries. b) reduced stroke volume. c) tachycardia. d) 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.
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? a) Epicardium b) Pericardium c) Myocardium d) Endocardium
Endocardium 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.
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? a) Enzymes b) RBC c) Platelets d) WBC
Enzymes 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
The area of the heart that is located at the third IC space to the left of the sternum is the a) pulmonic area. b) Erb's point. c) aortic area. d) epigastric area.
Erb's point Erb's 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.
The nurse is caring for a client scheduled for a cardiac stress test at 11:00 a.m. When the nurse enters the client's room at 8:00 a.m., the client complains that he has had no breakfast and would at least like some coffee. The appropriate response by the nurse would be which of the following? a) Make up a small breakfast tray from what is available on the unit. b) Ask the client's visitor to bring some coffee from the cafeteria for the client. c) Offer hot tea or coffee only. d) Explain that no food or drink is allowed for 4 hours before the stress test.
Explain that no food or drink is allowed for 4 hours before the stress test. The client must have no food or drink, especially caffeine, for 4 hours prior to the stress test. If caffeine is ingested prior to an adenosine stress test, the test will have to be rescheduled.
The nurse prepares to auscultate heart sounds. Which nursing interventions would be most effective to assist with this procedure? a) 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. b) Ask the client to sit on the edge of the bed and hold his breath while the nurse listens. c) Insist that the family members leave the room if they must speak to each other while the nurse is auscultating heart sounds. d) Ask the client to take deep breaths through his 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. During auscultation the client remains supine and the room should be as quiet as possible while the nurse listens to heart sounds. The client should breathe quietly during the examination.
A 79-year-old client with a history of right-sided heart failure lives in the long-term care facility where you practice nursing. In your daily assessment, you are required to record the level of this client's peripheral edema. Which of the following would be the main area for examination? a) Feet and ankles b) Knees and elbows c) Lips and earlobes d) Over the sacrum
Feet and ankles Edema occurs when blood is not pumped efficiently or plasma protein levels are inadequate to maintain osmotic pressure. When blood has nowhere else to go, the extra fluid enters the tissues. Particular areas for examination are the dependent parts of the body, such as the feet and ankles. The area over, not below, the sacrum is another area prone to edema. Particular areas for examination are the dependent parts of the body, such as the feet and ankles. Particular areas for examination are the dependent parts of the body, such as the feet and ankles.
The nurse auscultates the apex beat at which of the following anatomical locations? a) Midsternum b) Fifth intercostal space, midclavicular line c) 2 inch to the left of the lower end of the sternum d) 1 inch to the left of the xiphoid process
Fifth intercostal space, midclavicular line The left ventricle is responsible for the apex beat or the point of maximum impulse, which is normally palpable in the left midclavicular line of the chest wall at the fifth intercostal space. The right ventricle lies anteriorly, just beneath the sternum. Use of inches to identify the location of the apex beat is inappropriate based upon variations in human anatomy. Auscultation below and to the left of the xiphoid process will detect gastrointestinal sounds, but not the apex beat of the heart.
A harsh grating sound caused by abrasion of the pericardial surfaces during the cardiac cycle is termed which of the following? a) Murmur b) Friction rub c) Opening snap d) Ejection click
Friction rub In 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.
Identify which of the following as an age-related change associated with conduction system of the heart? a) Thrills b) Murmur c) Tachycardia d) Heart block
Heart block 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.
You are teaching a group of nursing students about adventitious heart sounds. You explain that auscultation of the heart requires familiarization with normal and abnormal heart sounds. What would you tell these students a ventricular gallop indicates in an adult? a) Normal functioning b) Heart failure c) Hypertensive heart disease d) Pericarditis
Heart failure 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
The nurse is caring for a patient in the ED who has a B-type natriuretic peptide (BNP) level of 115 pg/mL. The nurse understands that this finding is most suggestive of which of the following? a) Heart failure b) Myocardial infarction c) Pulmonary edema d) Ventricular hypertrophy
Heart failure Correct Explanation: A BNP level greater than 100 pg/mL is suggestive of HF. Because this serum laboratory test can be quickly obtained, BNP levels are useful for prompt diagnosis of HF in settings such as the ED. Elevations in BNP can occur from a number of other conditions such as pulmonary embolus, myocardial infarction (MI), and ventricular hypertrophy. Therefore, the clinician correlates BNP levels with abnormal physical assessment findings and other diagnostic tests before making a definitive diagnosis of HF
In presenting a workshop on parameters of cardiac function, which conditions should a nurse list as those most likely to lead to a decrease in preload? a) Hemorrhage, sepsis, and anaphylaxis b) Third spacing, heart failure, and diuresis c) Fluid overload, sepsis, and vasodilation d) Myocardial infarction, fluid overload, and diuresis
Hemorrhage, sepsis, and anaphylaxis 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 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.
A nurse is reviewing laboratory values for a client diagnosed with hyperlipidemia 6 months ago. Which results indicate that the client has been following his therapeutic regimen? a) Total cholesterol level increases from 250 mg/dl to 275 mg/dl. b) Low density lipoproteins (LDL) increase from 180 mg/dl to 190 mg/dl. c) High density lipoproteins (HDL) increase from 25 mg/dl to 40 mg/dl. d) Triglycerides increase from 225 mg/dl to 250 mg/dl.
High density lipoproteins (HDL) increase from 25 mg/dl to 40 mg/dl. 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 he's followed his therapeutic regimen. 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.
During the auscultation of a patient's heart sounds, the nurse notes an S4. The nurse recognizes that an S4 is associated with which of the following? a) Diseased heart valves b) Hypertensive heart disease c) Heart failure d) Turbulent blood flow
Hypertensive heart disease 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 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? a) In clients with an indwelling pacemaker b) In clients with heart valve replacement c) In pediatric clients d) In geriatric clients
In pediatric clients 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 patient prescribed warfarin (Coumadin) orally. The nurse reviews the patient's prothrombin time (PT) level to evaluate the effectiveness of the medication. The nurse should also evaluate which of the following laboratory values? a) Partial thromboplastic time (PTT) b) Complete blood count (CBC) c) International normalized ratio (INR) d) Sodium
International normalized ratio (INR) 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 Coumadin
The nurse is reviewing the morning laboratory test results for a client with cardiac problems. Which of the following would the nurse regard as a priority to report to the physician? a) Ca++ 9 mg/dL b) K+ 3.1 mEq/L c) Mg++ 2 mE/L d) Na+ 140 mEq/L
K+ 3.1 mEq/L All are within normal limits except for the K+, which is low. A low K+ level can cause ventricular tachycardia or fibrillation
The nurse is caring for a client who is scheduled for a transesophageal echocardiogram. After the procedure the nurse performs which of the following interventions? a) Observe for bloody urine and stools. b) Keep the client turned to the right side and watch for bleeding from the site. c) Keep the head of the bed elevated 45 degrees and keep NPO until return of the gag reflex. d) Monitor the puncture site and assess the affected extremity.
Keep the head of the bed elevated 45 degrees and keep NPO until return of the gag reflex. During the recovery period, the client must have the head of the bed elevated 45 degrees to avoid aspiration. The nurse should restrict food and fluids until the return of the gag reflex and the client is fully awake and alert.
The nurse is caring for a client who is scheduled for a transesophageal echocardiogram. After the procedure the nurse performs which of the following interventions? a) Keep the client turned to the right side and watch for bleeding from the site. b) Monitor the puncture site and assess the affected extremity. c) Keep the head of the bed elevated 45 degrees and keep NPO until return of the gag reflex. d) Observe for bloody urine and stools.
Keep the head of the bed elevated 45 degrees and keep NPO until return of the gag reflex. During the recovery period, the client must have the head of the bed elevated 45 degrees to avoid aspiration. The nurse should restrict food and fluids until the return of the gag reflex and the client is fully awake and alert.
Within the physiology of the heart, each chamber has a particular role in maintaining cellular oxygenation. Which chamber of the heart is responsible for receiving oxygenated blood from the lungs? a) Left atrium b) Left ventricle c) Right ventricle d) Right atrium
Left atrium 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.
Within the physiology of the heart, each chamber has a particular role in maintaining cellular oxygenation. Which chamber of the heart is responsible for pumping blood to all the cells and tissues of the body? a) Left atrium b) Right ventricle c) Left ventricle d) Right atrium
Left ventricle The left ventricle pumps that 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 caring for a client taking diltiazem (Cardizem) for arrhythmias. The nurse knows that diltiazem helps decrease arrhythmias by working during which phase of the cardiac action potential? a) Phase 3 b) Phase 0 c) Phase 2 d) Phase 1
Phase 0 Diltiazem, a calcium channel blocker, blocks the influx of calcium into the cells during phase 0 of the cardiac action potential. This action causes the sinoatrial node and atrioventricular (AV) node to slow their response times, which results in slowed AV conduction, decreased ventricular depolarization, and arrhythmias. Diltiazem doesn't work during phase 1, 2, or 3 of the cardiac action potential.
A nurse is preparing to assess a patient for postural BP changes. Which of the following indicates the need for further education? a) Taking the patient's BP with the patient sitting on the edge of the bed with feet dangling b) Positioning the patient supine for 10 minutes prior to taking the initial BP and HR c) Letting 30 seconds elapse after each position change before measuring BP and heart rate (HR) d) Obtaining the supine measurements prior to the sitting and standing measurements
Letting 30 seconds elapse after each position change before measuring BP and heart rate (HR) The following steps are recommended when assessing patients for postural hypotension: Position the patient supine for 10 minutes before taking the initial BP and HR measurements; reposition the patient to a sitting position with legs in the dependent position, wait 2 minutes then reassess both BP and HR measurements; if the patient is symptom free or has no significant decreases in systolic or diastolic BP, assist the patient into a standing position, obtain measurements immediately and recheck in 2 minutes; continue measurements every 2 minutes for a total of 10 minutes to rule out postural hypotension. Return the patient to supine position if postural hypotension is detected or if the patient becomes symptomatic. Document HR and BP measured in each position (e.g., supine, sitting, and standing) and any signs or symptoms that accompany the postural changes.
When preparing a patient for a cardiac catheterization, the patient states that she has allergies to seafood. Which of the following medications may give to her prior to the procedure? a) Phenytoin (Dilantin) b) Methylprednisolone (Solu-Medrol) c) Lorazepam (Ativan) d) Furosemide (Lasix)
Methylprednisolone (Solu-Medrol) 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. Lasix, Ativan, and Dilantin do not counteract allergic reactions.
The nurse is caring for a patient with clubbing of the fingers and toes. The nurse should complete which of the following actions given these findings? a) Assess the patient for pitting edema. b) Assess the patient's capillary refill. c) Obtain an oxygen saturation level. d) Obtain a 12-lead ECG tracing.
Obtain an oxygen saturation level. 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 patient's O2 saturation level and intervene as directed. The other assessments are not indicated
The nurse is providing discharge instructions to a client with unstable angina. The client is ordered Nitrostat 1/150 every 5 minutes as needed for angina. Which side effect, emphasized by the nurse, is common especially with the increased dosage? a) Rash b) Orthostatic hypotension c) Nausea d) Dry mouth
Orthostatic hypotension A common side effect of Nitrostat, especially at higher dosages, is orthostatic hypotension. The action of the medication is to dilate the blood vessels to improve circulation to the heart. The side effect of the medication is orthostatic hypotension. A rash, nausea, and dry mouth are not common side effects.
Which of the follow arteries carries deoxygenated blood? a) Left anterior descending artery b) Pulmonary artery c) Right coronary artery d) Left coronary artery
Pulmonary artery The pulmonary artery is the only artery carrying deoxygenated blood. Oxygenated blood returns to the left atrium via the pulmonary veins. The left coronary artery, right coronary artery, and left anterior descending artery do not carry deoxygenated blood
When the balloon on the distal tip of a pulmonary artery catheter is inflated and a pressure is measured, the measurement obtained is referred to as which of the following? a) Cardiac output b) Pulmonary artery pressure c) Pulmonary artery wedge pressure d) Central venous pressure
Pulmonary artery wedge pressure 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 and 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 involving injection of fluid into the pulmonary artery catheter.
A 97-year-old client with a history of atrial fibrillation is being admitted to the assisted living center where you practice nursing. In your initial assessment, you measure his apical pulse and compare it to his peripheral pulse. The difference between the two is known as what? a) Pulse rhythm b) Pulse deficit c) Pulse quality d) Pulse volume
Pulse deficit 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.
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? a) Rate, quality, and rhythm b) Pressure, rate, and rhythm c) Quality, volume, and rate d) Rate, rhythm, and volume
Rate, quality, and rhythm Assess apical and radial pulses, noting rate, quality, and rhythm. Pulse quality and volume are not assessed in this instance.
The physician orders medication to treat a client's cardiac ischemia. The nurse is aware that which of the following is causing the client's condition? a) Indigestion b) High blood pressure c) Pain on exertion d) Reduced blood supply to the heart
Reduced blood supply to the heart 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. Ischemia is reduced blood supply to body organs. Ischemia is reduced blood supply to body organs.
Decreased pulse pressure reflects which of the following? a) Elevated stroke volume b) Reduced distensibility of the arteries c) Tachycardia d) Reduced 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.
Which of the following nursing interventions is most appropriate when caring for a client with a nursing diagnosis of risk for injury related to side effects of medication (enoxaparin [Lovenox])? a) Assess for clubbing of the fingers. b) Administer calcium supplements. c) Assess for hypokalemia. d) Report any incident of bloody urine, stools, or both.
Report any incident of bloody urine, stools, or both. The client who takes an anticoagulant, such as a low-molecular-weight heparin, is routinely screened for bloody urine, stools, or both.
Within the physiology of the heart, each chamber has a particular role in maintaining cellular oxygenation. Which chamber of the heart is responsible for pumping blood to the lungs to be oxygenated? a) Right atrium b) Left atrium c) Right ventricle d) Left ventricle
Right ventricle The right ventricle pumps that 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.
One of your students asks what the consequences of uncorrected, left-sided heart failure would be. What would be your best response? a) Distention of the jugular vein b) Blood congestion in neck veins c) Right-sided heart failure d) Effort to lie down to breathe
Right-sided heart failure 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.
Which of the following is the term for the normal pacemaker of the heart? a) Purkinje fibers b) AV node c) SA node d) Bundle of His
SA node The sinoatrial node is the primary pacemaker of the heart. The AV node coordinates the incoming electrical impulses from the atria and after a slight delay relays the impulse to the ventricles. The Purkinje fibers rapidly conduct the impulses through the thick walls of the ventricles.
The nurse is observing a patient during an exercise stress test (bicycle). Which of the following findings indicates a positive test and the need for further diagnostic testing? a) ST-segment changes on the ECG b) Heart rate changes; 78 bpm to 112 bpm c) Dizziness and leg cramping d) BP changes; 148/80 mm Hg to 166/90 mm Hg
ST-segment changes on the ECG During the test, the following are monitored: two or more ECG leads for heart rate, rhythm, and ischemic changes; BP; 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 patient experiences signs of myocardial ischemia. Further diagnostic testing, such as a cardiac catheterization, may be warranted if the patient develops chest pain, extreme fatigue, a decrease in BP or pulse rate, serious dysrhythmias or ST-segment changes on the ECG during the stress test. The other findings would not warrant the testing to be stopped.
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 complaint increases the likelihood of a cardiovascular disorder? a) Shortness of breath b) Irritability c) Insomnia d) Lower substernal abdominal pain
Shortness of breath Common signs and symptoms of cardiovascular dysfunction include shortness of breath, chest pain, palpitations, fainting, fatigue, and peripheral edema. Insomnia seldom indicates a cardiovascular problem. Although irritability may occur if cardiovascular dysfunction leads to cerebral oxygen deprivation, this symptom more commonly reflects a respiratory or neurologic dysfunction. Lower substernal abdominal pain occurs with some GI disorders.
Admission lab values on a patient admitted with congestive heart failure are as follows: potassium 3.4 mEq/L; sodium 148 mEq/L; calcium 9.8 mg/dL; and magnesium 1.5 mEq/L. Which lab value is abnormal? a) Calcium b) Magnesium c) Potassium d) Sodium
Sodium The normal sodium level is 135 to 145 mEq/L. Potassium ranges from 3.3 to 4.9 mEq/L. The normal calcium level is 8.9 to 10.3 mg/dL. Magnesium levels range from 1.3 to 2.2 mEq/L.
Which of the following terms describes the amount of blood ejected per heartbeat? a) Afterload b) Stroke volume c) Cardiac output d) Ejection fraction
Stroke volume Stroke volume is determined by preload, afterload, and contractility of the heart. Cardiac output is the amount of blood pumped by each ventricle during a given period and is computed by multiplying the stroke volume of the heart by the heart rate. Ejection fraction is the percentage of the end-diastolic volume that is ejected with each stroke, measured at 42% to 50% in the normal heart. Afterload is defined as the pressure that the ventricular myocardium must overcome to eject blood during systole and is one of the determinants of stroke volume
The nurse correctly identifies which of the following data as an example of BP and HR measurements in a patient with postural hypotension? a) 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 b) 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 c) 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 d) 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 Correct 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 to a standing position. The following is an example of BP and HR measurements in a patient 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.
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. The nurse makes it a priority to notify the physician for which of the following reasons? a) These values show a risk for dysrhythmias. b) The client is over-hydrated, which puts him at risk for heart failure during the procedure. c) The client is at risk for bleeding. d) The client is at risk for renal failure due to the contrast agent that will be given during the procedure.
The client is at risk for renal failure due to the contrast agent that will be given during the procedure. The contrast medium must be excreted by the kidneys. If there is already a degree of renal impairment (which these laboratory values indicate), the risk for contrast agent-induced nepropathy and renal failure is high.
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? a) The client hears thumping sounds. b) The client lies still. c) The client wears a watch and wedding band. d) The client asks questions.
The client wears a watch and wedding band. 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 he 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 24-year-old obese woman describes her symptoms of palpitations, chronic fatigue, and dyspnea on exertion to the cardiologist. Upon completing the examination, the cardiologist schedules a procedure to confirm his suspected diagnosis. What diagnostic would you expect him to prescribe? a) Electrocardiography b) Transesophageal echocardiography c) Chest radiograph d) Radionuclide angiography
Transesophageal echocardiography TEE involves passing a tube with a small transducer internally from the mouth to the esophagus to obtain images of the posterior heart and its internal structures from the esophagus, which lies behind the heart. TEE provides superior views that are not possible using standard transthoracic echocardiography. Clients whose chests are rotund or who are obese are candidates for TEE. Chest radiography and fluoroscopy determine the size and position of the heart and condition of the lungs. The radionuclide technetium-99m is used to detect areas of myocardial damage. The radionuclide thallium-201 is used to diagnose ischemic heart disease during a stress test. Electrocardiography (ECG) is the graphic recording of the electrical currents generated by the heart muscle.
The nurse is awaiting results of cardiac biomarkers for a patient with severe chest pain. The nurse would identify which cardiac biomarker as remaining elevated the longest when myocardial damage has occurred? a) Troponin T and I b) Myoglobin c) Brain natriuretic peptide (BNP) d) CK-MB
Troponin T and I After myocardial injury, these biomarkers rise early (within 3 to 4 hours), peak in 4 to 24 hours, and remain elevated for 1 to 3 weeks. These early and prolonged elevations may make very early diagnosis of acute myocardial infarction (MI) possible and allow for late diagnosis in patients who have delayed seeking care for several days after the onset of acute MI symptoms. CK-MB returns to normal within 3 to 4 days. Myoglobin returns to normal within 24 hours. BNP is not considered a cardiac biomarker. It is a neurohormone that responds to volume overload in the heart by acting as a diuretic and vasodilator.
When assessing a patient with left-sided heart failure, what would be noted on auscultation of lungs? a) Labor b) Wheezes with wet lung sounds c) Stridor d) High-pitched sound
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 and 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 high pitch sound.
In caring for a client with vasovagal syncope, the nurse should know that the associated temporary loss of consciousness is most commonly related to: a) postural hypotension. b) vestibular dysfunction. c) bradyrhythmia. d) sudden vascular fluid shifting.
bradyrhythmia. Parasympathetic hyperactivity leading to sudden hypotension secondary to bradyrhythmia causes vasovagal syncope. That is, bradyrhythmia leads to cerebral ischemia which, in turn, leads to syncope. Vasovagal syncope isn't caused by vestibular (inner ear) dysfunction, postural hypotension, or vascular fluid shifting.
The ability of the cardiac muscle to shorten in response to an electrical impulse is termed a) diastole. b) depolarization. c) contractility. d) repolarization.
contractility. 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.
Following a myocardial infarction, a client develops an arrhythmia and requires a continuous infusion of lidocaine. To monitor the effectiveness of the intervention, the nurse should focus primarily on the client's: a) creatine kinase (CK) and troponin levels. b) electrocardiogram (ECG). c) urine output. d) blood pressure and heart rate.
electrocardiogram (ECG). Lidocaine is an antiarrhythmic and is given for the treatment of cardiac irritability and ventricular arrhythmias. The best indicator of its effectiveness is a reduction in or disappearance of ventricular arrhythmias as seen on an ECG. Urine output is an indicator of pump effectiveness; CK and troponin levels monitor myocardial damage. Blood pressure and heart rate measurements are too nonspecific to help determine the effectiveness of parenteral lidocaine
A nurse is assessing a client with heart failure. To assess hepatojugular reflux, the nurse should: a) press the right upper abdomen. b) press the left upper abdomen. c) lay the client flat in bed. d) elevate the client's head to 90 degrees.
press the right upper abdomen. 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.
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. a) Atrial cell stimulation b) Bundle branches c) Bundle of His d) Purkinje fibers e) AV node
• AV node • Atrial cell stimulation • Purkinje fibers • Bundle branches • Bundle of His In the normal sequence, the impulse starts in the SA node. The waves of stimulation spread through the atria to the AV node. The impulse then travels from the AV node to the bundle of His, then to the right and left bundle branches, and eventually to the Purkinje fibers
The nurse is interviewing a client who is complaining of chest pain. Which of the following questions related to the client's history are most important to ask? Select all that apply. a) How did your mother die? b) How would you describe your symptoms? c) Are you allergic to any medications or foods? d) Do you have any children?
• How did your mother die? • How would you describe your symptoms? • Are you allergic to any medications or foods? During initial assessment, the nurse should obtain important information about the client's history that focuses on a description of the symptoms before and during admission, family medical history, prescription and nonprescription drug use, and drug and food allergies.
Age-related changes associated with the cardiac system include which of the following? Select all that apply. a) Myocardial thinning b) Increase in the number of SA node cells c) Endocardial fibrosis d) Increased size of the left atrium
• Increased size of the left atrium • Endocardial fibrosis Age-related changes associated with the cardiac system include endocardial fibrosis, increased size of the left atrium, decreased number of SA node cells, and myocardial thickening.
When caring for a 48-year-old male client following a cardiac catheterization, the nurse performs which of the following assessments? Select all that apply. a) Palpate the pulse in different locations. b) Inspect the color in every extremity. c) Palpate the insertion site for tenderness. d) Monitor BP and pulse frequently. e) Inspect pressure dressing for signs of bleeding.
• Palpate the pulse in different locations. • Monitor BP and pulse frequently. • Inspect pressure dressing for signs of bleeding. After a cardiac catheterization, the nurse monitors BP and pulse frequently to detect complications, checks the dressing over the insertion site frequently for signs of bleeding, palpates the pulse in various locations, and checks the color and temperature in the extremity to confirm that blood is circulating well.
The nurse is assessing the cardiovascular status of a client who was found unresponsive in a lobby area. Following transfer of the client, the family asks how blood circulates through the body. The nurse is most correct to state the proper circulation as which? Place the pattern of circulation in the correct order beginning in the right atrium. Use all options. a) Pulmonary vein b) Right ventricle c) Pulmonary artery d) Aorta e) Left atrium f) Left ventricle
• Pulmonary vein • Right ventricle • Pulmonary artery • Aorta • Left atrium • Left ventricle The pathway of blood flow from the right atrium includes the right ventricle. The blood flows to the lungs via the pulmonary artery and returns to the heart in an oxygenated state via the pulmonary vein. The oxygenated blood then enters the left atrium then left ventricle pump through the aorta to the systemic circulation.
A client in the cardiac unit is undergoing procedures to determine the extent of his left-sided heart failure. As his nurse, what adventitious lung sounds would you expect to hear during your auscultation of his lungs to support his diagnosis? Select all that apply. a) Wet lung sounds b) Wheezes c) Stridor d) Labor
• Wet lung sounds • Wheezes 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.
