Chapter 25 prep-u cardiac assessment

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

*"Current evidence indicates that estrogen replacement is not effective at preventing cardiovascular disease and carries some risks."* "current reserach determines that estrogen replacement protects heart health for most women after menopause" "you need to research hormone replacement therapy and determine what you want to do" "that's a great idea. You don't want to have a heart attack"

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

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

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

*"Have you had any episodes of dizziness or fainting?"* "have you had any episodes when you are nauseous?" "have you had any episodes of mottling in your hands?" "have you had any episodes of pain radiating into your lower extremities?"

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

*Assess the client.* assess for mechanical dysfunction call the physician reposition the client

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.)

*Assessing the peripheral pulses in the affected extremity* *Checking the insertion site for hematoma formation* *Evaluating temperature and color in the affected extremity*

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* papillary tendons semilunar tendineae atrioventricular tendons

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.* Once the electrodes are applied, change then every 72 hours Apply baby powder to the clietn's chest prior to placing the electrodes Clean the client's chest with alcohol prior to application of the electrodes

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

*Contact the health care provider and report the findings.* encourage the client to perfrom isometric leg exercise to improve circulation in the legs document findings and check the client again in 1 hour slow the I.V. fluid to prevent any more swelling at the puncture site

A nurse is caring for a client with a central venous pressure (CVP) of 4 mm Hg. Which nursing intervention is appropriate?

*Continue to monitor the client as ordered.*

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

*Count the heart rate at the apex.* calculate the palpated volume calculate the pauses between pulsations count the radial pulse for 20-25 seconds

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

*Digoxin level* dyspnea activity level cardiac output

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

*Edema is collected in dependent extremities during the day; at night when the client lays down, it is reabsorbed into the circulation and excreted by the kidneys.* - the blood pressure is lower when the client is recumbent, which causes the kidneys to work harder; therfore, more urine is produced - fluid that is held in the lungs during the day becomes part of the circulation at night, causing the kidneys to produce and increased amount of urine - when the client is in the recumbent position, more pressure is put on the bladder, with the result of increased need to urinaet

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

*Enzymes*

The nurse is caring for a client scheduled for a cardiac stress test at 1100. When the nurse enters the client's room at 0800, the client requests toast or at least some coffee. What is the best response by the nurse?

*Explain that no food or drink is allowed for 4 hours before the stress test.* ask the client's visitor to bring some coffee from the cafeteria for the client offer hot tea/coffee only make up a small breakfast tray from what is avaliable on the unit

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

*Explain to the client that the nurse will be listening to different areas of the chest and may listen for a long time, but that does not mean that anything abnormal is heard.* ask the client to take deep breath through the mouth while the nurse auscultates heart sounds insist that the family members leave the room if they must speak to each other while the nurse is auscultating heart sounds ask the client to sit on the edge of the bed and hold breath while the nurse listens

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

*Impaired myocardial contractility* enhanced sensitivity to digitals inclincation to ventricular fibrilation increased risk of heart block

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 chronic chest pain cyanosis

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

*K+ 3.1 mEq/L* Na++ 140 mEq/L Mg++ 2mEq/L Ca++ 9 mg/dl

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

*Left 5th intercostal space at the midclavicular line* Right 3rd intercostal space at the midclavicular line Right 2nd intercostal space at the midclavicular line Left 2nd intercostal space at the midclavicular line

After a physical examination, the provider diagnosed a patient with a grade 4 heart murmur. When auscultating a murmur, what does the nurse expect to hear?

*Loud and may be associated with a thrill sound similar to (a purring cat).* quiet but readily heard easily heard with no palpable thrill very loud; can be heard with the stethoscope half-way off the chest

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* phenytoin furosemide lorazepam

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

*Metoprolol*

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.* obtain a 12-lead ECG tracing assess the client for pitting edema assess the client's cap refill

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?

*Palpate a peripheral pulse.* precuss the perimeter of the heart take the blood pressure in both arms auscultate the carotid artery

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

*Positive family history* hyperlipidemia stress obesity

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

*Pulse pressure* pulse deficit auscultatory gap Korotkoff sound

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

*Rate, quality, and rhythm* rate, rhythm, and volume pressure, rate, and rhythm quality, volume, and rate

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

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

*Right ventricular pressure must be higher than pulmonary arterial pressure.* right ventricular pressure must decrease with systole the atroventricular valves must be closed

A client in the ICU has a central venous pressure (CVP) line placed. The CVP reading is 10 mm Hg. To what condition does the nurse correlate the CVP reading?

*Right-sided heart failure* left-sided HF reduction in preload hypovolemia

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

*S3* S4 S1 S2

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

*ST-segment changes on the ECG* dixxiness and leg cramping heart rate changes; 78 bmp to 113 bpm BP changes; 140/80 mm Hg to 166/90 mm Hg

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

*The client is at risk for renal failure due to the contrast agent that will be given during the procedure.* the client is overhydrated, which puts him at risk for HF during the procedure the client is at risk for bleeding these values show a risk for dysrhythmias

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 had a vagal response.* the pt may have had a MI the pt may have an abdominal aortic aneurysm the pt was anxious about being constipated

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

*The sinoatrial node* Purkinje fibers AV node the ventricles

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

*The thin fibrous sac encasing the heart* the exterior laye of the heart the heart's muscle fibers the inner lining of the heart valves

The nurse accompanies a client to an exercise stress test. The client can achieve the target heart rate, but the electrocardiogram indicates ST-segment elevation. Which procedure will the nurse prepare the client for next?

*cardiac catheterization* telemetry monitoring transesophageal echocardiogram pharmacologic stress test

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

*catheter-related bloodstream infections* hemmorrhage pneumothorax air embolism

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

*contractility* diastole depolarization repolarization

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

*endocardium*

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

*erb point* epigastric area aortic area pulmonic area

Which symptom is an early warning sign of acute coronary syndrome (ACS) and heart failure (HF)?

*fatigue* hypotension weight gain change in level of consciousness

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

*increased size of the left atrium* *endocardial fibrosis* myocartial thinning increase in the number of SA node cells

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)* sodium partial thromboplastic time (PTT) complete blood count (CBC)

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* right ventricle right atrium left ventricle

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* right ventricle left atrium right atrium

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* lay the client flat in bed elevate the client's head of the bed 90 degrees press on the left upper abdomen

What does decreased pulse pressure reflect?

*reduced stroke volume* elevated stroke volume tachycardia reduced distensibility of the arteries

Central venous pressure is measured in which heart chamber?

*right atrium*

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

*wheezes with wet lung sounds* high-pitched sounds laborious breathing stridor

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

*withhold food and fluids.* position the client on his side insert an oral airway introduce nasogastric tube

What is a harsh grating sound caused by abrasion of the pericardial surfaces during the cardiac cycle?

Friction rub

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

Heart failure

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

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