Hinkle Ch. 21: Assessment of Cardiovascular Function

The nurse admits an adult female client with a medical diagnosis of "rule out MI." The client is very frightened and expresses surprise that a woman would have heart problems. What response by the nurse will be most appropriate? - "A woman's heart is smaller and has smaller arteries that become occluded more easily." - "A woman's resting heart rate is lower than a man's." - "It takes longer for an electrical impulse to travel from the sinoatrial node to the atrioventricular node in a woman." - "The stroke volume from a woman's heart is lower than from a man's heart."

- "A woman's heart is smaller and has smaller arteries that become occluded more easily." 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.

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 estrogen replacement protects heart health for most women after menopause." - "Current evidence indicates that estrogen replacement is not effective at preventing cardiovascular disease and carries some risks." - "You need to research hormone replacement therapy and determine what you want to do."

- "Current evidence indicates that estrogen replacement is not effective at preventing cardiovascular disease and carries some risks." 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 to prevent cardiovascular disease. However, hormone replacement therapy has not been shown to be harmful for all women, and it may be a good choice for some women seeking to reduce symptoms of menopause.

The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include? - "You can take a tub bath or a shower when you get home." - "Contact your primary care provider if you develop a temperature above 102°F." - "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." - "If any discharge occurs at the puncture site, call 911 immediately."

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

You are doing an admission assessment on a client who is having outpatient testing done for cardiac problems. What should you ask this client during your assessment? - "Have you had any episodes of dizziness or fainting?" - "Have you had any episodes when you are to nauseous?" - "Have you had any episodes of mottling in your hands?" - "Have you had any episodes of pain radiating into your lower extremities?"

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

The nurse is administering a stool softener to a client who experienced a myocardial infarction. The client says, "I had a heart attack; I don't have a problem with constipation." What explanation will the nurse use to answer the client's question? - "If you strain to have a bowel movement, you can cause a drop in your heart rate that can be dangerous." - "The heart attack sets you up for limited activity, so constipation is often a problem for clients after a heart attack." - "Please talk this over with your healthcare provider for further information." - "The prescribed stool softener will decrease stress with a bowel movement and protect your heart from further injury."

- "If you strain to have a bowel movement, you can cause a drop in your heart rate that can be dangerous." Explanation: When straining during defecation, the client bears down, which momentarily may cause the heart to slow and cause fainting or syncope in the client. The stool softener will allow easier pass of stool by increasing the amount of water the stool absorbs in the gut, making the stool softer and easier to pass. The client will not have prescribed limited activity after a myocardial infarction. The nurse needs to explain the medication and not refer the client back to the healthcare provider. Stool softeners do not decrease stress.

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 apex of the heart, which is on the right side." - "The aortic valve is located on the right side of the heart." - "The aortic valve is located near the base of the heart on the right side."

- "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 following clients are in need of exercise electrocardiography. Which client would the nurse indicate as most appropriate for a drug-induced stress test? - A 48-year-old policemen with history of knee replacement 4 years ago - A 68-year-old housewife with history of osteoporosis - A 72-year-old retired janitor obtaining a cardiac baseline - A 55-year-old recovering from a fall and broken femur

- A 55-year-old recovering from a fall and broken femur 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 is assessing a patient who reports feeling "light-headed." When obtaining orthostatic vital signs, what does the nurse determine is a significant finding? - A heart rate of more than 20 bpm above the resting rate - An unchanged systolic pressure - An increase of 10 mm Hg blood pressure reading - An increase of 5 mm Hg in diastolic pressure

- A heart rate of more than 20 bpm above the resting rate 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? - Apricots, dried peas and beans, dates - Asparagus, blueberries, green beans - Cranberries, apples, popcorn - Bok choy, cooked leeks, alfalfa sprouts

- Apricots, dried peas and beans, dates 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.

- 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.

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? - 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. - Returning to work immediately is okay.

- 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 - B-type natriuretic peptide (BNP) - C-reactive protein (CRP) - Platelet count

- 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

- 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.

A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). The client's blood pressure is 104/68 mm Hg. The client's pulse rate is 76 beats/minute. The nurse detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take? - Document findings and check the client again in 1 hour. - Slow the I.V. fluid to prevent any more swelling at the puncture site. - Contact the health care provider and report the findings. - Encourage the client to perform isometric leg exercise to improve circulation in the legs.

- Contact the health care provider and report the findings. 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.

A nurse is caring for a client with a central venous pressure (CVP) of 4 mm Hg. Which nursing intervention is appropriate? - Call the health care provider and obtain an order for a fluid bolus. - Re-zero the equipment and take another reading. - Call the physician and obtain an order for a diuretic. - Continue to monitor the client as ordered.

- Continue to monitor the client as ordered. Explanation: Normal CVP ranges from 2 to 6 mm Hg. The nurse doesn't need to take any action other than to monitor the client. It isn't necessary to re-zero the equipment. Calling a health care provider and obtaining an order for a fluid bolus would be an appropriate intervention if the client has a CVP less than 2 mm Hg. Administering a diuretic would be appropriate if the client had excess fluid, as demonstrated by a CVP greater than 6 mm Hg. (Note: normal values can vary by reference source.)

The clinic nurse caring for a client with a cardiovascular disorder is performing an assessment of the client's pulse. Which of the following steps is involved in determining the pulse deficit? - Count the radial pulse for 20 to 25 seconds. - Calculate the palpated volume. - Count the heart rate at the apex. - Calculate the pauses between pulsations.

- Count the heart rate at the apex. 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.

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

- 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 dysrhythmia. Which of the following assessment considerations is essential when caring for this client? - Digoxin level - Cardiac output - Activity level - Dyspnea

- 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.

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

- 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. The other options would not dilate the coronary arteries.

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. - When the client is in the recumbent position, more pressure is put on the bladder, with the result of increased need to urinate. - The blood pressure is lower when the client is recumbent, which causes the kidneys to work harder; therefore, 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 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. Explanation: 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. The client's sleeping position does not cause bladder constriction and increased urination. The client's blood pressure is not causing more urination. The fluid in the client's lungs does not move to the kidneys at night.

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

- 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.

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. - Make up a small breakfast tray from what is available on the unit. - Offer hot tea or coffee only.

- Explain that no food or drink is allowed for 4 hours before the stress test. Explanation: 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 client should not have any coffee or food, including toast, for 4 hours prior to the stress test.

The nurse prepares to auscultate heart sounds. What nursing intervention will be most effective to assist with this procedure? - Explain to the client that the nurse will be listening to different areas of the chest and may listen for a long time, but that does not mean that anything abnormal is heard. - Ask the client to sit on the edge of the bed and hold breath while the nurse listens. - Insist that the family members leave the room if they must speak to each other while the nurse is auscultating heart sounds. - Ask the client to take deep breaths through the mouth while the nurse auscultates heart sounds.

- Explain to the client that the nurse will be listening to different areas of the chest and may listen for a long time, but that does not mean that anything abnormal is heard. Explanation: 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 normally during the examination. Sitting on the edge of the bed is not the preferred client position. The room should be quiet so asking the families to remain quiet is acceptable. The client does not need to take deep breaths during heart auscultation.

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

- 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.

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.

- 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 most appropriate for the nurse to monitor the client for what condition? - Impaired myocardial contractility - Enhanced sensitivity to digitalis - Increased risk of heart block - Inclination to ventricular fibrillation

- Impaired myocardial contractility 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 nurse is reviewing the morning laboratory test results for a client with cardiac problems. Which finding is a priority to report to the healthcare provider? - Na+ 140 mEq/L - Ca++ 9 mg/dL - K+ 3.1 mEq/L - Mg++ 2 mEq/L

- K+ 3.1 mEq/L 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

- 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 (Bickley, 2009; Woods et al., 2009).

After a physical examination, the provider diagnosed a patient with a grade 4 heart murmur. During assessment, the nurse expects to hear a murmur that is: - Easily heard with no palpable thrill. - Quiet but readily heard. - Loud and may be associated with a thrill sound similar to (a purring cat). - Very loud; can be heard with the stethoscope half-way off the chest.

- Loud and may be associated with a thrill sound similar to (a purring cat). 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. When auscultating a murmur, what does the nurse expect to hear? - Easily heard with no palpable thrill. - Quiet but readily heard. - Loud and may be associated with a thrill sound similar to (a purring cat). - Very loud; can be heard with the stethoscope half-way off the chest.

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

- 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 administering a beta blocker to a patient in order to decrease automaticity. Which medication will the nurse administer? - Diltiazem - Metoprolol - Amiodarone - Propafenone

- Metoprolol Explanation: Patients may receive beta-blockers prior to the scan to control heart rate and rhythm.

The nurse is caring for a client with ECG changes consistent with a myocardial infarction. Which of the following diagnostic test does the nurse anticipate to confirm heart damage? - Fluoroscopy - Nuclear cardiology - Serum blood work - Chest radiography

- Nuclear cardiology Explanation: Nuclear cardiology uses a radionuclide to detect areas of myocardial damage. Chest radiography and fluoroscopy determine the size and position of the heart and condition of the lungs. Serum blood work notes elevations in enzymes suggesting tissue damage.

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.

- 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 O2 saturation level and intervene as directed. The other assessments are not indicated.

A critically ill client is admitted to the ICU. The health care provider decides to use intra-arterial pressure monitoring. After this intervention is performed, what assessment should the nurse prioritize? - Fluctuations in core body temperature - Signs and symptoms of esophageal varices - Signs and symptoms of compartment syndrome - Perfusion distal to the insertion site

- Perfusion distal to the insertion site Explanation: The radial artery is the usual site selected. However, placement of a catheter into the radial artery can further impede perfusion to an area that has poor circulation. As a result, the tissue distal to the cannulated artery can become ischemic or necrotic. Vigilant assessment is thus necessary. Alterations in temperature and the development of esophageal varices or compartment syndrome are not high risks.

The nurse is assessing a patient's blood pressure. What does the nurse document as the difference between the systolic and the diastolic pressure? - Pulse pressure - Auscultatory gap - Pulse deficit - Korotkoff sound

- Pulse pressure Explanation: The difference between the systolic and the diastolic pressures is called the pulse pressure.

The clinic nurse is assessing a client's pulse before outpatient diagnostic testing. What should the nurse document when assessing the client's pulse? - Rate, quality, and rhythm - Pressure, rate, and rhythm - Rate, rhythm, and volume - Quality, volume, and rate

- Rate, quality, and rhythm Explanation: Assess apical and radial pulses, noting rate, quality, and rhythm. Pulse pressure and volume are not assessed in this instance.

It is important for a nurse to understand cardiac hemodynamics. For blood to flow from the right ventricle to the pulmonary artery, the following must occur: - The atrioventricular valves must open. - The pulmonic valve must be closed. - Right ventricular pressure must be higher than pulmonary arterial pressure. - Right ventricular pressure must decrease with systole.

- Right ventricular pressure must be higher than pulmonary arterial pressure. 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.

The nurse is assessing heart sounds in a patient with heart failure. An abnormal heart sound is detected early in diastole. How would the nurse document this? - S1 - S2 - S3 - S4

- S3 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

- 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.

A nurse is aware that the patient's heart rate is influenced by many factors. The nurse understands that the heart rate can be decreased by: - An excess level of thyroid hormone. - Stimulation of the vagus nerve. - An increased level of catecholamines. - Sympathetic nervous system stimulation.

- Stimulation of the vagus nerve. 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.

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.

- 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 asks questions. - The client hears thumping sounds. - The client wears a watch.

- 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.

- 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

- 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 patient recently diagnosed with pericarditis asks the nurse to explain what area of the heart is involved. How does the nurse best describe the pericardium to the client? - Thin fibrous sac that encases the heart. - Inner lining of the heart and valves. - Heart's muscle fibers. - Exterior layer of the heart.

- Thin fibrous sac that encases the heart. Explanation: The pericardium is a thin, fibrous sac that encases the heart. It is composed of two layers, the visceral and the parietal pericardium. The space between these two layers is filled with fluid.

The cardiologist has scheduled a client for drug-induced stress testing. What instructions should the nurse provide to prepare the client for this test? - You will receive medication via IV administration. - You will need to wear comfortable shoes to the test. - You will begin exercising at a slow speed. - You may experience an onset of dizziness during the test.

- You will receive medication via IV administration. 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.

What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse? - contractility - depolarization - repolarization - diastole

- 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.

For both outpatients and inpatients scheduled for diagnostic procedures of the cardiovascular system, the nurse performs a thorough initial assessment to establish accurate baseline data. Which data is necessary to collect if the client is experiencing chest pain? - blood pressure in the left arm - pulse rate in upper extremities - description of the pain - sound of the apical pulses

- description of the pain Explanation: If the client is experiencing chest pain, a history of its location, frequency, and duration is necessary. A description of the pain is also needed, including if it radiates to a particular area, what precipitates its onset, and what brings relief. The nurse weighs the client and measures vital signs. The nurse may measure blood pressure 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.

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

- endocardium 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

- 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.

The nurse auscultates the apex beat at which anatomical location? - midsternum - 5 cm to the left of the lower end of the sternum - 2.5 cm to the left of the xiphoid process - fifth intercostal space, midclavicular line

- fifth intercostal space, midclavicular line Explanation: 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.

The nurse cares for a client in the emergency department who has a B-type natriuretic peptide (BNP) level of 115 pg/mL. The nurse recognizes that this finding is most indicative of which condition? - heart failure - ventricular hypertrophy - pulmonary edema - myocardial infarction

- heart failure 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? - congenital heart disease - heart failure - aortic stenosis - coronary artery disease

- 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.

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

- left atrium 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

- 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.

What does decreased pulse pressure reflect? - tachycardia - reduced distensibility of the arteries - reduced stroke volume - elevated stroke volume

- 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.

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

- 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 health care provider? - sodium 148 mEq/L - potassium 3.9 mEq/L - calcium 9.8 mg/dL - magnesium 2.5 mg/dL

- 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 3.5 to 5.0 mEq/L. The normal range for calcium level is 8.5 to 10.5 mg/dL. Normal magnesium levels range from 1.8 to 3.0 mg/dL.

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? - insert an oral airway. - withhold food and fluids. - position the client on his side. - introduce a nasogastric (NG) tube.

- withhold food and fluids. Explanation: Following a transesophageal echocardiogram in which the client's throat has been anesthetized, the nurse should withhold food and fluid until the client's gag reflex returns. There's no indication that oral airway placement would be appropriate. The client should be in the upright position, and the nurse needn't insert an NG tube.