Pulse
Which of the following would NOT increase heart rate?
Stimulation by the vagal nerve
As part of your assessment of Grace's radial pulse, you measure 4 characteristics. Which of these assessment findings is indicative of the strength of Grace's radial pulse?
The pulse weakens to a 2 with the irregular beats
What is your second step?
Use either side of the stethoscope chest piece
As part of your nursing assessment, you are going to calculate Grace's pulse deficit. Choose the correct steps you will follow.
What is your first step? Ask Jen, another nurse, to assist you
The difference between the maximum and resting cardiac output is called ____________.
cardiac reserve
Detemine the cardiac output of a patient with a heart rate of 80 beats/min with a stroke volume of 75 mL/beat.
6
A patient with a heart rate of 85 beats per minute has an end systolic volume of 70 mL and an end diastolic volume of 150 mL. Determine the cardiac output in L/min. Your answer should be rounded to the nearest 10th, and ensure you use the proper units.
6.8
You are the nurse assessing the radial pulse rate of your patient and are reviewing the EMR first. Highlight the cues you will be aware of in the patient's history below that may influence the patient's heart rate.
fever over 39.8⁰C and shortness of breath pneumonia chronic pain 5 years opioid medication anxious postural hypotension
To assess an apical pulse, the nurse must use:
stethoscope
Which of the following best defines binaural?
Angled to keep the earpieces firmly & comfortably in the ears
You are the nurse preparing to obtain a set of vital signs on your patient. Drag and drop the words from the available choices to correctly complete each statement. Some choices may fit with more than one statement.
Ascualate the apical pulse Ascualate the apical pulse Midclavicular line meets the 4th or 5th intercostal space Ascualate the apical pulse Palpate the brachial pulse
Which of the following best defines the bell?
Bowl-shaped with a rubber ring which transmits low-pitched sounds such as vascular sounds
Detemine the cardiac output of a patient with a heart rate of 80 beats/min with an end diastolic volume of 80 mL and an end systolic volume of 120 mL.
CO = EDV - ESV CO = 120 ml - 80 ml CO = 3200 ml = 3.2 L
What variable(s) determine the effects of cardiac output? Choose the best answer.
Changes to both HR and SV
What is your third step?
Do one of these and delegate the other to person to assist you
Which of the following best defines the diaphragm?
Flat, circular area covered by a think plastic disk which transmits high-pitched sounds such as the movement of air
Possible nursing diagnoses for a patient with tachycardia, bradycardia, and/or dysrhythmias includes which of the following? Select all that apply.
Hypervolemia Impaired peripheral tissue perfusion Impaired cardiac function Dehydration Activity intolerance
You are assessing your patient's pulse. Select the correct statements regarding pulse assessment. Select all that apply.
If the interval between beats is interrupted by an early beat, late beat, or missed beat this indicates a dysrhythmia (abnormal rhythm) Thrombus can cause unequal strength of pulses in one extremity compared to another You identify that for 60 seconds, there are occasional early beats. You characterize this as irregularly irregular.
Identify whether each item would increase or decrease stroke volume.
Increase stroke volume Increased venous return Systemic vasodilation Positive inotropic agent Decrease stroke volume Decreased venous return Decreased preload Negative inotropic agent
What is your fourth step?
Listen to and count the heart sounds for one full minute while the other person simultaneously palpates the radial pulse for one full minute and compare findings
Which of the following regions of the brain contains the cardioregulatory centers?
Medulla oblongata
Positive ionotropic agents include Catecholamine, angiotensin II, glucagon, and insulin, while negative ionotropic agents include antiarrhythmics and beta blockers.
Positive ionotropic agents include Catecholamine, angiotensin II, glucagon, and insulin, while negative ionotropic agents include antiarrhythmics and beta blockers.
Match the factor that affects stroke volume to its description.
Preload The stretch of the atria during ventricular filling. Afterload The pressure required to overcome the vascular resistance. Venous return The amount of blood returned to the heart via the veins. Contractility The intrinsic strength of the contractions of the cardiac muscle.
Which of the following is true regarding the nursing assessment of a pulse? Select all that apply.
Pulses are relatively superficial and should not require deep palpation The peripheral pulses will weaken as cardiac output decreases Carotid pulses should never be palpated simultaneously
You have assessed your patient's pulse and obtained the following measurements. What information is missing considering the 4 characteristics of a pulse? Palpated 44 beats in 30 seconds. Counted 88 beats in 60 seconds. Strong beat palpated
Rhythm, site, and equality
You are in your patient's hospital room with another nurse preparing to measure the patient's pulse deficit. Choose the correct actions/statements from the choices below. Select all that apply.
A pulse deficit is the result of Inefficient contractions of the heart that are too weak to transmit the pulse wave to the peripheral pulse A pulse deficit is associated with abnormal heart rhythms One of you measure the radial pulse on one wrist and the other auscultate the apical rate simultaneously and subtract the difference in rates A pulse deficit is when the difference between the apical and radial rates is 2 bpm or more
Which of the following statements are true regarding the measurement of peripheral pulse? Select all that apply.
Palpate the peripheral pulse for 30 seconds and multiply this number by 2 to calculate the pulse rate The normal rage for pulse rate varies by age
What is your fifth step?
Subtract the rates to determine the pulse deficit
Which of the following best defines the tubing?
Tubing: thick, flexible, and 12-18 inches long to promote the best sound transmission
Schwannomas are due to tumor formation within the Schwann cells of the peripheral nervous system. When they occur in the neck, removal is difficult due to the possibility of severing a cranial nerve responsible for parasympathetic activity in the heart. What is this cranial nerve?
Vagal
As blood pressure increases, the volume of blood returned to the left ventricle will increase, stretching it more than typical, leading to an increase in stroke volume. This is an example of ______________.
preload
You are the nurse assessing the vital signs of your patients on a Medical-Surgical unit. The nurse knows that the normal heart rate range varies by age. Select whether the pulse rate measured on your patients below is typically considered within the normal range or tachycardic/bradycardic for their age.
AgeNormal Heart Rate Range (bpm) Infant 120-160 (CDC <1 years old) 2 hours old 3 months old Toddler 90-140 (CDC 1-2 years old) 22 months old Preschooler 80-110 (CDC 2-3 years old) 3 years old School-age child 75-100 (4-11) 5 years old 8 years old Adolescent 60-90 (12 -17) 14 years old Adult 60-100 (CDC 18 years or older) 25 years old 48 years old 82 years old
Grace's radial pulse is irregular. Select the three (3) priority actions you will take at this time from the choices below.
Continue to assess other characteristics of the radial pulse in addition to the rhythm Auscultate the apical pulse for one full minute Ask her if she feels dizzy, has palpitations or is short of breath
Which of the following best defines the earpieces?
Pointing toward the face when in the ears to allow best sound transmission
Categorize the compounds below as either positive or negative chronotropic agents. Drag and drop the compounds to the correct column.
Positive chronotropic agents include dopamine and ephinephrine, while negative chronotropic agents include beta blockers and acetylcholine.
You are the nurse caring for a patient who has poor circulation due to diabetes and a cardiomyopathy. You are assessing the circulation and pulse measurement at different peripheral areas of his body. Match the peripheral pulse site(s) you will palpate for each area of the body.
Site Location RadialUse this site to teach patients how to monitor their own HRs at home BrachialUsed to auscultate blood pressure CarotidUsed during physiological shock or cardiac arrest when other sites are not palpable. TemporalUsed to assess pulse in children UlnarUsed to perform an Allen's test PoplitealUsed to assess circulation to lower part of the body Dorsalis PedisUsed to assess circulation in the feet.
Classify the following statements as belonging to either sympathetic or parasympathetic stimulation of the heart.
Sympathetic Stimulation Fibers pass through the cardiac plexus Increases the contraction strength of the heart Dilates the coronary arteries Parasympathetic Stimulation Little or no innervation to the myocardium Slows the heart rate
The nurse is preparing to assess a client's pulse rate and is choosing which site to use. Choose the site from the drop-down menu to correctly complete each statement.
When assessing vital signs routinely, the carotid and radial pulse sites are most used because of their relative superficiality, which should not require deep palpation. When assessing blood supply to the feet (for example, following an injury to the area), palpation of the pedal, popliteal, and femoral arteries would be used. When assessing blood supply to the hands (for example, as part of a full physical assessment), palpation of the radial, ulnar, and brachial arteries would be used. When a client's condition suddenly deteriorates, the carotid site is the best for quickly finding a pulse because the heart continues delivering blood through the carotid artery to the cerebral circulation for as long as possible. However, the peripheral circulation will weaken as cardiac output decreases.