310 - ATI Cardiovascular

A nurse is caring for a client who has a peripheral venous ulcer. Which of the following actions should the nurse take? (Select all that apply.) -Instruct the client to apply warm heat for pain -Instruct the client to sit with their legs uncrossed. - Encourage the client to avoid tobacco products. - Instruct the client to cleanse the area with mild soap - Instruct the client to wear shoes when ambulating

-Instruct the client to sit with their legs uncrossed. - Encourage the client to avoid tobacco products. - Instruct the client to cleanse the area with mild soap - Instruct the client to wear shoes when ambulating

Which of the following conditions is associated with jugular vein distention? Severe dehydration Heart failure Peripheral arterial disease Heart murmur

Heart failure

Which of the following an extra or unexpected heart sound? S1 S2 S4 S3 Murmur

S4 S3 Murmur

Which of the following patient reports indicates a medical emergency? "I have been wheezing when I am around flowers" "I forgot to take my water pill this morning" "I have a family history of heart disease" "I have a tight feeling in my chest"

"I have a tight feeling in my chest"

What is the correlating scale rating for mild pitting edema that is barely noticeable? +4 +3 +2 +1

+1

Which of the following rating should you assign to a bounding carotid pulse? +4 +3 +2 +1

+4

Which of the following provides the most accurate information to include in the medical records? +4 pitting edema Edema present in the leg +4 pitting edema in the left lower leg The client appears to have edema in the leg due to heart failure

+4 pitting edema in the left lower leg

Which of the following are nursing interventions for chest pain? (select all that apply) - Apply O2 -Monitor viral signs ever 4hrs - Encourage the client to ambulate -Provide continuous ECG monitoring - Obtain IV access

- Apply O2 -Provide continuous ECG monitoring - Obtain IV access

Which of the following are the risk factors for heart disease? (select all that apply) - BMI > 30 - Smoking tobacco - Aerobic exercise - Family history of hypertension - Type 2 diabetes

- BMI > 30 - Smoking tobacco - Family history of hypertension - Type 2 diabetes

A nurse is inspecting and palpating the neck vessels of a client. Which of the following findings should the nurse report to the provider? (Select all that apply.) - Visible pulsations observed in the carotid area on both sides of the neck - Full, bounding pulse noted bilaterally in the carotid arteries upon palpation is correct .- Distention of the jugular vein on one side of the neck is correct -Flattening of the jugular veins when the client sits upright .-The left carotid artery pulse is weak is correct

- Full, bounding pulse noted bilaterally in the carotid arteries upon palpation is correct .- Distention of the jugular vein on one side of the neck is correct .-The left carotid artery pulse is weak is correct

Which of the following client responses require the nurse to ask additional open-ended questions? - I feel so tired just to even put out the trash - I used to be able to walk every day, but lately it's been too hard - Neve a smoker. I like to have a beer occasionally, but that's it - I slipped and fell last year on an icy step but I didn't get hurt - Now that you mention it, I did have some chest pain yesterday when I was cleaning out the garage. I had to sit down for a while and rest.

- I feel so tired just to even put out the trash - I used to be able to walk every day, but lately it's been too hard - Now that you mention it, I did have some chest pain yesterday when I was cleaning out the garage. I had to sit down for a while and rest.

Which of the following are signs of peripheral arterial disease (PAD)? (select all that apply) - Leg pain that occurs with activity - Decreased or absent pulses - Ulcers on the toes - Warm skin temperature - A bleeding ulceration on the leg

- Leg pain that occurs with activity - Decreased or absent pulses - Ulcers on the toes

Which of the following should the nurse include when documenting objective findings? (select all that apply) - Vital signs -Inspection results -Reason for client encounter - Plan of care -Patient teaching

- Vital signs -Inspection results

A nurse is teaching a client about behaviors that promote cardiovascular health. Which of the following client statements indicate an understanding of the teaching? (Select all that apply.) -"I am going to start walking several times a week." -"I plan to join a support group to help me stop smoking." -"If my HDL cholesterol is high, it can hurt my heart" -"I will be sure to have my blood pressure checked at least every year." -"Eating more low-fiber foods are processed carbohydrates will make my heart healthier"

-"I am going to start walking several times a week." -"I plan to join a support group to help me stop smoking." -"I will be sure to have my blood pressure checked at least every year."

A nurse is completing a medical history on a client. Which of the following findings indicates the client has a family history of cardiovascular disease? -Patient who experienced a pulmonary embolism -Sibling who has hypertension -Cousin who has diabetes mellitus -Child who has epilepsy

-Sibling who has hypertension

A nurse is auscultating a client's heart sounds. Place the nursing actions for auscultation of the heart in the correct order. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Visualize the anatomy of the heart is the second step. Auscultate the apical pulse for 1 min is the fifth step. Place the stethoscope to the right sternal border at the second intercostal space is the third step. Place the stethoscope close to the sternal border at the fourth intercostal space is the fourth step. Elevate the head of the bed 30° and instruct the client to breath normally is the first step.

1. Elevate the head of the bed 30° and instruct the client to breath normally is the first step. 2. Visualize the anatomy of the heart is the second step. 3. Place the stethoscope to the right sternal border at the second intercostal space is the third step. 4. Place the stethoscope close to the sternal border at the fourth intercostal space is the fourth step. 5. Auscultate the apical pulse for 1 min is the fifth step.

What order does blood flow through the heart valves? Pulmonic valve Aortic valve Mitral valve Tricuspid valve

1. Tricuspid valve 2. Pulmonic valve 3. Mitral valve 4. Aortic valve

A nurse is assessing the anterior chest of a client. Which of the following findings should the nurse report? A forceful chest movement at the midclavicular line in the fourth intercostal space The point of maximum impulse located at the 5th intercostal space Symmetrical chest movements during inhalation and expiration Absent visual pulsations in the area at the point of maximal impulse

A forceful chest movement at the midclavicular line in the fourth intercostal space

A nurse is auscultating heart sounds in a group of clients. Which of the following should the nurse identify as an expected variation? An older adult who has a heart rate of 48/min A young adult who has a irregular apical pulse A middle adult who has a murmur An adolescent who has an s3 heart sound

An adolescent who has an s3 heart sound

Identify which interventions are appropriate Ensure the client has intravenous access Place the client on continuous ECG monitoring to assess fro changes to the heart rhythm Encourage the client to ambulate in the hallway with assistance Notify the Rapid Response Team Request an order for a proton pump inhibitor from the provider Assist the client to a semi-Flowlers position Reassure the client you will return to check on them in 30 minutes Administer oxygen via nasal cannula Instruct the client to use an incentive spirometer 8 to 10 times

Appropriate actions -Place the client on continuous ECG monitoring to assess fro changes to the heart rhythm -Assist the client to a semi-Flowlers position -Administer oxygen via nasal cannula -Notify the Rapid Response Team -Ensure the client has intravenous access Inappropriate actions -Instruct the client to use an incentive spirometer 8 to 10 time -Encourage the client to ambulate in the hallway with assistance -Reassure the client you will return to check on them in 30 minutes -Request an order for a proton pump inhibitor from the provider

A nurse is preparing to conduct a cardiovascular assessment on a client. Which of the following actions should the nurse plan to take? (Select all that apply.) Auscultate the apical pulse. Ask the client if they experience shortness of breath. Check the color of the client's skin. Auscultate bowel motility. Auscultate bowel mobility Inspect the extremities for the presence of edema.

Auscultate the apical pulse. Ask the client if they experience shortness of breath. Check the color of the client's skin. Inspect the extremities for the presence of edema.

A nurse has completed a cardiovascular assessment on a client. Which of the following findings should the nurse report to the provider? Capillary refill of 3 seconds 2+ radial pulse Fingernail with 160* curvature Oxygen saturation 98%

Capillary refill of 3 seconds

A nurse is assessing a client who reports an increase in their stress level related to the demands of their job. Which of the following interventions should the nurse recommend for the client to reduce their stress? Instruct the client to vary the time they go to sleep each night Have the client check their blood pressure Discuss the benefits of meditation with the client Have the client limit their exercise program until the stress has decreased

Discuss the benefits of meditation with the client

A nurse is assessing a client's jugular veins and carotid arteries. The nurse should assist the client into which of the following positions? Place the client in high-Fowler's position Have the client lay supine with the head of the bed at a 45° angle. Have the client seated with their chin touching their chest Place the client in a left lateral position

Have the client lay supine with the head of the bed at a 45° angle.

A nurse is preparing to teach a client who has a BMI of 32 about a heart-healthy diet. Which of the following dietary recommendations should the nurse include? Increase intake of red meat Limit sodium intake to less than 3,000 mg/day. Increase intake of foods high in trans fat Drink whole milk

Limit sodium intake to less than 3,000 mg/day.

A nurse is caring for a client who has a foot ulcer. Which of the following findings should the nurse identify as consistent with peripheral venous disease? Loss of hair on the lower leg Palpable dorsalis pedal pulse Cool skin temp in lower leg Regular, even wound border

Palpable dorsalis pedal pulse

Which of the following documentation provides the most accurate information to include in the medical records? Radial pulses +1 bilateral with rate 110 bpm Radial pulse strong Radial pulse present bilaterally Radial pulse +2

Radial pulses +1 bilateral with rate 110 bpm