Ch 25: Assessment of Cardiovascular Function (1)
What is considered the pacemaker of the heart? pg. 675
The SA node
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? pg. 694
K+ 3.1 mEq/L
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? pg. 680
"Have you had any episodes of dizziness or fainting?"
A nurse is preparing a client for a scheduled adenosine stress test. Which statement made by the client indicates a need for further education? pg. 700
"My family is bringing me a cup of coffee to drink before the test."
The nurse is assessing vital signs on a client who is 3 months status post myocardial infarction (MI). While the healthcare provider is examining the client, the client's spouse approaches the nurse and states "We are too afraid he will have another heart attack, so we just don't have sex anymore." What is the nurse's best response? pg. 684
"The physiologic demands are greatest during orgasm and are equivalent to walking 3 to 4 miles per hour on a treadmill."
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? pg. 678
Heart failure
The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include? pg. 705
"Do not bend at the waist, strain, or lift heavy objects for the next 24 hours."
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? pg. 692
Loud and may be associated with a thrill sound similar to (a purring cat).
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? pg. 693
Enzymes
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? pg. 682
High density lipoproteins (HDL) increase from 25 mg/dl to 40 mg/dl.
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? pg. 683
Report any incident of bloody urine, stools, or both.
One of the students asks what the consequences of uncorrected, left-sided heart failure would be. What would be the nursing instructor's best response? pg. 822
Right-sided heart failure
The nurse uses which term for the normal pacemaker of the heart? pg. 675
Sinoatrial (SA) node
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? pg. 683
The patient had a vagal response.
The patient has a heart rate of 72 bpm with a regular rhythm. Where does the nurse determine the impulse arises from? pg. 675
The sinoatrial node
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? pg. 673
Thin fibrous sac that encases the heart.
What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse? pg. 672
contractility
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? pg. 694
international normalized ratio (INR)
The nurse correctly identifies which data as an example of blood pressure and heart rate measurements in a client with postural hypotension? pg. 687
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
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? pg. 703
withhold food and fluids.
