Ch 25 NCLEX
The nurse is caring for a patient with an intra-arterial BP monitoring device. The nurse recognizes the most preventable complication associated with hemodynamic monitoring includes which of the following? a) Air embolism b) Catheter-related bloodstream infections (CRBSI) c) Pneumothorax d) Hemorrhage
a) Catheter-related bloodstream infections (CRBSI) Explanation: CRBSIs are the most common preventable complication associated with hemodynamic monitoring systems. Comprehensive guidelines for the prevention of these infections have been published by Centers for Disease Control and Prevention (CDC). Complications from use of hemodynamic monitoring systems are uncommon and can include pneumothorax, infection, and air embolism. A pneumothorax may occur during the insertion of catheters using a central venous approach (CVP and pulmonary artery catheters). Air emboli can be introduced into the vascular system if the stopcocks attached to the pressure transducers are mishandled during blood drawing, administration of medications, or other procedures that require opening the system to air.
The nurse is preparing to apply ECG electrodes to a male patient who requires continuous cardiac monitoring. Which of the following should the nurse complete to optimize skin adherence and conduction of the heart's electrical current? a) Clip the patient's chest hair prior to applying the electrodes. b) Once the electrodes are applied, change them every 72 hours. c) Clean the patient's chest with alcohol prior to application of the electrodes. d) Apply baby powder to the patient's chest prior to placing the electrodes.
a) Clip the patient's chest hair prior to applying the electrodes. Explanation: The nurse should complete the following actions when applying cardiac electrodes: Clip (do not shave) hair from around the electrode site, if needed; if the patient is diaphoretic (sweaty), apply a small amount of benzoin to the skin, avoiding the area under the center of the electrode; debride the skin surface of dead cells with soap and water and dry well (or as recommended by the manufacturer). Change the electrodes every 24 to 48 hours (or as recommended by the manufacturer); examine the skin for irritation and apply the electrodes to different locations.
A harsh grating sound caused by abrasion of the pericardial surfaces during the cardiac cycle is termed which of the following? a) Friction rub b) Murmur c) Ejection click d) Opening snap
a) Friction rub Explanation: In pericarditis, a harsh, grating sound that can be heard in both systole and diastole is called a friction rub. A murmur is created by the turbulent flow of blood. A cause of the turbulence may be a critically narrowed valve. An opening snap is caused by high pressure in the left atrium with abrupt displacement of a rigid mitral valve. An ejection click is caused by very high pressure within the ventricle, displacing a rigid and calcified aortic valve.
The nurse is caring for a patient prescribed warfarin (Coumadin) orally. The nurse reviews the patient's prothrombin time (PT) level to evaluate the effectiveness of the medication. The nurse should also evaluate which of the following laboratory values? a) International normalized ratio (INR) b) Complete blood count (CBC) c) Partial thromboplastic time (PTT) d) Sodium
a) International normalized ratio (INR) Explanation: The INR, reported with the PT, provides a standard method for reporting PT levels and eliminates the variation of PT results from different laboratories. The INR, rather than the PT alone, is used to monitor the effectiveness of warfarin. The therapeutic range for INR is 2 to 3.5, although specific ranges vary based on diagnosis. The other laboratory values are not used to evaluate the effectiveness of Coumadin.
The nurse auscultates the PMI (point of maximal impulse) at which of the following anatomic locations? a) Left midclavicular line, fifth intercostal space b) 1 inch to the left of the xiphoid process c) Midsternum d) 2 inches to the left of the lower end of the sternum
a) Left midclavicular line, fifth intercostal space Explanation: The left ventricle is responsible for the apical impulse 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 PMI is inappropriate based on variations in human anatomy. Auscultation below and to the left of the xiphoid process will detect gastrointestinal sounds, but not the PMI.
A nurse is preparing to assess a patient for postural BP changes. Which of the following indicates the need for further education? a) Letting 30 seconds elapse after each position change before measuring BP and heart rate (HR) b) Taking the patient's BP with the patient sitting on the edge of the bed with feet dangling c) Obtaining the supine measurements prior to the sitting and standing measurements d) Positioning the patient supine for 10 minutes prior to taking the initial BP and HR
a) Letting 30 seconds elapse after each position change before measuring BP and heart rate (HR) Explanation: The following steps are recommended when assessing patients for postural hypotension: Position the patient supine for 10 minutes before taking the initial BP and HR measurements; reposition the patient to a sitting position with legs in the dependent position, wait 2 minutes then reassess both BP and HR measurements; if the patient is symptom free or has no significant decreases in systolic or diastolic BP, assist the patient into a standing position, obtain measurements immediately and recheck in 2 minutes; continue measurements every 2 minutes for a total of 10 minutes to rule out postural hypotension. Return the patient to supine position if postural hypotension is detected or if the patient becomes symptomatic. Document HR and BP measured in each position (e.g., supine, sitting, and standing) and any signs or symptoms that accompany the postural changes.
The nurse is caring for a patient with clubbing of the fingers and toes. The nurse should complete which of the following actions given these findings? a) Obtain an oxygen saturation level. b) Obtain a 12-lead ECG tracing. c) Assess the patient's capillary refill. d) Assess the patient for pitting edema.
a) 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 patient's O2 saturation level and intervene as directed. The other assessments are not indicated.
When the balloon on the distal tip of a pulmonary artery catheter is inflated and a pressure is measured, the measurement obtained is referred to as which of the following? a) Pulmonary artery wedge pressure b) Pulmonary artery pressure c) Central venous pressure d) Cardiac output
a) Pulmonary artery wedge pressure Explanation: When the balloon is inflated, the tip of the catheter floats into smaller branches of the pulmonary artery until it can no longer be passed and the pressure is recorded, reflecting left atrial pressure and left ventricular end-diastolic pressure. Central venous pressure is measured in the right atrium. Pulmonary artery pressure is measured when the balloon tip is not inflated. Cardiac output is determined through thermodilution involving injection of fluid into the pulmonary artery catheter.
The nurse is observing a patient during an exercise stress test (bicycle). Which of the following findings indicates a positive test and the need for further diagnostic testing? a) ST-segment changes on the ECG b) BP changes; 148/80 mm Hg to 166/90 mm Hg c) Dizziness and leg cramping d) Heart rate changes; 78 bpm to 112 bpm
a) 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; BP; 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 patient experiences signs of myocardial ischemia. Further diagnostic testing, such as a cardiac catheterization, may be warranted if the patient develops chest pain, extreme fatigue, a decrease in BP or pulse rate, serious dysrhythmias or ST-segment changes on the ECG during the stress test. The other findings would not warrant the testing to be stopped.
The nurse correctly identifies which of the following data as an example of BP and HR measurements in a patient with postural hypotension? a) 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 b) Supine: BP 130/70 mm Hg, HR 80 bpm; sitting: BP 128/70 mm Hg, HR 80 bpm; standing: BP 130/68 mm Hg, HR 82 bpm c) Supine: BP 114/82 mm Hg, HR 90 bpm; sitting: BP 110/76 mm Hg, HR 95 bpm; standing: BP 108/74 mm Hg, HR 98 bpm d) Supine: BP 140/78 mm Hg, HR 72 bpm; sitting: BP 145/78 mm Hg, HR 74 bpm; standing: BP 144/78 mm Hg, HR 74 bpm
a) 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 Explanation: 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. The following is an example of BP and HR measurements in a patient with postural hypotension: 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. Normal postural responses that occur when a person moves from a lying to a standing position include (1) a HR 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.
The nurse is caring for a patient with diabetes who is scheduled for a cardiac catheterization. Prior to the procedure, it is most important for the nurse to ask which of the following questions? a) "When was the last time you ate or drank?" b) "Are you allergic to shellfish?" c) "What was your morning blood sugar reading?" d) "Are you having chest pain?"
b) "Are you allergic to shellfish?" Explanation: Radiopaque contrast agents are used to visualize the coronary arteries. Some contrast agents contain iodine, and the patient is assessed before the procedure for previous reactions to contrast agents or allergies to iodine-containing substances (e.g., seafood). If the patient has a suspected or known allergy to the substance, antihistamines or methylprednisolone (Solu-Medrol) may be administered before the procedure. Although the other questions are important to ask the patient, it is most important to ascertain if the patient has an allergy to shellfish.
The nurse is reviewing discharge instructions with a patient who underwent a left groin cardiac catheterization 8 hours ago. Which of the following instructions should the nurse include? a) "If any discharge occurs at the puncture site, call 911 immediately." b) "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." c) "Contact your primary care provider if you develop a temperature above 102°F." d) "You can take a tub bath or a shower when you get home."
b) "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." Explanation: The nurse should instruct the patient to complete the following: If the artery of the groin was used, for the next 24 hours, do not bend at the waist, strain, or lift heavy objects; the primary provider should be contacted if any of the following occur: swelling, new bruising or pain from your procedure puncture site, temperature of 101°F or more. 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 patient should not drive to the hospital.
Decreased pulse pressure reflects which of the following? a) Tachycardia b) Reduced stroke volume c) Elevated stroke volume d) Reduced distensibility of the arteries
b) 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.
Which of the following terms is used to describe the ability of the heart to initiate an electrical impulse? a) Contractility b) Excitability c) Automaticity d) Conductivity
c) Automaticity Explanation: Automaticity is the ability of specialized electrical cells of the cardiac conduction system to initiate an electrical impulse. Contractility refers to the ability of the specialized electrical cells of the cardiac conduction system to contract in response to an electrical impulse. Conductivity refers to the ability of the specialized electrical cells of the cardiac conduction system to transmit an electrical impulse from one cell to another. Excitability refers to the ability of the specialized electrical cells of the cardiac conduction system to respond to an electrical impulse.
Age-related changes associated with the cardiac system include which of the following? Select all that apply. a) Increase in the number of SA node cells b) Myocardial thinning c) Endocardial fibrosis d) Increased size of the left atrium
c) Endocardial fibrosis, d) Increased size of the left atrium Explanation: Age-related changes associated with the cardiac system include endocardial fibrosis, increased size of the left atrium, decreased number of SA node cells, and myocardial thickening.
The area of the heart that is located at the third intercostal (IC) space to the left of the sternum is which of the following? a) Aortic area b) Pulmonic area c) Erb's point d) Epigastric area
c) Erb's point Explanation: Erb's 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 is caring for a patient in the ICU who is being monitored with a central venous pressure (CVP) catheter. The nurse records the patient's CVP as 8 mm Hg. The nurse understands that this finding indicates the patient is experiencing which of the following? a) Overdiuresis b) Left-sided heart failure (HF) c) Hypervolemia d) Excessive blood loss
c) Hypervolemia Explanation: The normal CVP is 2 to 6 mm Hg. A CVP greater than 6 mm Hg indicates an elevated right ventricular preload. Many problems can cause an elevated CVP, but the most common is hypervolemia (excessive fluid circulating in the body) or right-sided HF. In contrast, a low CVP (<2 mm Hg) indicates reduced right ventricular preload, which is most often from hypovolemia.
The nurse is screening a patient prior to a magnetic resonance angiogram (MRA) of the heart. Which of the following actions should the nurse complete prior to the patient undergoing the procedure? Select all that apply. a) Position the patient on his/her stomach for the procedure. b) Sedate the patient prior to the procedure. c) Remove the patient's Transderm Nitro patch. d) Remove the patient's jewelry. e) Offer the patient a headset to listen to music during the procedure.
c) Remove the patient's Transderm Nitro patch., d) Remove the patient's jewelry., e) Offer the patient a headset to listen to music during the procedure. Explanation: Transdermal patches that contain a heat-conducting aluminized layer (e.g., NicoDerm, Androderm, Transderm Nitro, Transderm Scop, Catapres-TTS) must be removed before MRA to prevent burning of the skin. A patient who is claustrophobic may need to receive a mild sedative before undergoing an MRA. During an MRA, the patient is positioned supine on a table that is placed into an enclosed imager or tube containing the magnetic field. Patients are instructed to remove any jewelry, watches, or other metal items (e.g., ECG leads). An intermittent clanking or thumping that can be annoying is generated by the magnetic coils, so the patient may be offered a headset to listen to music.
Which of the following is the term for the normal pacemaker of the heart? a) Bundle of His b) Purkinje fibers c) Sinoatrial (SA) node d) Atrioventricular (AV) node
c) Sinoatrial (SA) node Explanation: The sinoatrial node is the primary pacemaker of the heart. The AV node coordinates the incoming electrical impulses from the atria and, after a slight delay, relays the impulse to the ventricles. The Purkinje fibers rapidly conduct the impulses through the thick walls of the ventricles.
The nurse is caring for a patient who has undergone peripheral arteriography. How should the nurse assess the adequacy of peripheral circulation? a) By observing the patient for bleeding b) By hemodynamic monitoring c) By checking for cardiac dysrhythmias d) By checking peripheral pulses
d) By checking peripheral pulses Explanation: Peripheral arteriography is used to diagnose occlusive arterial disease in smaller arteries. The nurse observes the patient for bleeding and cardiac dysrhythmias and assesses the adequacy of peripheral circulation by frequently checking the peripheral pulses. Hemodynamic monitoring is used to assess the volume and pressure of blood in the heart and vascular system.
The ability of the cardiac muscle to shorten in response to an electrical impulse is termed which of the following? a) Diastole b) Depolarization c) Repolarization d) Contractility
d) 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 of the following data is necessary to collect if the patient is experiencing chest pain? a) Blood pressure in the left arm b) Sound of the apical pulses c) Pulse rate in upper extremities d) Description of the pain
d) Description of the pain Explanation: If the patient is experiencing chest pain, a history of its location, frequency, and duration is necessary, as is a description of the pain, if it radiates to a particular area, what precipitates its onset, and what brings relief. The nurse weighs the patient and measures vital signs. The nurse may measure BP 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.
The nurse is caring for a patient in the ICU diagnosed with coronary artery disease (CAD). Which of the following assessment data indicates the patient is experiencing a decrease in cardiac output? a) Reduced pulse pressure and heart murmur b) Elevated jugular venous distention (JVD) and postural changes in BP c) BP 108/60 mm Hg, ascites, and crackles d) Disorientation, 20 mL of urine over the last 2 hours
d) Disorientation, 20 mL of urine over the last 2 hours Explanation: Assessment findings associated with reduced cardiac output include reduced pulse pressure, hypotension, tachycardia, reduced urine output, lethargy, or disorientation.
The nurse is caring for a patient in the ED who has a B-type natriuretic peptide (BNP) level of 115 pg/mL. The nurse understands that this finding is most suggestive of which of the following? a) Myocardial infarction b) Ventricular hypertrophy c) Pulmonary edema d) Heart failure
d) Heart failure Explanation: A BNP level greater than 100 pg/mL is suggestive of HF. Because this serum laboratory test can be quickly obtained, BNP levels are useful for prompt diagnosis of HF in settings such as the ED. Elevations in BNP can occur from a number of other conditions such as pulmonary embolus, myocardial infarction (MI), and ventricular hypertrophy. Therefore, the clinician correlates BNP levels with abnormal physical assessment findings and other diagnostic tests before making a definitive diagnosis of HF.
During the auscultation of a patient's heart sounds, the nurse notes an S4. The nurse recognizes that an S4 is associated with which of the following? a) Turbulent blood flow b) Heart failure c) Diseased heart valves d) Hypertensive heart disease
d) Hypertensive heart disease Explanation: Auscultation of the heart requires familiarization with normal and abnormal heart sounds. An extra sound just before S1 is an S4 heart sound, or atrial gallop. An S4 sound often is associated with hypertensive heart disease. A sound that follows S1 and S2 is called an S3 heart sound or a ventricular gallop. An S3 heart sound is often an indication of heart failure in an adult. In addition to heart sounds, auscultation may reveal other abnormal sounds, such as murmurs and clicks, caused by turbulent blood flow through diseased heart valves.
