Chapter 25: Assessment of Cardiovascular Function

Which area of the heart that is located at the third intercostal space to the left of the sternum? 1. pulmonic area 2. Erb point 3. epigastric area 4. aortic area

Correct Responce: Erb point Explanation: Erb point is located at the third intercostal space to the left of the sternum. The aortic area is located at the second intercostal space to the right of the sternum. The pulmonic area is at the second intercostal space to the left of the sternum. The epigastric area is located below the xiphoid process.

The nurse cares for a client with diabetes who is scheduled for a cardiac catheterization. Prior to the procedure, it is most important for the nurse to ask which question? 1. "Are you allergic to shellfish?" 2. "Are you having chest pain?" 3. "When was the last time you ate or drank?" 4. "What was your morning blood sugar reading?"

Correct response: "Are you allergic to shellfish?" Explanation: Radiopaque contrast agents are used to visualize the coronary arteries. Some contrast agents contain iodine, and the client is assessed before the procedure for previous reactions to contrast agents or allergies to iodine-containing substances (e.g., seafood). If the client has a suspected or known allergy to the substance, antihistamines or methylprednisolone may be administered before the procedure. Although the other questions are important to ask the client, it is most important to ascertain if the client has an allergy to shellfish.

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? 1. "You need to research hormone replacement therapy and determine what you want to do." 2. "Current evidence indicates that estrogen replacement is not effective at preventing cardiovascular disease and carries some risks." 3. "Current research determines that estrogen replacement protects heart health for most women after menopause." 4. "That's a great idea. You don't want to have a heart attack."

Correct response: "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? 1. "Contact your primary care provider if you develop a temperature above 102°F." 2. "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." 3. "You can take a tub bath or a shower when you get home." 4. "If any discharge occurs at the puncture site, call 911 immediately."

Correct response: "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.

The following clients are in need of exercise electrocardiography. Which client would the nurse indicate as most appropriate for a drug-induced stress test? 1. A 68-year-old housewife with history of osteoporosis 2. A 72-year-old retired janitor obtaining a cardiac baseline 3. A 48-year-old policemen with history of knee replacement 4 years ago 4. A 55-year-old recovering from a fall and broken femur

Correct response: 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? 1. A heart rate of more than 20 bpm above the resting rate 2. An unchanged systolic pressure 3. An increase of 10 mm Hg blood pressure reading 4. An increase of 5 mm Hg in diastolic pressure

Correct response: 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.

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? 1. C-reactive protein (CRP) 2. Potassium 3. Platelet count 4. B-type natriuretic peptide (BNP)

Correct response: 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? 1. Baroreceptors 2. Vagus nerve 3. Sympathetic nerve fibers 4. Chemoreceptors

Correct response: 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.

The nurse is taking a health history from a client admitted with the medical diagnosis of cardiovascular disease (CVD). Which symptoms correlate with the client's diagnosis? 1. Fatigue, ecchymosis, confusion 2. Dizziness, rash, extra-ocular eye movements 3. Chest pain, weight gain, fatigue 4. Petechiae, ascites, constipation

Correct response: Chest pain, weight gain, fatigue Explanation: Chest pain, weight gain, fatigue, dizziness, ascites, and confusion are all symptoms of CVD. Rash, extra-ocular eye movements, ecchymosis, and petechiae are not usually indicative of CVD.

The nurse is caring for a client with a damaged tricuspid valve. The nurse knows that the tricuspid valve is held in place by which of the following? 1. Chordae tendineae 2. Atrioventricular tendons 3. Papillary tendons 4. Semilunar tendineae

Correct response: Chordae tendineae Explanation: Attached to the mitral and tricuspid valves are cordlike structures known as chordae tendineae, which in turn attach to papillary muscles, two major muscular projections from the ventricles. Options B, C, and D are distractors for the question.

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? 1. Contact the health care provider and report the findings. 2. Slow the I.V. fluid to prevent any more swelling at the puncture site. 3. Document findings and check the client again in 1 hour. 4. Encourage the client to perform isometric leg exercise to improve circulation in the legs.

Correct response: 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 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? 1. Encourage the client to perform isometric leg exercise to improve circulation in the legs. 2. Contact the health care provider and report the findings. 3. Document findings and check the client again in 1 hour. 4. Slow the I.V. fluid to prevent any more swelling at the puncture site.

Correct response: 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.

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? 1. Count the heart rate at the apex. 2. Calculate the palpated volume. 3. Count the radial pulse for 20 to 25 seconds. 4. Calculate the pauses between pulsations.

Correct response: 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.

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? 1. Count the radial pulse for 20 to 25 seconds. 2. Calculate the palpated volume. 3. Count the heart rate at the apex. 4. Calculate the pauses between pulsations.

Correct response: 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.

The nurse is performing an assessment of a clients peripheral pulses and indicates that the pulse quality is +1 on a scale of 0-4. What does this documented finding indicate? 1. Full, easy to palpate, and cannot be obliterated with pressure. 2. Difficult to palpate and is obliterated with pressure. 3. Diminished, but cannot be obliterated with pressure. 4. Strong and bounding and may be abnormal.

Correct response: Difficult to palpate and is obliterated with pressure. Explanation: The quality of pulses is reported using descriptors and a scale of 0 to 4. The lower the number, the weaker the pulse and the easier it is to obliterate it. A +1 pulse is weak and thready and easily obliterated with pressure.

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? 1. Digoxin 2. Enoxaparin 3. Clopidogrel 4. Heparin

Correct response: 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? 1. Dyspnea 2. Digoxin level 3. Activity level 4. Cardiac output

Correct response: 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? 1. Thallium 2. Ativan 3. Diazepam 4. Dobutamine

Correct response: 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? 1. 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. 2. When the client is in the recumbent position, more pressure is put on the bladder, with the result of increased need to urinate. 3. The blood pressure is lower when the client is recumbent, which causes the kidneys to work harder; therefore, more urine is produced. 4. 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.

Correct response: 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? 1. RBC 2. Enzymes 3. Platelets 4. WBC

Correct response: 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.

Which area of the heart that is located at the third intercostal space to the left of the sternum? Erb point aortic area epigastric area pulmonic area

Correct response: Erb point Explanation: Erb point is located at the third intercostal space to the left of the sternum. The aortic area is located at the second intercostal space to the right of the sternum. The pulmonic area is at the second intercostal space to the left of the sternum. The epigastric area is located below the xiphoid process.

The nurse prepares to auscultate heart sounds. What nursing intervention will be most effective to assist with this procedure? 1. Insist that the family members leave the room if they must speak to each other while the nurse is auscultating heart sounds. 2. Ask the client to sit on the edge of the bed and hold breath while the nurse listens. 3. Ask the client to take deep breaths through the mouth while the nurse auscultates heart sounds. 4. 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.

Correct response: 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 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? Increased risk of heart block Impaired myocardial contractility Enhanced sensitivity to digitalis Inclination to ventricular fibrillation

Correct response: 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.

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? 1. Easily heard with no palpable thrill. 2. Quiet but readily heard. 3. Loud and may be associated with a thrill sound similar to (a purring cat). 4. Very loud; can be heard with the stethoscope half-way off the chest.

Correct response: 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? 1. Lorazepam 2. Methylprednisolone 3. Phenytoin 4. Furosemide

Correct response: 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? 1. Diltiazem 2. Propafenone 3. Metoprolol 4. Amiodarone

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

Which assessments should a nurse perform when caring for a client following a cardiac catheterization? Select all that apply. 1. Palpate the pulse in different locations. 2. Inspect pressure dressing for signs of bleeding. 3. Palpate the insertion site for tenderness. 4. Monitor BP and pulse frequently. 5. Inspect the color in every extremity.

Correct response: Monitor BP and pulse frequently. Inspect pressure dressing for signs of bleeding. Palpate the pulse in different locations. Explanation: After a cardiac catheterization, the nurse monitors BP and pulse frequently to detect complications, checks the dressing over the insertion site frequently for signs of bleeding, palpates the pulse in various locations, and checks the color and temperature in the affected extremity to confirm that blood is circulating well.

The nurse cares for a client with clubbing of the fingers and toes. The nurse should complete which action given these findings? 1. Obtain an oxygen saturation level. 2. Obtain a 12-lead ECG tracing. 3. Assess the client for pitting edema. 4. Assess the client's capillary refill.

Correct response: 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.

The nurse is educating a patient at risk for atherosclerosis. What nonmodifiable risk factor does the nurse identify for the patient? 1. Obesity 2. Positive family history 3. Stress 4. Hyperlipidemia

Correct response: Positive family history Explanation: The health history provides an opportunity for the nurse to assess patients' understanding of their personal risk factors for coronary artery, peripheral vascular, and cerebrovascular diseases and any measures that they are taking to modify these risks. Risk factors are classified by the extent to which they can be modified by changing one's lifestyle or modifying personal behaviors. Stress, obesity, and hyperlipidemia are all risk factors that can be modified by personal behaviors. Family history is a nonmodifiable risk factor, because it cannot be changed.

The nurse is assessing a patient's blood pressure. What does the nurse document as the difference between the systolic and the diastolic pressure? 1. Pulse pressure 2. Auscultatory gap 3. Pulse deficit 4. Korotkoff sound

Correct response: 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? 1. Pressure, rate, and rhythm 2. Rate, rhythm, and volume 3. Rate, quality, and rhythm 4. Quality, volume, and rate

Correct response: 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: 1. The pulmonic valve must be closed. 2. The atrioventricular valves must open. 3. Right ventricular pressure must be higher than pulmonary arterial pressure. 4. Right ventricular pressure must decrease with systole.

Correct response: 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.

A client in the ICU has a central venous pressure (CVP) line placed. The CVP reading is 10 mm Hg. To what condition does the nurse correlate the CVP reading? 1. Hypovolemia 2. Left-sided heart failure 3. Right-sided heart failure 4. Reduction in preload

Correct response: Right-sided heart failure Explanation: Normal CVP is 2 to 8 mm Hg. A CVP greater that 8 mm Hg indicates hypervolemia or right-sided heart failure. A CVP less than 2 mm Hg indicates a reduction in preload or hypovolemia.

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? 1. S4 2. S3 3. S1 4. S2

Correct response: 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? 1. Dizziness and leg cramping 2. BP changes; 148/80 mm Hg to 166/90 mm Hg 3. ST-segment changes on the ECG 4. Heart rate changes; 78 bpm to 112 bpm

Correct response: 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.

The nurse observes a client during an exercise stress test (bicycle). Which finding indicates a positive test and the need for further diagnostic testing? 1. Dizziness and leg cramping 2. ST-segment changes on the ECG 3. BP changes; 148/80 mm Hg to 166/90 mm Hg 4. Heart rate changes; 78 bpm to 112 bpm

Correct response: 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: 1. An excess level of thyroid hormone. 2. Stimulation of the vagus nerve. 3. An increased level of catecholamines. 4. Sympathetic nervous system stimulation.

Correct response: 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.

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: 1. Stimulation of the vagus nerve. 2. Sympathetic nervous system stimulation. 3. An excess level of thyroid hormone. 4. An increased level of catecholamines.

Correct response: 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 nurse is discussing the cardiac system with a client admitted with heart failure. The client asks "What determines the heart rate?" What is the nurse's best response? 1. Preload controls the heart rate. 2. Force of contractility controls the heart rate. 3. Stroke volume controls the heart rate. T4. he autonomic nervous system controls the heart rate.

Correct response: The autonomic nervous system controls the heart rate. Explanation: The autonomic nervous system primarily controls the heart rate. When the sympathetic branch is stimulated, heart rate increases. When the parasympathetic branch is stimulated, heart rate decreases. Stroke volume is the amount of blood pumped out of the ventricle with each contraction and depends on three factors: preload, afterload, and contractility.

The patient has a heart rate of 72 bpm with a regular rhythm. Where does the nurse determine the impulse arises from? 1. The AV node 2. The sinoatrial node 3. The ventricles 4. The Purkinje fibers

Correct response: 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).

The nurse is caring for a patient with a diagnosis of pericarditis. Where does the nurse understand the inflammation is located? 1. The inner lining of the heart and valves 2. The exterior layer of the heart 3. The thin fibrous sac encasing the heart 4. The heart's muscle fibers

Correct response: The thin fibrous sac encasing the heart Explanation: The heart is encased in a thin, fibrous sac called the pericardium, which is composed of two layers. Inflammation of this sac is known as pericarditis.

The nurse cares for a client with an intra-arterial blood pressure monitoring device. The nurse recognizes the most preventable complication associated with hemodynamic monitoring includes which condition? 1. hemorrhage 2. air embolism 3. pneumothorax 4. catheter-related bloodstream infections

Correct response: catheter-related bloodstream infections Explanation: Catheter-related bloodstream infections (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.

For a client who has undergone peripheral arteriography, how should the nurse assess the adequacy of peripheral circulation? 1. checking peripheral pulses 2. checking for cardiac dysrhythmias 3. observing the client for bleeding 4. hemodynamic monitoring

Correct response: checking peripheral pulses Explanation: Peripheral arteriography is used to diagnose occlusive arterial disease in smaller arteries. The nurse observes the client 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.

During an initial assessment, the nurse measures the client's apical pulse and compares it to the peripheral pulse. The difference between the two is known as pulse: 1. quality. 2. deficit. 3. volume. 4. rhythm.

Correct response: deficit. Explanation: To determine the pulse deficit, one nurse counts 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. Pulse rhythm is the pattern of the pulsations and the pauses between them. Pulse volume is described as feeling full, weak, or thready, meaning barely palpable. The pulse quality refers to its palpated volume.

Age-related changes associated with the cardiac system include 1. decreased size of the left atrium. 2. increase in the number of SA node cells. 3. endocardial fibrosis. 4. myocardial thinning.

Correct response: endocardial fibrosis. Explanation: Age-related changes associated with the cardiac system include: endocardial fibrosis, increased size of the left atrium, a decreasing number of SA node cells, and myocardial thickening.

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? 1. epicardium 2. pericardium 3. endocardium 4. myocardium

Correct response: 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.

What is a harsh grating sound caused by abrasion of the pericardial surfaces during the cardiac cycle? 1. murmur 2. ejection click 3. friction rub 4. opening snap

Correct response: friction rub Explanation: During 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 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? 1. pulmonary edema 2. myocardial infarction 3. heart failure 4. ventricular hypertrophy

Correct response: 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.

During the auscultation of heart, what is revealed by an atrial gallop? hypertensive heart disease diseased heart valves heart failure turbulent blood flow

Correct response: 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.

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? 1. partial thromboplastic time (PTT) 2. complete blood count (CBC) 3. international normalized ratio (INR) 4. Sodium

Correct response: 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 warfarin.

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? 1. left ventricle 2. left atrium 3. right ventricle 4. right atrium

Correct response: 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.

Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for pumping blood to the lungs to be oxygenated? 1. right ventricle 2. left atrium 3. left ventricle 4. right atrium

Correct response: right ventricle Explanation: The right ventricle pumps blood to the lungs to be oxygenated. 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 left atrium receives oxygenated blood from the lungs.