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Which type of pulse would the nurse expect when assessing a patient who is anxious? 1 Rapid 2 Thready 3 Irregular 4 Pulsus alternans
1 A rapid pulse, tachycardia, is associated with anxiety caused by increased adrenaline. A thready pulse is associated with peripheral arterial disease, aortic valve disease, and decreased cardiac output. The pulse is irregular in patients with cardiac dysrhythmias. Pulsus alternans is observed in patients with heart failure and cardiac tamponade.
The nurse performing a cardiovascular assessment on an 85-year-old patient expects which age-related finding? 1 Presence of S4 2 Decreased resting supine heart rate 3 Increased response to physical stress 4 Slight shortening of QRS complex interval
1 Due to changes in the heart with aging, a fourth heart sound (S4) might be heard. The supine heart rate is not affected by aging. The response to physical stress is decreased. The QRS complex interval may lengthen.
A patient with pericarditis is admitted to the hospital. In which patient position would the nurse assess for a pericardial friction rub? 1 Ask the patient to sit and lean forward. 2 Place the patient in a standing position. 3 Maintain the patient in a supine position. 4 Place the patient in three positions: supine, sitting, and standing.
1 In a patient with pericarditis, a high-pitched sound can be auscultated. This sound can be heard during heart sound S1 or S2 at the apex. The best position for hearing this sound is when the patient is in a sitting position and leaning forward. The sound is not well heard in other positions, such as supine or standing.
Which interpretation would the nurse make after assessing a patient and identifying murmurs? 1 The cardiac valves are affected. 2 The patient has high BP. 3 The patient has a pericardial friction rub. 4 There is decreased ventricular compliance.
1 Murmurs are heard when the blood flow is turbulent as a result of dysfunctional valves. The valves may be affected as a result of the accumulation of lipids, the degeneration of collagen, and fibrosis. High BP does not cause murmurs. A pericardial friction rub is usually heard as a high-pitched, scratchy sound. A decreased compliance of ventricles during filling would result in the S4 heart sound.
Which amount of time in seconds is considered normal for capillary refill? 1 1 2 4 3 6 4 8
1 The capillary refill test assesses arterial flow to the extremities. The fingernail is pressed, and the time required for the refilling of blood is noted. This refill is appreciated by the change in the color of the nail bed. This should occur in less than two seconds with normal tissue perfusion and cardiac output. Capillary refill times of four seconds, six seconds, and eight seconds indicate an underlying defect in circulation.
Which techniques will the nurse use while assessing a patient's heart sounds? Select all that apply. 1 Listen for friction rubs with the patient upright and leaning forward. 2 Use the diaphragm of the stethoscope to listen to S1 and S2 sounds. 3 Listen for S3 and S4 sounds with the bell of the stethoscope. 4 Ask the patient to lean forward to enhance the sounds at the mitral area. 5 Place the patient in a left side-lying position to detect sounds from the second intercostal space.
1, 2, 3 The nurse listens to the S1 and S2 sounds with the diaphragm of the stethoscope because they are high pitched. S3 and S4 are extra heart sounds. If these sounds are present, then they can be detected with the bell of the stethoscope. The nurse instructs the patient to lean forward while sitting. This helps to enhance sounds from the second intercostal space. The nurse listens to friction rubs when the patient sits in an upright position and leans forward following expiration. The patient is positioned in a left side-lying position to enhance the sounds at the mitral area.
The nurse is providing information about potential complications to a patient who is scheduled for a transesophageal echocardiography (TEE). Which information would the nurse include? Select all that apply. 1 Hemorrhage 2 Dysrhythmias 3 Renal impairment 4 Transient hypoxemia 5 High levels of lactate dehydrogenase
1, 2, 4 TEE evaluates mitral valve disease and endocarditis vegetation in the patient. Complications of this procedure include tearing of the esophagus, hemorrhage, dysrhythmias, and transient hypoxemia. Some contrast media cause nephrotoxicity in patients; however, transesophageal echocardiography does not involve the injection of contrast medium into the patient's heart. Increased levels of lactate dehydrogenase are not a complication of the procedure.
Which symptoms would the nurse expect to find when assessing the cardiovascular system of an 83-year-old patient? Select all that apply. 1 Systolic murmur 2 Diminished pedal pulses 3 A narrowed pulse pressure 4 Increased systolic BP 5 Difficulty in isolating the apical pulse
1, 2, 4, 5 Gerontologic differences in the assessment of the cardiovascular system include the presence of a systolic murmur, diminished pedal pulses, increased systolic BP, and difficulty in isolating the apical pulse. The pulse pressure may be widened, not narrowed.
The nurse assesses a patient with cardiac problems and finds that one calf is larger than the other. Which conditions are possible explanations for this finding? Select all that apply. 1 Lymphedema 2 Hypertension 3 Varicose veins 4 Angina pectoris 5 Venous thromboembolism
1, 3, 5 There may be asymmetries in the circumference of two limbs in disorders like lymphedema, varicose veins, and thromboembolism. In these disorders, the affected limb is generally increased in circumference. Hypertension doesn't cause swelling of the limbs. Angina pectoris refers to pain in the chest and doesn't cause changes in the circumference of the lower extremities.
The nurse is assessing a patient who has suspected cardiac failure. Which questions would the nurse ask related to the patient's sleep-rest pattern? Select all that apply. 1 "Do you need to sleep upright in a chair?" 2 "How long does it take you to fall asleep?" 3 "Do you fall asleep with the television on?" 4 "How many pillows do you need to sleep at night?" 5 "Do you exercise within two hours of going to bed?"
1, 4 Many patients with heart failure need to sleep upright in a chair or with several pillows. The nurse would note the number of pillows needed to sleep or the need to sleep upright (orthopnea) and whether this has changed recently. Indications of insomnia and sleeping habits (e.g., how long it takes to fall asleep, falling asleep with the television on, exercising before going to bed) are not part of the assessment for cardiovascular problems.
Which assessment findings would the nurse expect when assessing a patient with right-sided heart failure? Select all that apply. 1 Peripheral cyanosis 2 Splinter hemorrhages 3 Pericardial friction rub 4 Jugular vein distention 5 Pitting edema of the lower extremities
1, 4, 5 Reduced blood flow from heart failure may cause peripheral cyanosis. Jugular vein distention is the result of blood backup on the right side of the heart. Patients with right-sided heart failure may present with pitting edema of the lower extremities as a result of interruption of venous return to the heart. Splinter hemorrhages are often caused by infective endocarditis. A pericardial friction rub is indicative of pericarditis.
How will the nurse document a weakly palpable pulse? 1 0 2 1+ 3 2+ 4 3+
2 A weak pulse in a patient with cardiovascular disease is indicated by 1+. The absence of a pulse is indicated by 0. A normal pulse rate is indicated by 2+, and 3+ indicates an increased, full, bounding pulse.
A patient's laboratory report reveals increased creatine kinase (CK-MB) enzymes. Which condition is consistent with this result? 1 Stroke 2 Myocardial infarction (MI) 3 Coronary artery disease (CAD) 4 Peripheral vascular disease (PVD)
2 CK-MB enzymes are present in the cardiac muscle and are released into the blood as a result of cell injury. An increase in CK-BB enzymes indicates brain injury. Homocysteine is an amino acid produced during protein catabolism; elevated levels of this amino acid are an indication of stroke, CAD, and PVD.
A patient is scheduled for cardiac catheterization with coronary angiography. Which primary purpose for the procedure would the nurse explain to the patient? 1 Bypassing obstructed vessels 2 Assessing the presence of arterial blockages 3 Opening and dilating blocked coronary arteries 4 Assessing the need for antianginal medications
2 Cardiac catheterization with angiography is performed to assess the extent and severity of coronary artery blockage. The results of a cardiac catheterization will facilitate decisions regarding the need for coronary artery bypass surgery, angioplasty, or medical management.
Which action would the nurse take to assess a patient for jugular venous distention? 1 Place the patient in a supine position. 2 Raise the patient to about 45 degrees. 3 Place the patient in a sitting position, leaning forward. 4 Observe the vein in three positions: supine, sitting, and standing.
2 Jugular venous distention can be seen in right-sided heart failure. In this condition, the large veins in the neck are distended as a result of the back pressure exerted by the blood. It is best appreciated when the patient is raised to approximately 45 degrees or slightly less. This exerts pressure and helps in the visualization of the jugular veins. Placing the patient in other positions, such as supine, sitting, leaning, or standing, does not help in clear visualization of jugular venous distention.
Which finding in a patient's laboratory reports supports a conclusion that the patient is at high risk for myocardial injury? 1 Creatine kinase (CK)-MB value of 2% 2 Troponin I value of 3.5 ng/mL 3 Cholesterol value of 250 mg/dL 4 B-type natriuretic peptide (BNP) value of 140 pg/mL
2 Troponin is a contractile protein released after a myocardial infarction. If the value of troponin I is greater than 2.3 ng/mL, it indicates that the patient is at high risk for myocardial injury. A CK-MB value greater than 4% to 6% indicates myocardial infarction. A cholesterol value of 250 mg/dL indicates cardiovascular heart disease. A b-type natriuretic peptide (BNP) value of 140 pg/mL indicates heart failure.
Which abnormality is likely to result in a heart murmur? 1 Increased viscosity of the patient's blood 2 Turbulent blood flow across a heart valve 3 Friction between the heart and the pericardium 4 A deficit in heart conductivity that impairs contractility
2 Turbulent blood flow across the affected valve results in a murmur. A murmur is not a direct result of variances in blood viscosity or conductivity. Friction between the heart and pericardium may cause an audible friction rub.
Which findings would indicate to the nurse that a patient is experiencing prolonged oxygen deficiency? Select all that apply. 1 Erythematous rashes on the extremities 2 Bluish or purplish tinge in the central areas of the tongue 3 Pulse rate of 70 beats/minute and BP of 120/80 mm Hg 4 Obliteration of the normal angle between the base of the nail and the skin 5 Hands and feet warmer than normal and respiratory rate of 20 breaths/minute
2, 4 Prolonged oxygen deficiency is characterized by cyanosis and clubbing of the nails. Therefore the presence of a bluish or purplish tinge in the central areas of the tongue and obliteration of the normal angle between the base of the nail and the skin indicates that the patient has an oxygen deficiency. The presence of erythematous rashes on the extremities indicates that the patient has a skin infection but not an oxygen deficiency. A pulse rate of 70 beats/minute and a BP of 120/80 mm Hg are normal findings and do not indicate that the patient has an oxygen deficiency. A deficiency of oxygen results in hypothermia and may make the patient's hands and feet cooler than normal. A respiratory rate of 20 breaths/minute is a normal finding.
The nurse observes a bluish tinge around the ears of a patient with cardiovascular disease. Which condition is likely to be present? 1 Diabetes 2 Endocarditis 3 Vasoconstriction 4 Venous thromboembolism
3 A bluish tinge around the ears or in the ears indicates peripheral cyanosis, which is characterized by vasoconstriction. Vasoconstriction is the narrowing of blood vessels as a result of the contraction of the muscular walls of the vessels, resulting in reduced blood flow. This reduced blood flow will result in insufficient oxygen supply by the heart to other parts of the body, causing a bluish tinge in the extremities of ears. Diabetes causes ulcers in patients with cardiovascular disease. Endocarditis causes clubbing of the nail beds. Venous thromboembolism results in asymmetry in limb circumference.
Which artery is recommended for checking a patient's BP? 1 Radial 2 Carotid 3 Brachial 4 Femoral
3 BP is recorded using a device known as a sphygmomanometer and a stethoscope. The ideal and correct site for checking the BP is the brachial artery. This artery is on the arm near the elbow. The radial artery is on the wrist. The carotid artery is in the neck region, and the femoral artery is around the groin. Any other site other than the brachial artery is not suitable for checking the BP with a sphygmomanometer.
A patient with cardiovascular disease who is sitting at a 45-degree angle has distended neck veins. Which condition is a likely cause of this finding? 1 Vasoconstriction 2 Poor venous return 3 Elevated right atrial pressure 4 Incompetent valves in the veins
3 Bulging of the external jugular vein is known as jugular vein distention. When the arterial pressure in the right atrium increases, the pressure in the jugular vein increases; this results in distention of the veins. Vasoconstriction causes peripheral cyanosis. Poor venous return causes ulcers. Incompetent valves in veins lead to varicose veins.
The nurse observes that blanching of a patient's nail beds continues for three seconds after the release of pressure. Which condition is the potential cause of this finding? 1 Thyrotoxicosis 2 Intermittent claudication 3 Reduced arterial capillary perfusion 4 Interruption of venous return to the heart
3 Reduced arterial capillary perfusion results in a decreased amount of oxygen supply to body parts, which results in blanching of the nail beds for more than two seconds after the release of pressure. Hands and feet that are warmer than normal indicate thyrotoxicosis. When the hands and feet are cold to the touch, it indicates intermittent claudication. Visible finger pitting edema on the application of firm pressure indicates an interruption of venous return to the heart.
Which condition may be present if the nurse hears a patient's S4 heart sound? 1 Hypertension 2 Angina pectoris 3 Cardiomyopathy 4 Postural hypotension
3 S4 is an extra heart sound caused by atrial contraction. It can be normal in older adults. The common pathologies that cause this sound are cardiomyopathy, left ventricular hypertrophy, atrial stenosis, and coronary artery disease (CAD). Hypertension is increased BP, and postural hypotension is a fall in BP after standing, and these conditions do not cause S4. Angina pectoris is pain in the chest region and is not accompanied by S4.
A patient is diagnosed with venous thromboembolism. Which assessment finding would the nurse expect? 1 Abnormal capillary refill 2 Unusually warm extremities 3 Asymmetry in limb circumference 4 Pitting edema of lower extremities
3 Venous thrombosis is the formation of clots and most commonly occurs in the pelvis or lower extremity—that is, in the deep veins of the legs. This condition results in asymmetry in limb circumference. Possible reduced arterial capillary perfusion and anemia cause abnormal capillary refill. Thyrotoxicosis results in unusually warm extremities. Interruption of venous return to the heart and right-sided heart failure are associated with pitting edema of the lower extremities.
Which conditions are accompanied by a thready pulse? Select all that apply. 1 Hyperthyroidism 2 Hyperkinetic states 3 Aortic valve disease 4 Cardiac dysrhythmias 5 Peripheral arterial disease
3, 5 A thready pulse is a weak, slowly rising pulse observed in patients with aortic valve disease and peripheral arterial disease. Hyperthyroidism and hyperkinetic states are associated with a bounding pulse. An irregular pulse is observed in patients with cardiac dysrhythmias.
For which complication would the nurse monitor the patient taking amitriptyline? 1 Hypokalemia 2 Thromboembolism 3 Myocardial infarction 4 Orthostatic hypotension
4 Amitriptyline is a tricyclic antidepressant that alleviates the symptoms of depression by decreasing the levels of serotonin and epinephrine in the brain. Because of the decrease in epinephrine, the patient may have low BP, resulting in orthostatic hypotension. Therefore the nurse monitors for orthostatic hypotension in the patient. Hypokalemia occurs in patients receiving corticosteroids, not tricyclic antidepressants. Thromboembolism may occur in patients receiving hormone therapy, but this is not a risk for patients on amitriptyline. Patients taking hormone therapy and nonsteroidal antiinflammatory medications are at risk for developing myocardial infarctions, but amitriptyline does not increase the risk for myocardial infarctions.
A patient at risk for cardiovascular disease has splinter hemorrhages. Which condition is consistent with this finding? 1 Varicose veins 2 Arteriosclerosis 3 Vasoconstriction 4 Infective endocarditis
4 Splinter hemorrhages are small, red-to-black streaks under the fingernails that indicate the presence of infective endocarditis. Ulcers in a patient with a risk for cardiovascular disease indicate varicose veins or arteriosclerosis. Peripheral cyanosis indicates vasoconstriction.
The nurse provides postprocedural care to a patient admitted to an inpatient unit after cardiac catheterization. Which assessment is the highest priority? 1 Determining the level of pain 2 Checking for sensation in the feet 3 Verifying the patency of the IV site 4 Inspecting the procedure puncture site
4 The highest priority for a patient who has undergone cardiac catheterization, upon arrival to the nursing unit, is to first assess the catheterization site for signs of hemorrhage. Assessments of pain, sensation, and the IV site are all important assessments, but they are of lower priority than checking the cardiac catheterization site.
A nurse is caring for a patient who smokes tobacco and has a two-year history of using oral contraceptives. Based on the history, the patient would be assessed for which condition? 1 Hypotension 2 Cardiomyopathy 3 Dependent edema 4 Venous thromboembolism
4 The long-term use of oral contraceptives can lead to serious side effects. In addition, smoking enhances the risk of developing complications such as venous thromboembolism. Hypotension is not an effect of oral contraceptives. Similarly, contraceptives do not affect the muscles of the heart and do not cause cardiomyopathy. Dependent edema is not a common side effect of oral contraceptives.
In which order would the nurse perform the actions to measure a patient's BP?
The nurse would first place the appropriate size of cuff on the upper arm. This is because the brachial artery is the recommended site for measuring the BP, and the wrong cuff size can give an inaccurate reading. The cuff is then inflated to a pressure 20 to 30 mm Hg above the most recently recorded SBP. This causes the blood flow in the artery to cease. The nurse would then lower the pressure in the cuff while auscultating the artery and also note the first phase of the Korotkoff sound. It is a tapping sound caused by the spurt of blood into the constricted artery. This is the SBP. Finally, when the sound disappears, the nurse notes the diastolic pressure.
