Chapter 33-Assessment of the Cardiovascular System
An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first?
d. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest
A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure?
d. Allergies to iodine-based agents
A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at night. How should the nurse respond?
d. Use pillows to elevate your head and chest while you are sleeping.
A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema?
My shoes fit tighter by the end of the day.
A nurse assesses a client who is recovering from a myocardial infarction. The clients pulmonary artery pressure reading is 25
12 mm Hg. Which action should the nurse take first?/a. Compare the results with previous pulmonary artery pressure readings.
A nurse prepares a client with acute renal insufficiency for a cardiac catheterization. The provider prescribes 0.9% normal saline to infuse at 125 mL/hr for renal protection. The nurse obtains gravity tubing with a drip rate of 15 drops/mL. At what rate (drops/min) should the nurse infuse the fluids? (Record your answer using a whole number, and rounding to the nearest drop.) _____ drops/min
31 drops/min
A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease?
A 45-year-old American Indian woman with diabetes mellitus
A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.) a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. d. Insert a Foley catheter. e. Administer a prophylactic antibiotic. f. Insert a central venous catheter.
A,B,C
A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) a. Blood pressure of 140/88 mm Hg Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 276 b. Serum potassium of 2.9 mEq/L c. Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor
B,D,E
A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect?
Heart rate of 120 beats/min
An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?
I get short of breath when I climb stairs.
A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find?
Pulse decreased from 100 beats/min to 80 beats/min
A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below should the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation?
a. Location A
A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on heart tones heard?
b. Document the finding.
A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery?
b. Initiation of an external pacemaker
A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The clients health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take?
b. Notify the health care provider before scheduling the MRI.
A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this clients teaching?
b. You should balance weight loss with consuming necessary nutrients.
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take?
c. Assess the color and temperature of the left leg.
A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect?
c. Disorientation and confusion
A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention?
c. Slurred speech and confusion
A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond?
c. Tell me more about your concerns about the surgery.
A nurse cares for a client who is recovering from a myocardial infarction. The client states, I will need to stop eating so much chili to keep that indigestion pain from returning. How should the nurse respond?
c. What do you understand about what happened to you?
A nurse assesses an older adult client who has multiple chronic diseases. The clients heart rate is 48 beats
min. Which action should the nurse take first?/Assess the clients medications.
