NUR 2211 Medical Surgical Nursing -Chapter 12: Nursing Assessment: Cardiovascular and Circulatory Function
After which of the following diagnostic tests will the patient need to remain on bedrest for 2 to 6 hours?
Cardiac catheterization
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?
Chest pain, weight gain, fatigue
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?
Chordae tendineae
The nurse prepares to apply ECG electrodes to a male client who requires continuous cardiac monitoring. Which action should the nurse complete to optimize skin adherence and conduction of the heart's electrical current?
Clip the client's chest hair prior to applying the electrodes.
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?
Contact the health care provider and report the findings.
A nurse is caring for a client with a central venous pressure (CVP) of 4 mm Hg. Which nursing intervention is appropriate?
Continue to monitor the client as ordered.
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?
Count the heart rate at the apex.
The nurse is performing a focused assessment of a patient who has a complex cardiac history. The vital signs that the nurse obtains are as follows: Temperature 99.0°F (37.2°C); pulse 94 bpm; blood pressure 142/116 mm Hg; respiration 22 breaths per minute; SaO2 90% on room air. These findings should prompt the nurse to consider the possibility that this patient has:
Decreased cardiac output
A cardiac patient with a magnesium lab result of 2.5 mEq/L would most likely evidence which of the following?
Depressed myocardial contractility
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?
Difficult to palpate and is 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?
Digoxin
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?
Digoxin level
A client is being scheduled for a stress test. The client is unable to exercise during the test. The nurse would include information about which medication used for pharmacologic stress testing?
Dipyridamole
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?
Dobutamine
A patient's gradual decline in activity tolerance and increased shortness of breath have prompted her health care provider to assess the structure and size of her heart. Which of the following diagnostic tests is most likely to yield these assessment data?
Echocardiography
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?
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.
A nurse assesses a patient with dependent edema. The nurse knows that this accumulation of excessive interstitial fluid occurs when there is an imbalance in more than one of the primary controls for fluid filtering across the capillary membrane. Which of the following is the most likely cause of the imbalance?
Elevated venous pressure
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?
Endocardium
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?
Enzymes
Which area of the heart that is located at the third intercostal space to the left of the sternum?
Erb point
The nurse is aware of the importance of synchronization of the atrial and ventricular events in the maintenance of normal cardiac function. What are the physiologic characteristics of the nodal and Purkinje cells that provide this synchronization? Select all that apply.
Excitability Automaticity Conductivity
The nurse prepares to auscultate heart sounds. What nursing intervention will be most effective to assist with this procedure?
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.
The nurse receives a laboratory report indicating the client's magnesium level is 5.2 mEq/L. What symptoms is the client at risk to experience? Select all that apply.
Headache Hypotension Irregular heartbeat
Following the morning assessment of an older adult patient, the nurse has documented, "Edema 3+ present to ankles and feet; dorsalis pedis and posterior tibial pulses palpable bilaterally." The nurse should recognize that this patient may be exhibiting symptoms of:
Heart failure
The nurse instructor is teaching a group of nursing students about adventitious heart sounds. The instructor explains that auscultation of the heart requires familiarization with normal and abnormal heart sounds. What would the instructor tell these students a ventricular gallop indicates in an adult?
Heart failure
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?
Heart failure
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?
High density lipoproteins (HDL) increase from 25 mg/dl to 40 mg/dl.
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?
Impaired myocardial contractility
Which of the following signs or symptoms are indications for performing an ankle-brachial index (ABI)?
Intermittent claudication
A nurse is performing a cardiac assessment on an elderly client. Which finding warrants further investigation?
Irregularly irregular heart rate
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?
K+ 3.1 mEq/L
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?
Loud and may be associated with a thrill sound similar to (a purring cat).
The nurse is administering a beta blocker to a patient in order to decrease automaticity. Which medication will the nurse administer?
Metoprolol
The nurse is caring for a client with ECG changes consistent with a myocardial infarction. Which of the following diagnostic test does the nurse anticipate to confirm heart damage?
Nuclear cardiology
During the assessment of a newly admitted female patient, the nurse has assessed the amplitude of the woman's temporal, dorsalis pedis, and posterior tibial pulses. The amplitude of these peripheral pulses contributes to the nurse's determination of this patient's:
Peripheral arterial circulation
A patient is admitted to the emergency room after blunt chest trauma resulting from a motor vehicle accident. The nurse confirms that the patient's symptoms are consistent with the diagnosis of a dissecting aorta. Which of the following descriptions of pain is characteristic of this diagnosis?
Persistent and tearing, located in the anterior chest and radiating to the shoulders
A nurse is caring for a client taking diltiazem for arrhythmias. The nurse knows that diltiazem helps decrease arrhythmias by working during which phase of the cardiac action potential?
Phase 0
The nurse is assessing a patient's blood pressure. What does the nurse document as the difference between the systolic and the diastolic pressure?
Pulse pressure
A client with cardiovascular disease is scheduled for transesophageal echocardiography (TEE). Which information in the health history increases the client's risk of developing a complication from the procedure?
Radiation to the chest 4 years ago
The clinic nurse is assessing a client's pulse before outpatient diagnostic testing. What should the nurse document when assessing the client's pulse?
Rate, quality, and rhythm
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?
Report any incident of bloody urine, stools, or both.
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:
Right ventricular pressure must be higher than pulmonary arterial pressure.
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?
Right-sided heart failure
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?
S3
The nurse observes a client during an exercise stress test (bicycle). Which finding indicates a positive test and the need for further diagnostic testing?
ST-segment changes on the ECG
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:
Stimulation of the vagus nerve.
The client is admitted for a scheduled cardiac catheterization. On the morning of the procedure, while assessing the client's morning laboratory values, the nurse notes a blood urea nitrogen (BUN) of 34 mg/dL and a creatinine of 4.2 mg/dL. What priority reason will the nurse notify the healthcare provider?
The client is at risk for renal failure due to the contrast agent that will be given during the procedure.
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?
The patient had a vagal response.
A 64-year-old man has sought care because of recent lower leg pain that occurs when he walks and diminishes when he rests. The nurse recognizes that this patient is experiencing intermittent claudication. What should the nurse suspect from this finding?
The patient has arterial insufficiency to his lower extremities.
The patient has a heart rate of 72 bpm with a regular rhythm. Where does the nurse determine the impulse arises from?
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?
Thin fibrous sac that encases the heart.
The nurse is caring for a patient admitted with unstable angina. The laboratory results reveal that the initial troponin I level is elevated in this patient. What conclusion should the nurse draw from this fact?
This is an accurate indicator of myocardial injury.
The critical care nurse is caring for a patient with a pulmonary artery pressure monitoring system. The nurse is aware that pulmonary artery pressure monitoring is used to assess left ventricular function (cardiac output). What else are pulmonary artery pressure monitoring systems used for?
To assess the patient's response to interventions such as fluid administration and drug administration
The nurse is auscultating a client's heart sounds and notes a murmur at the left fourth intercostal space. At which cardiac valve would the nurse document this murmur?
Tricuspid valve
A man was just admitted after experiencing chest pain and shortness of breath. Blood tests were sent while he was in the emergency department, and the nurse is evaluating the results. An elevation in which one of the following blood tests indicates that he is having an acute myocardial infarction?
Troponin
A patient with atrial fibrillation is experiencing dizziness and episodes of hypotension. The nurse is aware that these symptoms are the result of decreased cardiac output. Based on this diagnoses, which one of the following is the initial alteration in the cardiac cycle that causes this clinical result?
Uncoordinated atrial contractions
The cardiologist has scheduled a client for drug-induced stress testing. What instructions should the nurse provide to prepare the client for this test?
You will receive medication via IV administration.
The nurse accompanies a client to an exercise stress test. The client can achieve the target heart rate, but the electrocardiogram indicates ST-segment elevation. Which procedure will the nurse prepare the client for next?
cardiac catheterization
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?
catheter-related bloodstream infections
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 data is necessary to collect if the client is experiencing chest pain?
description of the pain
Which area of the heart is located at the third intercostal (IC) space to the left of the sternum?
erb point
What is a harsh grating sound caused by abrasion of the pericardial surfaces during the cardiac cycle?
friction rub
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?
heart failure
The nurse is monitoring a client experiencing a decrease in cardiac output. What medical conditions will lead to a decrease in preload?
hemorrhage, sepsis, and anaphylaxis
A client's chart indicates an S4 heart sound, and is scheduled for a cardiac workup. The nurse is aware that this client may have which cardiac condition?
hypertensive heart disease
The nurse cares for a client in the ICU who is being monitored with a central venous pressure (CVP) catheter. The nurse records the client's CVP as 8 mm Hg and recognizes that this finding indicates the client is experiencing which condition?
hypervolemia
Age-related changes associated with the cardiac system include which conditions? Select all that apply.
increased size of the left atrium endocardial fibrosis
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?
international normalized ratio (INR)
Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for receiving oxygenated blood from the lungs?
left atrium
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?
left ventricle
A nurse is assessing a client with heart failure. When assessing hepatojugular reflux, what is the appropriate action for the nurse to take?
press the right upper abdomen.
The physician orders medication to treat a client's cardiac ischemia. What is causing the client's condition?
reduced blood supply to the heart
What does decreased pulse pressure reflect?
reduced stroke volume
Central venous pressure is measured in which heart chamber?
right atrium
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?
right ventricle
The electrical conduction system of the heart has several components, all of which are instrumental in maintaining polarization, depolarization, and repolarization of cardiac tissue. Which of the conductive structures is known as the pacemaker of the heart?
sinoatrial node
The nurse is reviewing the laboratory results for a client with heart failure. Which laboratory value will the nurse report to the health care provider?
sodium 148 mEq/L
The nurse correctly identifies which data as an example of blood pressure and heart rate measurements in a client 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
During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure?
wheezes with wet lung sounds
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?
withhold food and fluids.
The nurse admits an adult female client with a medical diagnosis of "rule out MI." The client is very frightened and expresses surprise that a woman would have heart problems. What response by the nurse will be most appropriate?
"A woman's heart is smaller and has smaller arteries that become occluded more easily."
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?
"Current evidence indicates that estrogen replacement is not effective at preventing cardiovascular disease and carries some risks."
The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include?
"Do not bend at the waist, strain, or lift heavy objects for the next 24 hours."
While being prepared for echocardiography, the client asks nurse why this test is necessary. What would be the nurse's best response?
"Echocardiography is a way of determining the functioning of the left ventricle of your heart."
Your client is being prepared for echocardiography when they ask you why they need to have this test. What would be your best response?
"Echocardiography is a way of determining the functioning of the left ventricle of your heart."
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?
"Have you had any episodes of dizziness or fainting?"
The nurse is conducting patient teaching about cholesterol levels in the body. When discussing the patient's elevated low-density lipoprotein (LDL) and lowered high-density lipoprotein (HDL) levels, the patient shows an understanding of the significance of these levels by stating what?
"Increased LDL and decreased HDL increase my risk of coronary artery disease."
A 71-year-old woman has complained of chest pain that appears when she is doing housework or climbing stairs. The woman claims that the pain dissipates when she stops exerting herself and rests for a few minutes. The woman's history, combined with these complaints, prompted her primary care provider to order cardiac catheterization. What instructions should the nurse provide this patient in anticipation of her procedure?
"Make sure that you don't eat or drink before the procedure."
A student nurse is to perform a cardiac assessment for a client and asks the instructor why the aortic valve closure is best heard on the right side of the sternum. What is the best response by the nurse?
"The aortic arch causes the closure of the aortic valve to be heard best on the right side of the sternum."
A 76-year-old resident of an assisted living facility who has a history of heart failure has presented to her primary care provider for a scheduled appointment. Which of the woman's statements suggests that her heart failure is worsening?
"The last few weeks I've found that I'm more comfortable sleeping in a chair than in my bed."
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?
"The physiologic demands are greatest during orgasm and are equivalent to walking 3 to 4 miles per hour on a treadmill."
The following clients are in need of exercise electrocardiography. Which client would the nurse indicate as most appropriate for a drug-induced stress test?
A 55-year-old recovering from a fall and broken femur
The nurse assesses the patient and records the data collected. What would lead the nurse to anticipate that the patient will experience a decrease in cardiac output?
A heart rate of 54 beats per minute
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?
A heart rate of more than 20 bpm above the resting rate
The nurse is performing a cardiac examination of a patient who has HF. When auscultating over the apical area, the nurse hears an extra sound between S1 and S2. This sound may be caused by:
A systolic murmur, indicating a mitral valve regurgitation
A 45-year-old woman who has a history of diabetes, hypertension, and cigarette smoking walks into the emergency room with shortness of breath, indigestion, and diaphoresis. She should be evaluated immediately for:
Acute coronary syndrome
The client states, "My doctor says that because I am now taking this water pill, I need to eat more foods that contain potassium. Can you give me some ideas about what foods would be good for this?" What is the appropriate response by the nurse?
Apricots, dried peas and beans, dates
An older adult patient experienced a fall during the previous night shift, and the care team suspects that the patient may be experiencing orthostatic hypotension. When assessing this patient for postural changes in blood pressure (BP), the nurse should:
Assess the patient's BP in supine, feet dangling, and then standing positions with 1 to 3 minutes of waiting between each reading.
The nurse is conducting a head-to-toe assessment of a patient at the beginning of a shift. The nurse has palpated the patient's radial pulse for 1 minute to determine the patient's heart rate and has detected an irregular rhythm. How should the nurse follow-up this assessment finding?
Auscultate the patient's apical pulse while simultaneously palpating the patient's radial pulse.
The nurse is providing discharge education for a client going home after cardiac catheterization. What information is a priority to include when providing discharge education?
Avoid tub baths, but shower as desired.
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?
B-type natriuretic peptide (BNP)
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?
Baroreceptors
