ATI - Cardiovascular Test

A nurse is preparing to teach a client who has a BMI of 32 about a heart-healthy diet. Which of the following dietary recommendations should the nurse include? A. Increase intake of red meat. B. Limit sodium intake to less than 3,000 mg/day. C. Increase intake of foods high in trans fats. D. Drink whole milk.

B. Limit sodium intake to less than 3,000 mg/day.

A nurse is auscultating heart sounds. Identify the location where the apical pulse is auscultated.

D is correct. The nurse should auscultate in this area for 1 min to determine the rate, rhythm, and pitch of the apical pulse. This area, at the apex of the heart, is where sounds generated by the mitral valve between the left atrium and ventricle are best heard and is termed the apical impulse or point of maximal impulse. The mitral heart sound is located at the fifth intercostal space in the left midclavicular area.

A nurse is auscultating a client's heart sounds. Place the nursing actions for auscultation of the heart in the correct order. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

1. Elevate the head of the bed 30° and instruct the client to breath normally is the first step. 2. Visualize the anatomy of the heart is the second step. 3. Place the stethoscope to the right sternal border at the second intercostal space is the third step. 4. Place the stethoscope close to the sternal border at the fourth intercostal space is the fourth step. 5. Auscultate the apical pulse for 1 min is the fifth step.

A nurse is assessing the anterior chest of a client. Which of the following findings should the nurse report to the provider? A. The point of maximal impulse (PMI) located at the fifth intercostal space B. Symmetrical chest movements during inhalation and expiration C. Absent visible pulsations in the area of the point of maximal impulse (PMI) D. A forceful chest movement at the midclavicular line in the fourth intercostal space

D. A forceful chest movement at the midclavicular line in the fourth intercostal space A forceful thrusting movement of the chest at the point of maximal impulse (PMI) is termed a heave or lift. This finding is associated with an enlarged left ventricle. This is an unexpected finding and should be reported to the provider.

A nurse is teaching about behaviors that promote cardiovascular health. Which of the following client statements indicate an understanding of the teaching? (Select all that apply) a. "I am going to start walking several times a week." b. "I plan to join a support group to help me stop smoking." c. "If my HDL cholesterol levels are high, it can hurt my heart." d. "I will be sure to have my blood pressure checked at least every year." e. "Eating more low-fiber foods and processed carbohydrates will make my heart healthier."

a. "I am going to start walking several times a week." b. "I plan to join a support group to help me stop smoking." d. "I will be sure to have my blood pressure checked at least every year."

A nurse is preparing to perform a cardiovascular assessment on a client. The client asks, "Why do you need to use a penlight?" Which of the following responses should the nurse make? a. "The penlight will allow me to look at the pulses in your neck." b. "The penlight will allow me to locate your pedal pulse." c. "The penlight will be used to check your skin turgor." d. "The penlight will be used to evaluate the effort that you use to breathe."

a. "The penlight will allow me to look at the pulses in your neck."

A nurse is auscultating heart sounds in a group of clients. Which of the following should the nurse identify as an expected variation? a. An adolescent who has an S3 heart sound b. An older adult who has a heart rate of 48/min c. A young adult who has an irregular apical pulse d. A middle adult who has a murmur

a. An adolescent who has an S3 heart sound

A nurse is preparing to conduct a cardiovascular assessment on a client. Which of the following actions should the nurse plan to take? (Select all that apply.) a. Auscultate the apical pulse. b. Ask the client if they experience shortness of breath. c. Check the color of the client's skin. d. Auscultate bowel motility. e. Inspect the extremities for the presence of edema.

a. Auscultate the apical pulse. b. Ask the client if they experience shortness of breath. c. Check the color of the client's skin. e. Inspect the extremities for the presence of edema.

A nurse has completed a cardiovascular assessment on a client. Which of the following findings should the nurse report to the provider? a. Capillary refill of 3 seconds b. +2 radial pulse c. Fingernail with 160° curvature d. Oxygen saturation 98%

a. Capillary refill of 3 seconds

A nurse is inspecting and palpating the neck vessels of a client. Which of the following findings should the nurse report to the provider? (Select all that apply) a. Visible pulsations observed in the carotid area on both sides of the neck. b. Full, bounding pulse noted bilaterally in the carotid arteries upon palpation. c. Distention of the jugular vein on one side of the neck. d. Flattening of the jugular veins when the client sits upright. e. The left carotid artery pulse is weak.

b. Full, bounding pulse noted bilaterally in the carotid arteries upon palpation. c. Distention of the jugular vein on one side of the neck. e. The left carotid artery pulse is weak.

A nurse is assessing a client's jugular veins and carotid arteries. The nurse should assist the client into which of the following positions? a. Place the client in high-Fowler's position. b. Have the client lay supine with the head of their bed at a 45° angle. c. Have the client seated with their chin touching their chest. d. Place the client in a left lateral position.

b. Have the client lay supine with the head of their bed at a 45° angle. Having the client positioned supine with the head of their bed at a 35° to 45° angle assists the nurse in visualizing the pulsation of the carotid arteries and the jugular vein.

A nurse is caring for a client who has a peripheral venous ulcer. Which of the following actions should the nurse take? (Select all that apply) a. Instruct the client to apply warm heat for pain. b. Instruct the client to sit with their legs uncrossed. c. Encourage the client to avoid tobacco products. d. Instruct the client to cleanse the area with mild soap. e. Instruct the client to wear shoes when ambulating.

b. Instruct the client to sit with their legs uncrossed. c. Encourage the client to avoid tobacco products. d. Instruct the client to cleanse the area with mild soap. e. Instruct the client to wear shoes when ambulating.

A nurse is completing a medical history on a client. Which of the following findings indicates the client has a family history of cardiovascular disease? a. Parent who experienced a pulmonary embolism b. Sibling who has hypertension c. Cousin who has diabetes mellitus d. Child who has epilepsy

b. Sibling who has hypertension

A nurse is assessing a client who reports an increase in their stress level related to the demands of their job. Which of the following interventions should the nurse recommend for the client to reduce their stress? a. Instruct the client to vary the time they go to sleep each night. b. Have the client check their BP daily. c. Discuss the benefits of meditation with the client. d. Have the client limit their exercise program until the stress has decreased.

c. Discuss the benefits of meditation with the client.

A nurse is caring for a client who has a foot ulcer. Which of the following findings should the nurse identify as consistent with peripheral venous disease? a. Loss of hair on the lower leg b. Cool skin temperature in the lower leg c. Palpable dorsalis pedal pulse d. Regular, even wound border

c. Palpable dorsalis pedal pulse The pedal pulses remain present in clients who have peripheral venous disease. Absent pedal pulses are consistent with arterial insufficiency.