Ch 31 - Assessment of Cardiovascular System - Med-Surg Nursing

When admitting a patient for a cardiac catheterization and coronary angiogram, which information about the patient is most important for the nurse to communicate to the health care provider? a. The patient's pedal pulses are +1. b. The patient is allergic to shellfish. c. The patient had a heart attack 1 year ago. d. The patient has not eaten anything today.

ANS: B The contrast dye used for the procedure is iodine based, so patients who have shellfish allergies will require treatment with medications such as corticosteroids and antihistamines before the angiogram. The other information is also communicated to the health care provider but will not require a change in the usual precardiac catheterization orders or medications. DIF: Cognitive Level: Analyze (analysis) REF: 677

When auscultating over the patient's abdominal aorta, the nurse hears a loud humming sound. The nurse documents this finding as a a. thrill. b. bruit. c. murmur. d. normal finding.

ANS: B A bruit is the sound created by turbulent blood flow in an artery. Thrills are palpable vibrations felt when there is turbulent blood flow through the heart or in a blood vessel. A murmur is the sound caused by turbulent blood flow through the heart. Auscultating a bruit in an artery is not normal and indicates pathology. DIF: Cognitive Level: Understand (comprehension) REF: 667

the nurse caring for a patient immediately following a transesophageal echocardiogram (TEE) should consider which action the highest priority? a. monitor the ECG b. monitor pulse oximetry c. assess vital signs (BP, HR, RR, Temp) d. maintain NPO status until gag reflex has returned

ans: d

what is a significant finding in the health history of a patient during an assessment of the cardiovascular system? a. metastatic cancer b. calcium supplementation c. frequent viral pharyngitis d. frequent use of recreational drugs

ans: d

when palpating the patient's popliteal pulse, the nurse feels a vibration at the site. How should the nurse record this finding? a. thready, weak pulse b. bruit at the artery site c. bounding pulse volume d. thrill of the popliteal artery

ans: d

The nurse hears a murmur between the S1 and S2 heart sounds at the patient's left fifth intercostal space and midclavicular line. How will the nurse record this information? a. Systolic murmur heard at mitral area b. Systolic murmur heard at Erb's point c. Diastolic murmur heard at aortic area d. Diastolic murmur heard at the point of maximal impulse

ANS: A The S1 signifies the onset of ventricular systole. S2 signifies the onset of diastole. A murmur occurring between these two sounds is a systolic murmur. The mitral area is the intersection of the left fifth intercostal space and the midclavicular line. The other responses describe murmurs heard at different landmarks on the chest and/or during the diastolic phase of the cardiac cycle. DIF: Cognitive Level: Apply (application) REF: 663

The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular unit. Which laboratory result is most important to communicate as soon as possible to the health care provider? a. High troponin I level b. Increased triglyceride level c. Very low homocysteine level d. Elevated high-sensitivity C-reactive protein level

ANS: A The elevation in troponin I indicates that the patient has had an acute myocardial infarction. Further assessment and interventions are indicated. The other laboratory results are indicative of increased risk for coronary artery disease but are not associated with acute cardiac problems that need immediate intervention. DIF: Cognitive Level: Analyze (analysis) REF: 670

The standard policy on the cardiac unit states, "Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg." The nurse will need to call the health care provider about the a. postoperative patient with a BP of 116/42 mm Hg. b. newly admitted patient with a BP of 150/87 mm Hg. c. patient with left ventricular failure who has a BP of 110/70 mm Hg. d. patient with a myocardial infarction who has a BP of 140/86 mm Hg.

ANS: A The mean arterial pressure (MAP) is calculated using the formula MAP = (systolic BP + 2 diastolic BP)/3. The MAP for the postoperative patient in answer 3 is 67. The MAP in the other three patients is higher than 70 mm Hg. DIF: Cognitive Level: Apply (application) REF: 662

The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. The laboratory test result most helpful in indicating myocardial damage will be a. myoglobin. b. troponins T and I. c. homocysteine (Hcy) d. creatine kinase-MB (CK-MB).

ANS: B Cardiac troponins start to elevate 4 to 6 hours after myocardial injury and are highly specific to myocardium. They are the preferred diagnostic marker for myocardial infarction. Myoglobin rises in response to myocardial injury within 30 to 60 minutes. It is rapidly cleared from the body, thus limiting its use in the diagnosis of myocardial infarction. Low-density lipoprotein cholesterol is useful in assessing cardiovascular risk but is not helpful in determining whether a patient is having an acute myocardial infarction. Creatine kinase (CK-MB) is specific to myocardial injury and infarction and increases 4 to 6 hours after the infarction occurs. It is often trended with troponin levels. Homocysteine (Hcy) is an amino acid that is produced during protein catabolism. Elevated Hcy levels can be either hereditary or acquired from dietary deficiencies of vitamin B6, cobalamin (vitamin B12), or folate. Elevated levels of Hcy have been linked to a higher risk of CVD, peripheral vascular disease, and stroke. DIF: Cognitive Level: Analyze (analysis) REF: 670

To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the a. diaphragm of the stethoscope with the patient lying flat. b. bell of the stethoscope with the patient in the left lateral position. c. diaphragm of the stethoscope with the patient in a supine position. d. bell of the stethoscope with the patient sitting and leaning forward.

ANS: B Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall. The diaphragm of the stethoscope is best to use for the higher pitched sounds such as S1 and S2. DIF: Cognitive Level: Apply (application) REF: 668

When assessing a newly admitted patient, the nurse notes a murmur along the left sternal border. To acquire more information about the murmur, which action will the nurse take? a. Palpate the peripheral pulses. b. Determine the timing of the sound. c. Find the point of maximal impulse. d. Compare apical and radial pulse rates.

ANS: B Murmurs are caused by turbulent blood flow, such as occurs when blood flows through a damaged valve. Relevant information includes the position in which the murmur is heard best (e.g., sitting and leaning forward), the timing of the murmur in relation to the cardiac cycle (e.g., systole, diastole), and where on the thorax the murmur is heard best. The other information is important in the cardiac assessment but will not provide information that is relevant to the murmur. DIF: Cognitive Level: Apply (application) REF: 662

A registered nurse (RN) is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student nurse a. presses on the skin over the tibia for 10 seconds to check for edema. b. palpates both carotid arteries simultaneously to compare pulse quality. c. documents a murmur heard along the right sternal border as a pulmonic murmur. d. places the patient in the left lateral position to check for the point of maximal impulse.

ANS: B The carotid pulses should never be palpated at the same time to avoid vagal stimulation, dysrhythmias, and decreased cerebral blood flow. The other assessment techniques also need to be corrected. However, they are not dangerous to the patient. DIF: Cognitive Level: Analyze (analysis) REF: 666

The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four patients. Which nursing action can be delegated to the UAP? a. Teaching a patient about exercise electrocardiography b. Attaching ECG monitoring electrodes after a patient bathes c. Checking the catheter insertion site for a patient who is recovering from a coronary angiogram d. Monitoring a patient who has just returned to the unit after a transesophageal echocardiogram

ANS: B UAP can be educated in standardized lead placement for ECG monitoring. Assessment of patients who have had procedures where airway maintenance (transesophageal echocardiography) or bleeding (coronary angiogram) is a concern must be done by the registered nurse (RN). Patient teaching requires RN level education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 660

A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that a. it will be important not to move at all during the procedure. b. monitored anesthesia care will be provided during the procedure. c. a flushed feeling may be noticed when the contrast dye is injected. d. arterial pressure monitoring will be required for 24 hours after the test.

ANS: C A sensation of warmth or flushing is common when the contrast material is injected, which can be anxiety producing unless it has been discussed with the patient. The patient may receive a sedative drug before the procedure, but monitored anesthesia care is not used. Arterial pressure monitoring is not routinely used after the procedure to monitor blood pressure. The patient is not immobile during cardiac catheterization and may be asked to cough or take deep breaths. DIF: Cognitive Level: Apply (application) REF: 677

When the nurse is monitoring a patient who is undergoing exercise (stress) testing on a treadmill, which assessment finding requires the most rapid action by the nurse? a. Patient complaint of feeling tired b. Sinus tachycardia at a rate of 110 beats/min c. Inversion of T waves on the electrocardiogram d. Blood pressure (BP) increase from 134/68 to 150/80 mm Hg

ANS: C ECG changes associated with coronary ischemia (such as T-wave inversions and ST segment depression) indicate that the myocardium is not getting adequate O2 delivery and that the exercise test should be terminated immediately. Increases in BP and heart rate are normal responses to aerobic exercise. Feeling tired is also normal as the intensity of exercise increases during the stress testing. DIF: Cognitive Level: Analyze (analysis) REF: 675

Which information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI) will be important to report to the health care provider before the MRI? a. The patient has an allergy to shellfish. b. The patient has a history of atherosclerosis. c. The patient has a permanent cardiac pacemaker. d. The patient took the prescribed heart medications today.

ANS: C MRI is contraindicated for patients with implanted metallic devices such as pacemakers. The other information does not affect whether or not the patient can have an MRI. DIF: Cognitive Level: Apply (application) REF: 676

During a physical examination of an older patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The best follow-up action for the nurse to take will be to a. ask about risk factors for atherosclerosis. b. determine family history of heart disease. c. assess for symptoms of left ventricular hypertrophy. d. auscultate carotid arteries for the presence of a bruit.

ANS: C The PMI should be felt at the intersection of the fifth intercostal space and left midclavicular line. A PMI located outside these landmarks indicates possible cardiac enlargement, such as with left ventricular hypertrophy (LVH). The other assessments are part of a general cardiac assessment but do not represent follow-up for LVH. Cardiac enlargement is not necessarily associated with atherosclerosis or carotid artery disease. DIF: Cognitive Level: Analyze (analysis) REF: 667

Which action will the nurse implement for a patient who arrives for a calcium-scoring CT scan? a. Insert an IV catheter. b. Administer oral sedative medications. c. Teach the patient about the procedure. d. Confirm that the patient has been fasting.

ANS: C The nurse will need to teach the patient that the procedure is rapid and involves little risk. None of the other actions are necessary. DIF: Cognitive Level: Apply (application) REF: 677

A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which action included in the standard TEE orders will the nurse need to accomplish first? a. Start an IV line. b. Start O2 per nasal cannula. c. Place the patient on NPO status. d. Give lorazepam (Ativan) 1 mg IV.

ANS: C The patient will need to be NPO for 6 hours preceding the TEE, so the nurse should place the patient on NPO status as soon as the order is received. The other actions also will need to be accomplished but not until just before or during the procedure. DIF: Cognitive Level: Analyze (analysis) REF: 671

To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory test result will the nurse plan to review? a. Troponin b. Homocysteine (Hcy) c. Low-density lipoprotein (LDL) d. B-type natriuretic peptide (BNP)

ANS: D Increased levels of BNP are a marker for heart failure. The other laboratory results would be used to assess for myocardial infarction (troponin) or risk for coronary artery disease (Hcy and LDL). DIF: Cognitive Level: Apply (application) REF: 670

A 74-yr-old patient has just arrived in the emergency department. After assessment reveals a pulse deficit of 46 beats, the nurse will anticipate that the patient may require a. emergent cardioversion. b. a cardiac catheterization. c. hourly blood pressure (BP) checks. d. electrocardiographic (ECG) monitoring.

ANS: D Pulse deficit is a difference between simultaneously obtained apical and radial pulses. It indicates that there may be a cardiac dysrhythmia that would best be detected with ECG monitoring. Frequent BP monitoring, cardiac catheterization, and emergent cardioversion are used for diagnosis and/or treatment of cardiovascular disorders but would not be as helpful in determining the immediate reason for the pulse deficit. DIF: Cognitive Level: Apply (application) REF: 668

The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to a. connect the recorder to a computer once daily. b. exercise more than usual while the monitor is in place. c. remove the electrodes when taking a shower or tub bath. d. keep a diary of daily activities while the monitor is worn.

ANS: D The patient is instructed to keep a diary describing daily activities while Holter monitoring is being accomplished to help correlate any rhythm disturbances with patient activities. Patients are taught that they should not take a shower or bath during Holter monitoring and that they should continue with their usual daily activities. The recorder stores the information about the patient's rhythm until the end of the testing, when it is removed and the data are analyzed. DIF: Cognitive Level: Apply (application) REF: 674

The nurse is reviewing the 12-lead electrocardiograph (ECG) for a healthy 74-yr-old patient who is having an annual physical examination. What finding is of most concern to the nurse? a. A right bundle-branch block. b. The PR interval is 0.21 seconds. c. The QRS duration is 0.13 seconds. d. The heart rate (HR) is 41 beats/min.

ANS: D The resting HR does not change with aging, so the decrease in HR requires further investigation. Bundle-branch block and slight increases in PR interval or QRS duration are common in older individuals because of increases in conduction time through the AV node, bundle of His, and bundle branches. DIF: Cognitive Level: Analyze (analysis) REF: 662

While doing the hospital admission assessment for a thin older adult, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take next? a. Teach the patient about aneurysms. b. Notify the hospital rapid response team. c. Instruct the patient to remain on bed rest. d. Document the finding in the patient chart.

ANS: D Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals. The nurse should simply document the finding in the admission assessment. Unless there are other abnormal findings (such as a bruit, pain, or hyper/hypotension) associated with the pulsation, the other actions are not necessary. DIF: Cognitive Level: Apply (application) REF: 667

The nurse notes that a patient who was admitted with heart failure has jugular venous distention (JVD) when lying flat in bed. Which follow-up action should the nurse take next? a. Obtain vital signs, including oxygen saturation. b. Have the patient perform the Valsalva maneuver. c. Document this JVD finding in the patient's record. d. Observe for JVD with the patient elevated 45 degrees.

ANS: D When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but not a clinically significant) finding. Obtaining vital signs and oxygen saturation is not warranted at this point. JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure increases. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant. The nurse will document the JVD in the medical record if it persists when the head is elevated. DIF: Cognitive Level: Analyze (analysis) REF: 666

a patient is scheduled for exercises nuclear imaging stress testing. the nurse explains to the patient that this test involves a. IV administration of a radioisotope at the maximum heart rate during exercise to identify the heart's response to physical stress b. placement of olectrodes inside the right-sided heart chambers through a vein to record the electrical activity of the heart directly c. exercising on a treadmill or stationary bicycle with continuous ECG monitoring to detect ischemic changes in the heart during exercise d. placement of a small transducer in four positions on the chest to record the direction and flow of the blood through the heart by the reflection of sound waves

ans: a

increases in which blood studies are diagnostic for acute coronary syndrome (ACS) (select all that apply) a. copeptin b. creatine kinase (CK-MM) c. cardiac troponin T (cTnT) d. b-type natriuretic peptide (BNP) e. high sensitivity C-reactive protein (hs-CRP) f. lipoprotein-associated phospholipase A2 (Lp-PLA2)

ans: a, c

which method is used to evaluate the ECG responses to normal activity over a period of 1 to 2 days a. serial ECGs b. holter monitoring c. 6-min walk test d. event monitor or loop recorder

ans: b

What can be auscultated in a patient with cardiac valve problems (select all that apply)? a. arterial bruit b. heart murmurs c. pulsus alternans d. third heart sound (s3) e. pericardial friction rub f. fourth heart sound (S4)

ans: b, d, f

which effects result from sympathetic nervous system stimulation of b-adrenergic receptors (select all that apply)? a. vasoconstriction b. increased heart rate c. decrease heart rate d. increased rate of impulse conduction e. decreased rate of impulse conduction f. increased force of cardiac contraction

ans: b, d, f

the nursing student is seeking assistance in hearing the patient's abnormal heart sounds. what should the nurse tell the student to do for a more effective assessment? a. use the diaphragm of the stethoscope with the patient prone. b. use the diaphragm of the stethoscope with the patient supine c. use the bell of the stethoscope with the patient leaning forward d. use the bell of the stethoscope with the patient on the right side

ans: c

when caring for a patient after a cardiac catheterization with coronary angiography, which finding should be of most concern to the nurse? a. swelling at the catheter insertion site b. development of raised wheals on the patient's trunk c. absence of pulses distal to the catheter insertion site d. patient pain at the insetion site at 4 on a scale of 0-10

ans: c

which finding is associated with a blue tinge around the lips and conjunctiva? a. finger clubbing b. central cyanosis c. peripheral cyanosis d. delayed capillary filling time

ans: c

Which arteries are the major providers of cornary ciruclation (select all that apply)? a. left marginal artery b. right marginal artery c. left circumflex artery d. right coronary artery e. posterior descending artery f. left anterior descending artery

ans: c, d, f

a female patien has a total cholesterol level of 232 mg/dl (6.0 mmol/L) and a high-density lipoprotein (HDL) of 65 mg/dl (1.68mmol/L). A male patient has a total cholesterol level of 200mg/dl (5.172mmol/L) and an HDL of 32mg/dl (0.83mmol/L). based on these findings, which patient has the highest cardiac risk? a. the man, because his HDL is lower b. the woman, because her HDL is higher c. the woman, because her cholesterol is higher d. theman, because his cholesterol-to-HDL ratio is higher

ans: d