Chapter 25
During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure? wheezes with wet lung sounds stridor high-pitched sounds laborious breathing
wheezes with wet lung sounds
During an initial assessment, the nurse measures the client's apical pulse and compares it to the peripheral pulse. The difference between the two is known as pulse: A) deficit. B) rhythm. C) volume. D) quality.
deficit.
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? A) blood pressure in the left arm B) pulse rate in upper extremities C) description of the pain D) sound of the apical pulses
description of the pain
The nurse cares for a client in the ICU diagnosed with coronary artery disease (CAD). Which assessment data indicates the client is experiencing a decrease in cardiac output? A) BP 108/60 mm Hg, ascites, and crackles B) disorientation, 20 mL of urine over the last 2 hours C) reduced pulse pressure and heart murmur D) elevated jugular venous distention and postural changes in BP
disorientation, 20 mL of urine over the last 2 hours
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? Na+ 140 mEq/L Ca++ 9 mg/dL K+ 3.1 mEq/L Mg++ 2 mEq/L
K+ 3.1 mEq/L
The nurse is caring for a client who is scheduled for a transesophageal echocardiogram. What nursing intervention is a priority after the procedure? A) Keep the head of the bed elevated 45 degrees and keep NPO until return of the gag reflex. B) Monitor the puncture site and assess the affected extremity. C) Keep the client turned to the right side and watch for bleeding from the site. D) Observe for bloody urine and stools.
Keep the head of the bed elevated 45 degrees and keep NPO until return of the gag reflex.
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 radial pulse for 20 to 25 seconds. Calculate the palpated volume. Count the heart rate at the apex. Calculate the pauses between pulsations.
Count the heart rate at the apex.
Which area of the heart that is located at the third intercostal space to the left of the sternum? A) aortic area B) pulmonic area C) Erb point D) epigastric area
Erb point
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. A) 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. B) Ask the client to sit on the edge of the bed and hold breath while the nurse listens. C) Insist that the family members leave the room if they must speak to each other while the nurse is auscultating heart sounds. D) Ask the client to take deep breaths through the mouth while the nurse auscultates heart sounds.
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.
A nurse is completing a head to toe assessment on a client diagnosed with right-sided heart failure. To assess peripheral edema, which of the following areas should be examined? A) Feet and ankles B) Under the sacrum C) Lips and earlobes D) Shoulders and elbows
Feet and ankles
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? A) "That's a great idea. You don't want to have a heart attack." B) "Current research determines that the replacement of estrogen will protect a woman after she goes into menopause." C) "Current evidence indicates that estrogen is ineffective as a cardioprotectant; estrogen is actually potentially harmful and is no longer a recommended therapy." D) "You need to research it and determine what you want to do."
"Current evidence indicates that estrogen is ineffective as a cardioprotectant; estrogen is actually potentially harmful and is no longer a recommended therapy."
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? "That's a great idea. You don't want to have a heart attack." "Current research determines that the replacement of estrogen will protect a woman after she goes into menopause." "Current evidence indicates that estrogen is ineffective as a cardioprotectant; estrogen is actually potentially harmful and is no longer a recommended therapy." "You need to research it and determine what you want to do."
"Current evidence indicates that estrogen is ineffective as a cardioprotectant; estrogen is actually potentially harmful and is no longer a recommended therapy."
The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include? "You can take a tub bath or a shower when you get home." "Contact your primary care provider if you develop a temperature above 102°F." "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." "If any discharge occurs at the puncture site, call 911 immediately."
"Do not bend at the waist, strain, or lift heavy objects for the next 24 hours."
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? A) "Have you had any episodes of dizziness or fainting?" B) "Have you had any episodes when you are to nauseous?" C) "Have you had any episodes of mottling in your hands?" D) "Have you had any episodes of pain radiating into your lower extremities?"
"Have you had any episodes of dizziness or fainting?"
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? A) insert an oral airway. B) withhold food and fluids. C) position the client on his side. D) introduce a nasogastric (NG) tube.
B) withhold food and fluids.
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? A) Potassium B) B-type natriuretic peptide (BNP) C) C-reactive protein (CRP) D) Platelet count
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? A) Chemoreceptors B) Sympathetic nerve fibers C) Baroreceptors D) Vagus nerve
Baroreceptors
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? A) Chordae tendineae B) Atrioventricular tendons C) Semilunar tendineae D) Papillary tendons
Chordae tendineae
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 Atrioventricular tendons Semilunar tendineae Papillary tendons
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. Apply baby powder to the client's chest prior to placing the electrodes. Clean the client's chest with alcohol prior to application of the electrodes. Once the electrodes are applied, change them every 72 hours.
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? A) Document findings and check the client again in 1 hour. B) Slow the I.V. fluid to prevent any more swelling at the puncture site. C) Contact the health care provider and report the findings. D) Encourage the client to perform isometric leg exercise to improve circulation in the legs.
Contact the health care provider and report the findings.
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? Document findings and check the client again in 1 hour. Slow the I.V. fluid to prevent any more swelling at the puncture site. Contact the health care provider and report the findings. Encourage the client to perform isometric leg exercise to improve circulation in the legs.
Contact the health care provider and report the findings.
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? A) Count the radial pulse for 20 to 25 seconds. B) Calculate the palpated volume. C) Count the heart rate at the apex. D) Calculate the pauses between pulsations.
Count the heart rate at the apex.
The nurse is caring for an elderly client with left-sided heart failure. When auscultating lung sounds, which adventitious sound is expected? A) Whistling B) Rhonchi C) Crackles D) Coarseness
Crackles
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. When the client is in the recumbent position, more pressure is put on the bladder, with the result of increased need to urinate. The blood pressure is lower when the client is recumbent, which causes the kidneys to work harder; therefore, more urine is produced. Fluid that is held in the lungs during the day becomes part of the circulation at night, causing the kidneys to produce an increased amount of urine.
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.
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? RBC Platelets Enzymes WBC
Enzymes
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? A) Impaired myocardial contractility B) Enhanced sensitivity to digitalis C) Increased risk of heart block D) Inclination to ventricular fibrillation
Impaired myocardial contractility
The nurse is performing an assessment of the patient's heart. Where would the nurse locate the apical pulse if the heart is in a normal position? A) Left 2nd intercostal space at the midclavicular line B) Right 2nd intercostal space at the midclavicular line C) Right 3rd intercostal space at the midclavicular line D) Left 5th intercostal space at the midclavicular line
Left 5th intercostal space at the midclavicular line
After a physical examination, the provider diagnosed a patient with a grade 4 heart murmur. During assessment, the nurse expects to hear a murmur that is: A) Easily heard with no palpable thrill. B) Quiet but readily heard. C) Loud and may be associated with a thrill sound similar to (a purring cat). D) Very loud; can be heard with the stethoscope half-way off the chest.
Loud and may be associated with a thrill sound similar to (a purring cat).
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? A) Easily heard with no palpable thrill. B) Quiet but readily heard. C) Loud and may be associated with a thrill sound similar to (a purring cat). D) Very loud; can be heard with the stethoscope half-way off the chest.
Loud and may be associated with a thrill sound similar to (a purring cat).
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? Easily heard with no palpable thrill. Quiet but readily heard. Loud and may be associated with a thrill sound similar to (a purring cat). Very loud; can be heard with the stethoscope half-way off the chest.
Loud and may be associated with a thrill sound similar to (a purring cat).
While the nurse is preparing a client for a cardiac catheterization, the client states that they have allergies to seafood. Which of the following medications may the nurse give prior to the procedure? Methylprednisolone Furosemide Lorazepam Phenytoin
Methylprednisolone
The nurse is educating a patient at risk for atherosclerosis. What nonmodifiable risk factor does the nurse identify for the patient? A) Stress B) Obesity C) Positive family history D) Hyperlipidemia
Positive family history
The nurse is assessing a patient's blood pressure. What does the nurse document as the difference between the systolic and the diastolic pressure? A) Pulse pressure B) Auscultatory gap C) Pulse deficit D) Korotkoff sound
Pulse pressure
The clinic nurse is assessing a client's pulse before outpatient diagnostic testing. What should the nurse document when assessing the client's pulse? A) Rate, quality, and rhythm B) Pressure, rate, and rhythm C) Rate, rhythm, and volume D) Quality, volume, and rate
Rate, quality, and rhythm
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 Pressure, rate, and rhythm Rate, rhythm, and volume Quality, volume, and rate
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? A) Report any incident of bloody urine, stools, or both. B) Administer calcium supplements. C) Assess for hypokalemia. D) Assess for clubbing of the fingers.
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: A) The atrioventricular valves must open. B) The pulmonic valve must be closed. C) Right ventricular pressure must be higher than pulmonary arterial pressure. D) Right ventricular pressure must decrease with systole.
Right ventricular pressure must be higher than pulmonary arterial pressure.
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: The atrioventricular valves must open. The pulmonic valve must be closed. Right ventricular pressure must be higher than pulmonary arterial pressure. Right ventricular pressure must decrease with systole.
Right ventricular pressure must be higher than pulmonary arterial pressure.
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? A) S1 B) S2 C) S3 D) S4
S3
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: A) An excess level of thyroid hormone. B) Stimulation of the vagus nerve. C) An increased level of catecholamines. D) Sympathetic nervous system stimulation.
Stimulation of the vagus nerve.
The nurse is caring for a patient with a diagnosis of pericarditis. Where does the nurse understand the inflammation is located? A) The thin fibrous sac encasing the heart B) The inner lining of the heart and valves C) The heart's muscle fibers D) The exterior layer of the heart
The thin fibrous sac encasing the heart
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? A) hemorrhage B) catheter-related bloodstream infections C) air embolism D) pneumothorax
catheter-related bloodstream infections
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? A) endocardium B) myocardium C) pericardium D) epicardium
endocardium
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 myocardium pericardium epicardium
endocardium
Which area of the heart is located at the third intercostal (IC) space to the left of the sternum? A) aortic area B) pulmonic area C) erb point D) epigastric area
erb point
The nurse is performing an assessment for an older adult client and auscultates an S3 heart sound. What condition does the nurse determine may correlate with this finding? A) congenital heart disease B) heart failure C) aortic stenosis D) coronary artery disease
heart failure
The nurse is explaining vasovagal syncope to a client. What does the nurse associate the temporary loss of consciousness with for the client? A) vertigo B) increase fluid intake C) blood pressure 190/50 standing D) heart rate 48
heart rate 48
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? A) hypertensive heart disease B) heart failure C) pericarditis D) diseased heart valves
hypertensive heart disease
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? A) left ventricle B) left atrium C) right ventricle D) right atrium
left ventricle
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 left atrium right ventricle right atrium
left ventricle
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? A) international normalized ratio (INR) B) partial thromboplastic time (PTT) C) complete blood count (CBC) D) Sodium
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? A) left atrium B) left ventricle C) right atrium D) right ventricle
left atrium
The physician orders medication to treat a client's cardiac ischemia. What is causing the client's condition? reduced blood supply to the heart pain on exertion high blood pressure indigestion
reduced blood supply to the heart
What does decreased pulse pressure reflect? A) tachycardia B) reduced distensibility of the arteries C) reduced stroke volume D) elevated stroke volume
reduced stroke volume
What does decreased pulse pressure reflect? tachycardia reduced distensibility of the arteries reduced stroke volume elevated stroke volume
reduced stroke volume
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? A) sinoatrial node B) atrioventricular node C) bundle of His D) bundle branches
sinoatrial node
