CHAPTER 31 ASSESSMENT OF THE CARDIOVASCULAR SYSTEM

A NURSE ASSESS A CLIENT WHO HAS AORTIC REGURGITATION. IN WHICH LOCATION IN THE ILLUSTRTION SHOWN. 1). Location A 2). Location B 3). Location C 4). Location D

Location A

An emergency room nurse obtains the health history of a patient. Which statement by the patient would alert the nurse to the occurrence of heart failure? 1). "I have lost weight over the past month." 2). "I get short of breath when I climb stairs." 3). "I have trouble remembering things." 4). "I see halos floating around my head."

"I get short of breath when I climb stairs."

A nurse obtains the health history of a patient who is newly admitted to the medical unit. Which statement by the patient would alert the nurse to the presence of edema? 1). "I seem to be feeling more anxious lately." 2). "I drink at least eight glasses of water a day." 3). "I wake up to go to the bathroom at night." 4). "My shoes fit tighter by the end of the day."

"My shoes fit tighter by the end of the day."

A nurse prepares a patient for coronary cardiac catheterization surgery. The patient states, "I am afraid I might die." What is the nurse's best response? 1). "What support systems do you have to assist you?" 2). "This is a routine test and the risk of death is very low." 3). "Tell me more about your concerns about the test." 4). "Would you like to speak with a chaplain prior to test?"

"Tell me more about your concerns about the test."

A nurse cares for a patient who has advanced cardiac disease and states, "I am having trouble sleeping at night." What is the nurse's best response? 1). "You become hypoxic while sleeping; oxygen therapy via nasal cannula will help." 2). "I will consult the provider to prescribe a sleep study to determine the problem." 3). "Use pillows to elevate your head and chest while you are sleeping." 4). "A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night."

"Use pillows to elevate your head and chest while you are sleeping."

A nurse cares for a patient who is recovering from a myocardial infarction. The patient states, "I will need to stop eating so much chili to keep that indigestion pain from returning." What is the nurse's best response? 1). "Chili is high in fat and calories; it would be a good idea to stop eating it." 2). "What do you understand about what happened to you?" 3). "When did you start experiencing this indigestion?" 4). "The provider has prescribed an antacid for you to take every morning."

"What do you understand about what happened to you?"

A nurse teaches a patient with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition would the nurse include in this patient's teaching? 1). "The best way to lose weight is a high-protein, low-carbohydrate diet." 2). "You should balance weight loss with consuming necessary nutrients." 3). "If you exercise more frequently, you won't need to change your diet." 4)."A nutritionist will provide you with information about your new diet."

"You should balance weight loss with consuming necessary nutrients."

A nurse prepares a patient for a pharmacologic stress echocardiogram. What actions would the nurse take when preparing this patient for the procedure? (Select all that apply.) 1). Assist the provider to place a central venous access device. 2). Prepare for continuous blood pressure and pulse monitoring. 3). Administer the client's prescribed beta blocker. 4). Give the client nothing by mouth 3 to 6 hours before the procedure. 5). Explain to the client that dobutamine will simulate exercise for this examination.

- Explain to the patient that dobutamine will simulate exercise for this examination. - Give the patient nothing by mouth 3 to 6 hours before the procedure. - Prepare for continuous blood pressure and pulse monitoring.

A nurse assesses a patient who is recovering from a myocardial infarction. The patient's blood pressure reading is 140/88 mm Hg. What action would the nurse take first? 1). Compare the results with previous pulmonary artery pressure readings. 2). Increase the intravenous fluid rate because these readings are low. 3). Immediately notify the health care provider of the elevated pressures. 4). Document the finding in the client's chart as the only action.

1Compare the results with previous pulmonary artery pressure readings.

A nurse assesses patients on a medical-surgical unit. Which patient would the nurse identify as having the greatest risk for cardiovascular disease? 1). A 45-year-old American Indian woman with diabetes mellitus 2). A 32-year-old Asian-American man with colorectal cancer 3). An 86-year-old man with a history of asthma 4). A 53-year-old postmenopausal woman who is on hormone therapy

A 45-year-old American Indian woman with diabetes mellitus

An emergency department nurse triages patients who present with chest discomfort. Which patient would the nurse plan to assess first? 1). A 42-year-old female who describes her pain as a dull ache with numbness in her fingers 2). A 53-year-old female who reports substernal pain that radiates to her abdomen 3). A 58-year-old male who describes his pain as intense stabbing that spreads across his chest 4). A 49-year-old male who reports moderate pain that is worse on inspiration

A 58-year-old male who describes his pain as intense stabbing that spreads across his chest

A nurse assesses a patient who is scheduled for a cardiac catheterization. Which assessment would the nurse complete prior to this procedure? 1). Cardiac rhythm and heart rate 2). Ability to turn self in bed 3). Allergies to iodine-based agents 4). Patient's level of anxiety

Allergies to iodine-based agents

A nurse is caring for a patient with a history of renal insufficiency who is scheduled for a cardiac catheterization. What actions would the nurse take prior to the catheterization? (Select all that apply.) 1). Assess for allergies to iodine. 2). Administer intravenous fluids. 3). Assess blood urea nitrogen (BUN) and creatinine results. 4). Insert a Foley catheter. 5). Administer a prophylactic antibiotic. 6). Insert a central venous catheter

Assess for allergies to iodine. Administer intravenous fluids. Assess blood urea nitrogen (BUN) and creatinine results.

A nurse assesses a patient 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. What action would the nurse take? 1). Assess the color and temperature of the left leg. 2). Increase the flow rate of intravenous fluids. 3). Elevate the leg and apply a sandbag to the entrance site. 4). Document the finding as "left pedal pulse of +1/4."

Assess the color and temperature of the left leg.

A nurse assesses an older adult patient who has multiple chronic diseases. The patient's heart rate is 48 beats/min. What action would the nurse take first? 1). Document the finding in the chart. 2). Initiate external pacing. 3). Assess the patient's medications. 4). Administer 1 mg of atropine.

Assess the patient's medications.

A nurse assesses an older adult patient who is experiencing a myocardial infarction. Which clinical manifestation would the nurse expect? 1). Excruciating pain on inspiration 2). Numbness and tingling of the arm 3). Left lateral chest wall pain 4). Disorientation and confusion

Disorientation and confusion

A nurse assesses a patient who had a myocardial infarction and is hypotensive. Which additional assessment finding would the nurse expect? 1). Cool, clammy skin 2). Respiratory rate of 8 breaths/min 3). Heart rate of 120 beats/min 4). Oxygen saturation of 90%

Heart rate of 120 beats/min

An emergency room nurse assesses a female patient. Which assessment findings would alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) 1). Shortness of breath 2). Indigestion 3). Abdominal pain 4). Hypertension 5). Fatigue despite adequate rest

Indigestion, Shortness of breath, Fatigue despite adequate rest

A nurse cares for a patient who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention would the nurse be prepared to implement while this patient waits for surgery? 1). Initiation of an external pacemaker 2). Placement of central venous access 3). Assistance with endotracheal intubation 4). Administration of IV furosemide (Lasix)

Initiation of an external pacemaker

A nurse cares for a patient who is prescribed magnetic resonance imaging (MRI) of the heart. The patient's health history includes a previous myocardial infarction and pacemaker implantation. What action would the nurse take? 1). Schedule an electrocardiogram just before the MRI. 2). Call the physician and request a laboratory draw for cardiac enzymes. 3). Instruct the patient to increase fluid intake the day before the MRI. 4). Notify the healthcare provider before scheduling the MRI.

Notify the healthcare provider before scheduling the MRI.

A nurse assesses a patient after administering a prescribed beta-blocker. Which assessment would the nurse expect to find? 1). Respiratory rate decreased from 25 to 14 breaths/min 2). Oxygen saturation increased from 88% to 96% 3). Pulse decreased from 100 to 80 beats/min 4). Blood pressure increased from 98/42 to 132/60 mm Hg

Pulse decreased from 100 to 80 beats/min

A nurse assesses a patient 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.) 1). Blood pressure of 140/88 mm Hg 2). Serum potassium of 2.9 mEq/L 3). Warmth and redness at the site 4). Expanding groin hematoma 5). Rhythm changes on the cardiac monitor

Serum potassium of 2.9 mEq/L Expanding groin hematoma Rhythm changes on the cardiac monitor

A nurse assesses a patient who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? 1). Urinary output less than intake 2). Bruising at the insertion site 3). Slurred speech and confusion 4). Discomfort in the left leg

Slurred speech and confusion

A nurse cares for a patient who is recovering from a right-sided heart catheterization. For which complications of this procedure would the nurse assess? (Select all that apply.) 1). Thrombophlebitis 2). Stroke 3). Pulmonary embolism 4). Myocardial infarction 5). Cardiac tamponade

Thrombophlebitis, Cardiac tamponade, Pulmonary embolism

A nurse reviews a patient's laboratory results. Which findings would alert the nurse to the possibility of atherosclerosis? (Select all that apply.) 1). Total cholesterol: 280 mg/dL 2). High-density lipoprotein cholesterol: 50 mg/dL 3). Triglycerides: 200 mg/dL 4). Serum albumin: 4 g/dL 5). Low-density lipoprotein cholesterol: 160 mg/dL

Total cholesterol: 280 mg/dL Triglycerides: 200 mg/dL Low-density lipoprotein cholesterol: 160 mg/dL