Heart and Neck Vessels

The RN uses the SBAR method when communicating with the primary HCP. Which are components of the SBAR method? (Select all that apply) 1. Assessment 2. Response 3. Recommendation 4. Action 5. Situation.

Assessment Recommendation Situation

4. To obtain information that will help distinguish whether the client's fatigue is cardiac in nature, what question should the nurse ask the client? 1. Why do you feel your fatigue is related to your age? At what time of the day do you feel most fatigued? 2. Can you describe the quality of your fatigue? 3. What do you do when you feel tired? 4. At what time of the day do you feel most fatigued?

At what time of the day do you feel most fatigued?

2. After palpating an irregular pulse rhythm at the left radial pulse site, what action should the nurse take to confirm the client's heart rate? 1. Palpate both radial pulses simultaneously. 2. Auscultate the apical pulse for one minute. 3. Compare the ulnar pulse to the radial pulse. 4. Ask the client if he experiences palpitations.

Auscultate the apical pulse for one minute.

20. What assessment should the nurse include? 1. Check for jugular vein distention. 2. Note the onset of nailed clubbing. 3. Check for diminished skin elasticity. 4. Assess for orthostatic hypotension.

Check for jugular vein distention.

11. Which test result can the nurse review to obtain the same information that might be obtained during precordial percussion? 1. Creatine phosphokinase 2. Carotid Ultrasound 3. Serum liver enzymes. 4. Chest x-ray. 5. Echocardiogram.

Chest x-ray. Echocardiogram

5. Before developing the client's plan of care, what information is most important for the nurse to obtain regarding the client's spirituality? 1. Whether the client participates in formal religious services regularly. 2. How the client's spiritual beliefs impact his health care expectations. 3. What beliefs the client holds regarding the existence of a higher power. 4. The old played by a spiritual advisor within the client's faith tradition.

How the client's spiritual beliefs impact his health care expectations.

1. Based on Mr. Depodi's Report of increasingly frequent periods of dyspnea, dizziness and minor chest discomfort, what assessment should the nurse perform next? 1. Ask the client to stand and the recheck the blood pressure. 2. Place the client in a supine position and observe for orthopnea. 3. Measure the apical and radial pulse rates at the same time. 4. Determine if the client is currently experiencing any angina.

Determine if the client is currently experiencing any angina.

6. Is it most important for the nurse to obtain further information related to which aspect of the client's care? 1. Hygiene practices. 2. Sleep patterns. 3. Exercise habits. 4. Dietary needs. 5. Herbs or purgatives used

Dietary needs Herbs or purgatives used

22. What action should the nurse take? 1. Use a stethoscope to auscultate the pulsation. 2. Palpate the pulsation again, using less pressure. 3. Reposition the client's head and attempt to palpate again. 4. Document the level at which the pulsation is observed.

Document the level at which the pulsation is observed.

15. What action should the nurse take in response to this finding? 1. Document this normal finding on the initial assessment record. 2. Confirm the finding on the beside cardiac telemetry monitor. 3. Assess for a change in the client's oxygen saturation reading. 4. Contact the healthcare provider to report the assessment finding.

Document this normal finding on the initial assessment record.

3. To gather data about Tomas' history of chest pain, how should the nurse begin? 1. Encourage the client to describe his chest discomfort. 2. Determine if the chest pain has radiated to other sites. 3. Question the client about the frequency of his symptoms. 4. Ask the client to rate his chest pain on a numeric scale.

Encourage the client to describe his chest discomfort.

7. How should the nurse prepare the client for inspection of the precordium? 1. Assist the client to a left side-lying position with his chest and back exposed. 2. Open the back of the client's gown while he sits on the side of the bed. 3. Help the client to a supine position on the bed with his chest exposed. 4. Loosen the client's gown and ask him to lean forward in the bedside chair.

Help the client to a supine position on the bed with his chest exposed.

12. How should the nurse plan to continue auscultation from that site? 1. Move the stethoscope back and forth across the sternum. 2. Slide the stethoscope over and up in a n"X" pattern. 3. Lift the stethoscope from one valve area to the next. 4. Inch the stethoscope across and down in a "Z" pattern.

Inch the stethoscope across and down in a "Z" pattern.

8. The nurse should observe the force of the impulse at what location? 1. Left midclavicular line, 2nd intercostal space. 2. Left sternal border, 4th intercostal space. 3. Right sternal border, 2nd intercostal space. 4. Left midclavicular line, 5th intercostal space.

Left midclavicular line, 5th intercostal space.

24. The nurse does not hear a bruit. What should the nurse do next? 1. Reassure the client that his right artery sounds "clear" and listen on the left side. 2. Listen at the base of the neck again, this time using the diaphragm of the stethoscope. 3. Move the bell of the stethoscope up the right side of the neck to the mid-cervical area. 4. Press the bell of the stethoscope more firmly against the base of the neck and listen again.

Move the bell of the stethoscope up the right side of the neck to the mid-cervical area.

17. To determine the grade of the murmur, what action should the nurse take? 1. Listen in surrounding areas for the extend of radiation of the sound. 2. Assess for a change in the murmur during a change in the client's position. 3. Determine the location on the client's chest where the murmur is best heard, 4. Note how easily the murmur is heard by gradually lifting the stethoscope.

Note how easily the murmur is heard by gradually lifting the stethoscope.

25. Which assessment data is important for the nurse to report to the client's physician? 1. Presence of S1 and S2 heart sounds. 2. Onset of an S3 heart sound. 3. Observe jugular vein distenstion. 4. Noted absence of a carotid bruit. 5. Assessed carotid artery volume of +2. 6. Client's subjective report of dyspnea.

Onset of an S3 heart sound. Observe jugular vein distenstion. Client's subjective report of dyspnea.

23. How should the nurse begin the carotid artery assessment? 1. Palpate one artery while listening to the other side with a stethoscope. 2. Palpate one artery and then palpate the artery on the opposite side. 3. Gently compress both arteries simultaneously to compare the volume. 4. Avoid palpation and only use a stethoscope to listen to each artery.

Palpate one artery and then palpate the artery on the opposite side.

14. White continuing to listen at the aortic site, what action should the nurse take? 1. Observe the P wave on the telemetry monitor. 2. Watch the client's inhalation and exhalation. 3. Palpate the carotid artery pulse. 4. Check for a pulse deficit.

Palpate the carotid artery pulse.

21. To inspect for jugular vein distention, what action should the nurse take? 1. Place the client in a Fowler's position with his head straight. 2. Lower the head of the bed while observing the neck veins. 3. Remove the client's pillow and turn his head away slightly. 4. Assist the client to lean forward at a 30-45 degree angle.

Remove the client's pillow and turn his head away slightly. Place the client in a Semi-Fowler's position.

18. What action should the nurse take next? 1. Document the findings and report the murmur to the charge nurse. 2. Repeat auscultation across the chest using the bell of the stethoscope. 3. Continue assessment of heart sounds across the client's posterior thorax. 4. Plan to repeat the assessment in one hour, after the client rests.

Repeat auscultation across the chest using the bell of the stethoscope.

9. To begin palpation at the base of the heart, where should the nurse palpate first? 1. Right sternal border, 2nd intercostal space. 2. Right sternal border, 4th intercostal space. 3. Left sternal border, 5th intercostal space. 4. Left midclavicular line 5th intercostal space.

Right sternal border, 2nd intercostal space.

10. Before attempting to palpate again, what instruction should the nurse give the client? 1. Lift his left arm above his head. 2. Turn onto his right side. 3. Externally rotate his right shoulder. 4. Roll half-way to his left side.

Roll half-way to his left side.

13. In listening at this site, what should the nurse attempt to distinguish first? 1. S1 and S2 heart sounds. 2. Diastolic hear murmur. 3. S3 and S4 heart sounds. 4. Systolic heart murmur.

S1 and S2 heart sounds.

16. How should the nurse identify this sound? 1. Diastolic murmur. 2. Systolic murmur. 3. S4 heart sound. 4. S3 heart sound.

Systolic murmur.

19. What action will help the nurse confirm the presence of this sound? 1. Move the diaphragm of the stethoscope to the base of the heart. 2. Use the bell of the stethoscope to continue listening at the apical site. 3. Palpate the apical impulse while listening at the base of the heart. 4. Place the bell of the stethoscope at the right sternal border at the third interspace.

Use the bell of the stethoscope to continue listening at the apical site