Med-Surge Nursing Cardio Prep U ch 25

The nurse cares for a client with diabetes who is scheduled for a cardiac catheterization. Prior to the procedure, it is most important for the nurse to ask which question?

"Are you allergic to shellfish?" Radiopaque contrast agents are used to visualize the coronary arteries. Some contrast agents contain iodine, and the client is assessed before the procedure for previous reactions to contrast agents or allergies to iodine-containing substances (e.g., seafood). If the client has a suspected or known allergy to the substance, antihistamines or methylprednisolone may be administered before the procedure. Although the other questions are important to ask the client, it is most important to ascertain if the client has an allergy to shellfish.

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?

"Current evidence indicates that estrogen is ineffective as a cardioprotectant; estrogen is actually potentially harmful and is no longer a recommended therapy." In the past hormone therapy was routinely prescribed for postmenopausal women with the belief that it would deter the onset and progression of coronary artery disease (CAD). However, based on results from the multisite, prospective, longitudinal Women's Health Initiative study, the American Heart Association (AHA) no longer recommends the use of hormone therapy as a prevention strategy for women. In the most recently published AHA guidelines for primary prevention of CAD in women, the use of hormone therapy (estrogen) is noted to be ineffective and potentially harmful

The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include?

"Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." The nurse should instruct the client to follow these guidelines: For the next 24 hours, do not bend at the waist, strain, or lift heavy objects if the artery of the groin was used; contact the primary provider if swelling, new bruising or pain from the procedure puncture site, or a temperature of 101°F or more occur. If bleeding occurs, lie down (groin approach) and apply firm pressure to the puncture site for 10 minutes. Notify the primary provider as soon as possible and follow instructions. If there is a large amount of bleeding, call 911. The client should not drive to the hospital.

Your client is being prepared for echocardiography when they ask you why they need to have this test. What would be your best response?

"Echocardiography is a way of determining the functioning of the left ventricle of your heart." Echocardiography uses ultrasound waves to determine the functioning of the left ventricle and to detect cardiac tumors, congenital defects, and changes in the tissue layers of the heart. All answers are correct. C is the best answer as it addresses the client's question without making them anxious or minimizing their question.

A nurse is preparing a client for an exercise stress test the following morning. Which client statement indicates a need for additional teaching?

"I won't eat or drink anything after midnight tonight." The client requires additional teaching if he states that he'll fast from midnight until the test. Clients need to abstain from eating and drinking for only 4 hours before the test. The client should refrain from smoking for several hours before the test. Although the physician may direct the client to avoid certain medications, it's more likely that the physician will direct the client to take all his normal medications. The client must sign a consent form before the test.

The nurse is administerting a stool softner to a client who experienced a myocardial infarction. The client says, "I had a heart attack; I don't have a problem with constipation." What explanation will the nurse use to answer the client's question?

"If you strain to have a bowel movement, you can cause a drop in your heart rate that can be dangerous." When straining during defication, the client bears down, which momentarily may cause the heart to slow and cause fainting or syncope in the client. The stool softner will allow easier pass of stool by increasing the amount of water the stool absorbs in the gut, making the stool softer and easier to pass. The client will not have prescribed limited activty after a myocardial infarction. The nurse needs to explain the medication and not refer the client back to the healthcare provider. Stool softenrs do not decrease stress.

The client asks the nurse what the urine output has to do with his cardiac function. What is the best response by the nurse?

"Poor urine output may indicate inadequate blood flow to the kidneys." Urine output is an important indicator of cardiac function. Low-urine output is caused by the inability of the heart to generate enough cardiac output, leading to reduced blood flow to the brain and other vital organs such as the kidneys. High urine output amy indicate an endocrine problem.

A student nurse is to perform a cardiac assessment for a client and asks the instructor why the aortic valve closure is best heard on the right side of the sternum. What is the best response by the nurse?

"The aortic arch causes the closure of the aortic valve to be heard best on the right side of the sternum." The location of the aortic arch causes the sound of the aortic valve closure to be best heard at the 2nd intercostal space on the right sternal border.

A patient had a cardiac catheterization and is now in the recovery area. What nursing interventions should be included in the plan of care? (Select all that apply.)

1. Assessing the peripheral pulses in the affected extremity 2. Checking the insertion site for hematoma formation 3. Evaluating temperature and color in the affected extremity The nurse should observe the catheter access site for bleeding or hematoma formation and assess peripheral pulses in the affected extremity (dorsalis pedis and posterior tibial pulses in the lower extremity, radial pulse in the upper extremity) every 15 minutes for 1 hour, every 30 minutes for 1 hour, and hourly for 4 hours or until discharge. Blood pressure and heart rate should also be assessed during these same time intervals, not every 8 hours. The nurse should evaluate temperature, color, and capillary refill of the affected extremity during these same time intervals. The patient should maintain bed rest for 2 to 6 hours after the procedure.

A client is experiencing an irregular heartbeat. The client asks the nurse how a heartbeat occurs. The nurse explains the conduction system of the heart beginning with the sinoatrial node (SA node). Place the conduction sequence of the heart in order beginning with the SA node. Use all options.

1. Atrial cell stimulation 2. AV node 3. Bundle of His 4. Bundle branches 5. Purkinje fibers In the normal sequence, the impulse starts in the SA node. The waves of stimulation spread through the atria to the AV node. The impulse then travels from the AV node to the bundle of His, then to the right and left bundle branches, and eventually to the Purkinje fibers.

A client reports chest pain. Which questions related to the client's history are most important to ask? Select all that apply.

1. How would you describe your symptoms? 2. Are you allergic to any medications or foods? 3. How did your mother die? During initial assessment, the nurse should obtain important information about the client's history that focuses on a description of the symptoms before and during admission, family medical history, prescription and nonprescription drug use, and drug and food allergies.

Which assessments should a nurse perform when caring for a client following a cardiac catheterization? Select all that apply.

1. Monitor BP and pulse frequently. 2. Inspect pressure dressing for signs of bleeding. 3. Palpate the pulse in different locations. After a cardiac catheterization, the nurse monitors BP and pulse frequently to detect complications, checks the dressing over the insertion site frequently for signs of bleeding, palpates the pulse in various locations, and checks the color and temperature in the extremity to confirm that blood is circulating well.

The nurse screens a client prior to a magnetic resonance angiogram (MRA) of the heart. Which action should the nurse complete prior to the client undergoing the procedure? Select all that apply.

1. Offer the client a headset to listen to music during the procedure. 2. Remove the client's Transderm Nitro patch. 3. Remove the client's jewelry. Transdermal patches that contain a heat-conducting aluminized layer (e.g., NicoDerm, Androderm, Transderm Nitro, Transderm Scop, Catapres-TTS) must be removed before MRA to prevent burning of the skin. A client who is claustrophobic may need to receive a mild sedative before undergoing an MRA. During an MRA, the client is positioned supine on a table that is placed into an enclosed imager or tube containing the magnetic field. Clients are instructed to remove any jewelry, watches, or other metal items (e.g., ECG leads). An intermittent clanking or thumping that can be annoying is generated by the magnetic coils, so the client may be offered a headset to listen to music.

The nurse is assessing the cardiovascular status of a client who was found unresponsive in a lobby area. Following transfer of the client, the family asks how blood circulates through the body. The nurse is most correct to state the proper circulation as which? Place the pattern of circulation in the correct order beginning in the right atrium. Use all options.

1. Right ventricle 2. Pulmonary artery 3. Pulmonary vein 4. left atrium 5. Left ventricle 6. Aorta

Age-related changes associated with the cardiac system include which conditions? Select all that apply.

1. increased size of the left atrium 2. endocardial fibrosis Age-related changes associated with the cardiac system include endocardial fibrosis, increased size of the left atrium, decreased number of SA node cells, and myocardial thickening.

A nurse is conducting procedures to determine the extent of a client's left-sided heart failure. What adventitious lung sounds would the nurse expect to hear during auscultation of the lungs to support the diagnosis? Select all that apply.

1. wheezes 2. wet lung sounds With left-sided heart failure, auscultation reveals a crackling sound and possibly wheezes and gurgles. Wet lung sounds are accompanied by dyspnea and an effort to sit up to breathe.

The following clients are in need of exercise electrocardiography. Which client would the nurse indicate as most appropriate for a drug-induced stress test?

A 55-year-old recovering from a fall and broken femur An exercise electrocardiography or stress test monitors the electrical activity of the heart while the client walks on a treadmill. If a client has a sedentary lifestyle or physical disability, cardiac medications may be administered to stress the heart similar to activity. Even though the client is middle aged at 55 years old, the client is recovering from a broken femur thus would be unable to have vigorous exercise. None of the other clients have a history which precludes them from exercise electrocardiography.

The nurse is assessing a patient who reports feeling "light-headed." When obtaining orthostatic vital signs, what does the nurse determine is a significant finding?

A heart rate of more than 20 bpm above the resting rate Normal postural responses that occur when a person moves from a lying to a standing position include (1) a heart rate increase of 5 to 20 bpm above the resting rate; (2) an unchanged systolic pressure, or a slight decrease of up to 10 mm Hg; and (3) a slight increase of 5 mm Hg in diastolic pressure. Postural (orthostatic) hypotension is a sustained decrease of at least 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP within 3 minutes of moving from a lying or sitting to a standing position (Freeman et al., 2011). It is usually accompanied by dizziness, lightheadedness, or syncope.

The nurse observes that a patient has 2+ pitting edema in the lower extremities. What does the nurse know that the presence of pitting edema indicates regarding fluid retention?

A weight gain of 10 lbs Pitting edema, in which indentations in the skin remain after even slight compression with the fingertips (Fig. 29-2), is generally obvious after retention of at least 4.5 kg (10 lb) of fluid (4.5 L).

A client is seen in the emergency department and reports left arm pain, fatigue, palpitations, and shortness of breath. Which condition would the nurse suspect?

Acute coronary syndrome Some of the more common signs and symptoms of acute coronary syndrome are chest or arm discomfort, palpitations, fatigue, and shortness of breath. Renal failure is associated with decreased urine output, fluid retention, and nausea not arm pain. Diabetes mellitus has symptoms of polyuria, polydyphasia, and polydipsia not arm pain. Diabetes insipidus has common symptoms of polydipsia, polyuria, and dry skin not arm pian or shortness of breath.

The nurse is caring for a client on a monitored telemetry unit. During morning assessment, the nurse notes abnormal ECG waves on the telemetry monitor. Which action would the nurse do first?

Assess the client. When a nurse notes an abnormal rhythm on a telemetry monitor, the first action is to assess the client. After client assessment, the nurse is able to make an informed decision on the next nursing action.

The nurse is taking a health history from a client admitted with the medical diagnosis of cardiovascular disease (CVD). Which symptoms correlate with the client's diagnosis?

Chest pain, weight gain, fatigue Chest pain, weight gain, fatigue, dizziness, ascites, and confusion are all symptoms of CVD. Rash, extra-ocular eye movements, ecchymosis, and petechiae are not usually indicative of CVD.

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 Attached to the mitral and tricuspid valves are cordlike structures known as chordae tendineae, which in turn attach to papillary muscles, two major muscular projections from the ventricles.

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. The nurse should complete the following actions when applying cardiac electrodes: (1) Clip (do not shave) hair from around the electrode site, if needed; (2) if the client is diaphoretic (sweaty), apply a small amount of benzoin to the skin, avoiding the area under the center of the electrode; (3) debride the skin surface of dead cells with soap and water and dry well (or as recommended by the manufacturer); (4) change the electrodes every 24 to 48 hours (or as recommended by the manufacturer); (5) examine the skin for irritation and apply the electrodes to different locations.

The nurse is performing a skin assessment for a client and observes a blue tinge in the buccal mucosa and tongue. What condition does the nurse correlate this finding with?

Congenital heart disease. Cyanosis is due to serious cardiac disorders. A bluish tinge in the tongue and buccal mucosa are signs of central cyanosis caused by venous blood passing through the pulmonary circulation without being oxygenated. In the absence of pulmonary edema and cardiogenic shock, this sign is indicative of congenital heart disease. Refer to Table 12-3 in the text.

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 heart rate at the apex. The nurse determines the pulse deficit by counting the heart rate through auscultation at the apex while a second nurse simultaneously palpates and counts the radial pulse for a full minute. The difference, if any, is the pulse deficit. The pulse quality refers to its palpated volume. Pulse rhythm is the pattern of the pulsations and the pauses between them.

The nurse is preparing discharge instructions for an elderly client with cardiovascular health changes. What is an age-related change in the cardiovascular system that the nurse considers that may affect the sympathetic nervous system?

Decreased response to beta-blockers The sympathetic nervous system exhibits structural and functional changes that are age-related. Heart rate will decrease, and it will take longer for the heart rate to return to baseline. The ability to sustain increased contractility with a high level of exercise for a prolonged period of time decreases with age, even with healthy aging. Elderly clients will have a decreased response to beta blockers.

A patient has a high magnesium level. Identify how hypermagnesemia affects cardiac function.

Decreases myocardial contractility Hypermagnesemia can cause depression of myocardial contractility and excitability heart block and asystole. Hypomagnesemia predisposes patient to atrial or ventricular tachycardias.

A cardiac patient with a magnesium lab result of 2.5 mEq/L would most likely evidence which of the following?

Depressed myocardial contractility The normal magnesium level is 1.3 to 2.2 mEq/L. An elevated magnesium level can depress myocardial contractility and excitability, which can lead to heart block or asystole.

The nurse is preparing a client for a transesophageal echocardiography. What will be an indication for the client to have a transesophageal echocardiography?

Determination of atrial thrombi The TEE is an important diagnostic tool for determining if atrial or ventricular thrombi are present in patients with heart failure, valvular heart disease, and dysrhythmias. The electrocardiogram (ECG) is a graphic recording of the electrical activity of the heart to determine dysrhthmias. Stress testing is used to evaluate the response of the cardiovascular system to increased demands for oxygen and nutrients. Thallium is used with exercise or pharmacologic stress testing to assess changes in myocardial perfusion at rest and after exercise.

The nurse is performing an assessment of a clients peripheral pulses and indicates that the pulse quality is +1 on a scale of 0-4. What does this documented finding indicate?

Difficult to palpate and is obliterated with pressure. The quality of pulses is reported using descriptors and a scale of 0 to 4. The lower the number, the weaker the pulse and the easier it is to obliterate it. A +1 pulse is weak and thready and easily obliterated with pressure.

A patient has been diagnosed with congestive heart failure (CHF). The health care provider has ordered a medication to enhance contractility. The nurse would expect which medication to be prescribed for the patient?

Digoxin Contractility is enhanced by circulating catecholamines, sympathetic neuronal activity, and certain medications, such as Lanoxin. Increased contractility results in increased stroke volume. The other medications are classified as platelet-inhibiting medications.

The nurse is caring for a geriatric client. The client is ordered Lanoxin (digoxin) tablets 0.125mg daily for a cardiac dysrhythmias. Which of the following assessment considerations is essential when caring for this age-group?

Digoxin level The action of Digoxin slows and strengthens the heart rate. Assessment of the pulse rate is essential prior to administration in all clients. Due to decreased perfusion common in geriatric clients, toxicity may occur more often. The nurse must monitor Digoxin levels in the body. Monitoring symptoms reflecting cardiac output, activity level, and dyspnea are also important assessment considerations for all clients.

A client is being scheduled for a stress test. The client is unable to exercise during the test. The nurse would include information about which medication used for pharmacologic stress testing?

Dipyridamole If the patient is unable to exercise, a pharmacologic stress test is performed by injecting a vasodilating agent, dipyridamole or adenosine, to mimic the physiologic effects of exercise. The stress test may be combined with an echocardiogram or radionuclide imaging techniques to examine myocardial function during exercise and rest. Digoxin would not be used for stress testing. Thallium 201 and Cardiolite are radioisotopes used in myocardial perfusion scanning.

When caring for a client with dysfunction in the conduction system, at which period would the nurse note that cells are resistant to stimulation?

During the refractory period The refractory period is the time when cells are resistant to electrical stimulation. Repolarization is when the ions realign themselves to wait for an electrical signal. Depolarization occurs during muscle contraction when positive ions move inside the myocardial cell membrane and negative ions move outside. Before an impulse is generated, the cells are in a polarized state.

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?

Enzymes When tissues and cells break down, are damaged, or die, great quantities of certain enzymes are released into the bloodstream. Enzymes can be elevated in response to cardiac or other organ damage. After an MI, RBCs and platelets should not be elevated. WBCs would only be elevated if there was a bacterial infection present.

The nurse is assessing an older adult client's electrocardiogram (ECG). What age related change to the conduction system may the nurse observe?

Heart block Age-related changes to the conduction system may include bradycardia and heart block. Age-related changes to the heart valves include the presence of a murmur or thrill.

The nurse instructor is teaching a group of nursing students about adventitious heart sounds. The instructor explains that auscultation of the heart requires familiarization with normal and abnormal heart sounds. What would the instructor tell these students a ventricular gallop indicates in an adult?

Heart failure A sound that follows S1 and S2 is called an S3 heart sound or a ventricular gallop. An S3, normal in children, often is an indication of heart failure in an adult. An extra sound before S1 is an S4 heart sound, or atrial gallop. An S4 sound often is associated with hypertensive heart disease. A friction rub may cause a rough, grating, or scratchy sound that is an indication of pericarditis or inflammation of the pericardium.

The critical care nurse is caring for clients in an emergency department. When caring for a variety of clients, when is the presence of a third heart sound normal?

In pediatric clients When caring for a variety of clients, it is important to consider that a third heart sound is normal in children. In adults, a third heart sound may signify heart failure. There is no correlation between third heart sounds with heart valve replacement and an indwelling pacemaker.

The nurse is caring for a client who is diagnosed with an infarction of the posterior wall of the right atrium. Which assessment finding would the nurse anticipate relating to the infarction location?

Irregular heart rate The posterior wall of the right atrium is the location of the sinoatrial node (SA node), which is the pacemaker of the heart. Damage to this location may result in an irregular heart rate due to a disturbance of electrical pulse initiation. Depending on muscle damage, the client may have respiratory compromise, chest pain, and/or cyanosis.

A nurse is performing a cardiac assessment on an elderly client. Which finding warrants further investigation?

Irregularly irregular heart rate An irregularly irregular heart rate indicates atrial fibrillation and should be investigated further. It's normal for an elderly client to have a prolonged systole, which causes an S4 heart sound. It's also normal for an elderly client to have slowed conduction, causing an increased PR interval. As a person ages, it's normal for baroreceptors in the body to decrease their response to changes in body position, which can cause orthostatic hypotension.

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?

Left 5th intercostal space at the midclavicular line As a result of this close proximity to the chest wall, the pulsation created during normal ventricular contraction, called the apical impulse (also called the point of maximal impulse [PMI]), is easily detected. In the normal heart, the PMI is located at the intersection of the midclavicular line of the left chest wall and the fifth intercostal space

After a physical examination, the provider diagnosed a patient with a grade 4 heart murmur. When ausculatating a murmur, what does the nurse expect to hear?

Loud and may be associated with a thrill sound similar to (a purring cat). Heart murmurs are characterized by location, timing, and intensity. A grading system is used to describe the intensity or loudness of a murmur. A grade 1 is very faint and difficult to describe, whereas a grade 6 is extremely loud. Refer to Box 12-3 in the text for a description of grades 1 to 6.

The nurse is caring for a client in the cardiac intensive care unit (CICU) after a myocardial infarction (MI). Which drug will the nurse administer that will decrease contractility?

Metoprolol Contractility is depressed by beta-adrenergic blocking medications. The other choices all enhance contractility.

The nurse is caring for a client with ECG changes consistent with a myocardial infarction. Which of the following diagnostic test does the nurse anticipate to confirm heart damage?

Nuclear cardiology Nuclear cardiology uses a radionuclide to detect areas of myocardial damage. Chest radiography and fluoroscopy determine the size and position of the heart and condition of the lungs. Serum blood work notes elevations in enzymes suggesting muscle damage.

The nurse cares for a client with clubbing of the fingers and toes. The nurse should complete which action given these findings?

Obtain an oxygen saturation level. Clubbing of the fingers and toes indicates chronic hemoglobin desaturation (decreased oxygen supply) and is associated with congenital heart disease. The nurse should assess the client's O2 saturation level and intervene as directed. The other assessments are not indicated.

You are working on a telemetry unit. Your client was admitted with a cardiac event and is now on a cardiac monitor. You know a cardiac monitor reveals the heart's electrical but not its mechanical activity. How would you assess the mechanical activity of the client's heart?

Palpate a peripheral pulse. A cardiac monitor reveals the heart's electrical but not its mechanical activity. The healthcare provider must palpate a peripheral pulse or auscultate the apical heart rate to obtain this information. You cannot obtain information on the mechanical activity of the heart by taking the client's blood pressure, auscultating the carotid artery, or attempting to percuss the perimeter of the heart.

A nurse is caring for a client taking diltiazem for arrhythmias. The nurse knows that diltiazem helps decrease arrhythmias by working during which phase of the cardiac action potential?

Phase 0 Diltiazem, a calcium channel blocker, blocks the influx of calcium into the cells during phase 0 of the cardiac action potential. This action causes the sinoatrial node and atrioventricular (AV) node to slow their response times, which results in slowed AV conduction, decreased ventricular depolarization, and arrhythmias. Diltiazem doesn't work during phase 1, 2, or 3 of the cardiac action potential.

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?

Report any incident of bloody urine, stools, or both. The client who takes an anticoagulant, such as a low-molecular-weight heparin, is routinely screened for bloody urine, stools, or both. Clients taking enoxaparin will not need to take caclium supplements or have potassium imbalances related to the medication. The clubbing of fingers may occur with chronic pulmonary diseases.

The nurse is caring for a client with nursing diagnosis of ineffective tissue perfusion. Which area of the heart would the nurse anticipate being compromised?

Right ventricle There are four chambers to the heart. The right and left ventricles is the heart's major pumping chamber. The right ventricle pumps to the lungs to oxygenate the blood. The left ventricle pumps blood to the tissues and cells. The pulmonary artery and aorta are not of the heart.

One of the students asks what the consequences of uncorrected, left-sided heart failure would be. What would be the nursing instructor's best response?

Right-sided heart failure If uncorrected, left-sided heart failure is followed by right-sided heart failure because the circulatory system is a continuous loop. With left-sided congestive heart failure, auscultation reveals a crackling sound, wheezes, and gurgles. Wet lung sounds are accompanied by dyspnea and an effort to sit up to breathe. If the right side of the heart fails to pump efficiently, blood becomes congested in the neck veins, and the nurse may inspect the distention of external jugular vein.

A client in the ICU has a central venous pressure (CVP) line placed. The CVP reading is 10 mm Hg. To what condition does the nurse correlate the CVP reading?

Right-sided heart failure Normal CVP is 2 to 8 mm Hg. A CVP greater than 8 mm Hg indicates hypervolemia or right-sided heart failure. A CVP less than 2 mm Hg indicates a reduction in preload or hypovolemia.

You are evaluating the expected outcomes on a client who is recovering from a cardiac catheterization. What is an expected outcome that you would evaluate?

The client and family understands the discharge instructions. The client is relaxed and feels secure. The test is performed uneventfully or the client is stabilized when complications are managed successfully. The client and family have an accurate understanding of the diagnostic testing process and discharge instructions. The scenario does not indicate that the client has a CV diagnosis, a need for medication, or a need to restrict their activity for 72 hours.

A patient tells the nurse, "I was straining to have a bowel movement and felt like I was going to faint. I took my pulse and it was so slow." What does the nurse understand occurred with this patient?

The patient had a vagal response. When straining during defecation, the patient bears down (the Valsalva maneuver), which momentarily increases pressure on the baroreceptors. This triggers a vagal response, causing the heart rate to slow and resulting in syncope in some patients. Straining during urination can produce the same response. A myocardial infarction is damage to the hearta nd clients will experience pain or shortness of breath. Anxiety causes the heart rate to increase. The client with an abdominal aortic aneurysm will experience back or abdominal pain not a decrease in heart rate.

The nurse is performing an assessment for an older adult client with reports of chest pain. What assessment finding correlates with a potential age-related change?

The presence of an S4 sound With age, the heart rate will decrease, and heart block can occur with changes in the conduction system. Auscultation may reveal the presence of an S4 sound. Pulse pressure will widen, and the systolic pressure will increase because of stiffening of the blood vessels. The heart rate should decrease.

The patient has a heart rate of 72 bpm with a regular rhythm. Where does the nurse determine the impulse arises from?

The sinoatrial node The sinoatrial node, the primary pacemaker of the heart, in a normal resting adult heart has an inherent firing rate of 60 to 100 impulses per minute; however, the rate changes in response to the metabolic demands of the body

A patient recently diagnosed with pericarditis asks the nurse to explain what area of the heart is involved. How does the nurse best describe the pericardium to the client?

Thin fibrous sac that encases the heart. The pericardium is a thin, fibrous sac that encases the heart. It is composed of two layers, the visceral and the parietal pericardium. The space between these two layers is filled with fluid.

A nurse is caring for a dying client following myocardial infarction. The client is experiencing apnea with a falling blood pressure of 60 per palpation. Which documentation of pulse quality does the nurse anticipate?

Thready pulse The nurse is most correct to anticipate a thready (barely palpable) pulse quality. A bounding pulse indicates a strong cardiac output. A weak pulse indicates a lower pulse quality. A pulse deficit occurs when the pulses between the apex of the heart differs from the radial pulse.

The nurse is auscultating a client's heart sounds and notes a murmur at the left fourth intercostal space and lateral to the sternum. At which cardiac valve would the nurse document this murmur?

Tricuspid valve The tricuspid valve is at the left fourth intercostal space and lateral to the sternum. The mitral valve is heard at the left fifth intercostal space and midclavicular line. The aortic valve is heard at the right second intercostal space, lateral to the sternum. The pulmonic valve is left second intercostal space, lateral to the sternum.

Which term describes the ability of the heart to initiate an electrical impulse?

automaticity Automaticity is the ability of specialized electrical cells of the cardiac conduction system to initiate an electrical impulse. Contractility refers to the ability of the specialized electrical cells of the cardiac conduction system to contract in response to an electrical impulse. Conductivity refers to the ability of the specialized electrical cells of the cardiac conduction system to transmit an electrical impulse from one cell to another. Excitability refers to the ability of the specialized electrical cells of the cardiac conduction system to respond to an electrical impulse.

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?

catheter-related bloodstream infections Catheter-related bloodstream infections (CRBSIs) are the most common preventable complication associated with hemodynamic monitoring systems. Comprehensive guidelines for the prevention of these infections have been published by Centers for Disease Control and Prevention (CDC). Complications from use of hemodynamic monitoring systems are uncommon and can include pneumothorax, infection, and air embolism. A pneumothorax may occur during the insertion of catheters using a central venous approach (CVP and pulmonary artery catheters). Air emboli can be introduced into the vascular system if the stopcocks attached to the pressure transducers are mishandled during blood drawing, administration of medications, or other procedures that require opening the system to air.

For a client who has undergone peripheral arteriography, how should the nurse assess the adequacy of peripheral circulation

checking peripheral pulses Peripheral arteriography is used to diagnose occlusive arterial disease in smaller arteries. The nurse observes the client for bleeding and cardiac dysrhythmias and assesses the adequacy of peripheral circulation by frequently checking the peripheral pulses. Hemodynamic monitoring is used to assess the volume and pressure of blood in the heart and vascular system.

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:

deficit. To determine the pulse deficit, one nurse counts the heart rate through auscultation at the apex while a second nurse simultaneously palpates and counts the radial pulse for a full minute. The difference, if any, is the pulse deficit. Pulse rhythm is the pattern of the pulsations and the pauses between them. Pulse volume is described as feeling full, weak, or thready, meaning barely palpable. The pulse quality refers to its palpated volume.

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?

disorientation, 20 mL of urine over the last 2 hours Assessment findings associated with reduced cardiac output include reduced pulse pressure, hypotension, tachycardia, reduced urine output, lethargy, or disorientation.

The nurse is administering an Amiodarone drip for a client that develops a ventricular dysrhythmia after having a myocardial infarction (MI). What is the best indication that the medication is having the desired effect?

electrocardiogram (ECG) Lidocaine is an antiarrhythmic and is given for the treatment of cardiac irritability and ventricular arrhythmias. The best indicator of its effectiveness is a reduction in or disappearance of ventricular arrhythmias as seen on an ECG. Urine output is an indicator of pump effectiveness; CK and troponin levels monitor myocardial damage. Blood pressure and heart rate measurements are too nonspecific to help determine the effectiveness of parenteral lidocaine.

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 The inner layer, the endocardium, is composed of a thin, smooth layer of endothelial cells. Folds of endocardium form the heart valves. The middle layer, the myocardium, consists of muscle tissue and is the force behind the heart's pumping action. The pericardium is a saclike structure that surrounds and supports the heart. The outer layer, the epicardium, is composed of fibrous and loose connective tissue.

Which area of the heart is located at the third intercostal (IC) space to the left of the sternum?

erb point Erb point is located at the third IC space to the left of the sternum. The aortic area is located at the second IC space to the right of the sternum. The pulmonic area is at the second IC space to the left of the sternum. The epigastric area is located below the xiphoid process.

Which symptom is an early warning sign of acute coronary syndrome (ACS) and heart failure (HF)?

fatigue Fatigue is an early warning symptom of ACS, heart failure, and valvular disease. Other signs and symptoms of cardiovascular disease are hypotension, change in level of consciousness, and weight gain.

A client with a history of right-sided heart failure lives in a long-term care facility. In the daily assessment, the nurse is required to record the level of this client's peripheral edema. Which would be the main area for examination?

feet and ankles Edema occurs when blood is not pumped efficiently or plasma protein levels are inadequate to maintain osmotic pressure. When blood has nowhere else to go, the extra fluid enters the tissues. Particular areas for examination are the dependent parts of the body, such as the feet and ankles. The area over, not below, the sacrum is another area prone to edema.

What is a harsh grating sound caused by abrasion of the pericardial surfaces during the cardiac cycle?

friction rub During pericarditis, a harsh, grating sound that can be heard in both systole and diastole is called a friction rub. A murmur is created by the turbulent flow of blood. A cause of the turbulence may be a critically narrowed valve. An opening snap is caused by high pressure in the left atrium with abrupt displacement of a rigid mitral valve. An ejection click is caused by very high pressure within the ventricle, displacing a rigid and calcified aortic valve.

During the auscultation of a client's heart sounds, the nurse notes an S4. The nurse recognizes that an S4 is associated with which condition?

hypertensive heart disease Auscultation of the heart requires familiarization with normal and abnormal heart sounds. An extra sound just before S1 is an S4 heart sound, or atrial gallop. An S4 sound often is associated with hypertensive heart disease. A sound that follows S1 and S2 is called an S3 heart sound or a ventricular gallop. An S3 heart sound is often an indication of heart failure in an adult. In addition to heart sounds, auscultation may reveal other abnormal sounds, such as murmurs and clicks, caused by turbulent blood flow through diseased heart valves.

During the auscultation of heart, what is revealed by an atrial gallop?

hypertensive heart disease Auscultation of the heart requires familiarization with normal and abnormal heart sounds. An extra sound just before S1 is an S4 heart sound, or atrial gallop. An S4 sound often is associated with hypertensive heart disease. A sound that follows S1 and S2 is called an S3 heart sound or a ventricular gallop. An S3 heart sound is often an indication of heart failure in an adult. In addition to heart sounds, auscultation may reveal other abnormal sounds, such as murmurs and clicks, caused by turbulent blood flow through diseased heart valves.

The nurse cares for a client in the ICU who is being monitored with a central venous pressure (CVP) catheter. The nurse records the client's CVP as 8 mm Hg and recognizes that this finding indicates the client is experiencing which condition?

hypervolemia The normal CVP is 2 to 6 mm Hg. A CVP greater than 6 mm Hg indicates an elevated right ventricular preload. Many problems can cause an elevated CVP, but the most common is hypervolemia (excessive fluid circulating in the body) or right-sided HF. In contrast, a low CVP (<2 mm Hg) indicates reduced right-ventricular preload, which is most often from hypovolemia.

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 The left ventricle pumps blood to all the cells and tissues of the body. The left atrium receives oxygenated blood from the lungs. The right ventricle pumps blood to the lungs to be oxygenated. The right atrium receives deoxygenated blood from the venous system.

A student nurse prepares to assess a client for postural blood pressure changes. Which action indicates the student nurse needs further education?

letting 30 seconds elapse after each position change before measuring BP and HR The following steps are recommended when assessing clients for postural hypotension: (1) Position the client supine for 10 minutes before taking the initial BP and HR measurements; (2) reposition the client to a sitting position with legs in the dependent position, and wait 2 minutes to reassess both BP and HR measurements; (3) if the client is symptom free or has no significant decreases in systolic or diastolic BP, assist the client into a standing position, obtain measurements immediately and recheck in 2 minutes; (4) continue measurements every 2 minutes for a total of 10 minutes to rule out postural hypotension. Return the client to supine position if postural hypotension is detected or if the client becomes symptomatic. Document HR and BP measured in each position (e.g., supine, sitting, and standing) and any signs or symptoms that accompanied the postural changes.

A nurse is assessing a client with heart failure. When assessing hepatojugular reflux, what is the appropriate action for the nurse to take?

press the right upper abdomen As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a client has positive hepatojugular reflux. Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree, not 90-degree, angle.

The balloon on the distal tip of a pulmonary artery catheter is inflated and the pressure is measured. What is the term for the measurement obtained?

pulmonary artery wedge pressure When the balloon is inflated, the tip of the catheter floats into smaller branches of the pulmonary artery until it can no longer be passed. The pressure is recorded, reflecting left-atrial pressure and left-ventricular end-diastolic pressure. Central venous pressure is measured in the right atrium. Pulmonary artery pressure is measured when the balloon tip is not inflated. Cardiac output is determined through thermodilution, which involves injection of fluid into the pulmonary artery catheter.

The physician orders medication to treat a client's cardiac ischemia. What is causing the client's condition?

reduced blood supply to the heart Ischemia is reduced blood supply to body organs. Cardiac ischemia is caused by reduced blood supply to the heart muscle. It may lead to a myocardial infarction. Chest pain is a symptom of ischemia.

What does decreased pulse pressure reflect?

reduced stroke volume Decreased pulse pressure reflects reduced stroke volume and ejection velocity or obstruction to blood flow during systole. Increased pulse pressure would indicate reduced distensibility of the arteries, along with bradycardia

Central venous pressure is measured in which heart chamber?

right atrium The pressure in the right atrium is used to assess right ventricular function and venous blood return to the heart. The left atrium receives oxygenated blood from the pulmonary circulation. The left ventricle receives oxygenated blood from the left atrium. The right ventricle is not the central collecting chamber of venous circulation.

Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for pumping blood to the lungs to be oxygenated?

right ventricle The right ventricle pumps blood to the lungs to be oxygenated. The left ventricle pumps that blood to all the cells and tissues of the body. The right atrium receives deoxygenated blood from the venous system. The left atrium receives oxygenated blood from the lungs.

Which term describes the amount of blood ejected per heartbeat?

stroke volume Stroke volume is determined by preload, afterload, and contractility of the heart. Cardiac output is the amount of blood pumped by each ventricle during a given period and is computed by multiplying the stroke volume of the heart by the heart rate. Ejection fraction is the percentage of the end-diastolic volume that is ejected with each stroke, measured at 42% to 50% in the normal heart. Afterload is defined as the pressure that the ventricular myocardium must overcome to eject blood during systole and is one of the determinants of stroke volume.

An obese client describes symptoms of palpitations, chronic fatigue, and dyspnea on exertion to the cardiologist. Upon completing the examination, the cardiologist schedules a procedure to confirm the suspected diagnosis. What diagnostic procedure would the nurse expect to be prescribed?

transesophageal echocardiography TEE involves passing a tube with a small transducer internally from the mouth to the esophagus to obtain images of the posterior heart and its internal structures from the esophagus, which lies behind the heart. TEE provides superior views that are not possible using standard transthoracic echocardiography. Clients whose chests are rotund or who are obese are candidates for TEE. Chest radiography and fluoroscopy determine the size and position of the heart and condition of the lungs. The radionuclide technetium-99m is used to detect areas of myocardial damage. The radionuclide thallium-201 is used to diagnose ischemic heart disease during a stress test. Electrocardiography (ECG) is the graphic recording of the electrical currents generated by the heart muscle.

Which test used to diagnose heart disease is least invasive?

transthoracic echocardiography Transthoracic echocardiography uses high-frequency sound waves that pass through the chest wall (transthoracic) and are displayed on an oscilloscope. MRI uses magnetism to identify disorders that affect many different structures in the body without performing surgery. While an MRI does not expose clients to radiation, it does require intravenous infusion to instill medication and contrast medium. Cardiac catheterization requires the insertion of a long, flexible catheter from a peripheral blood vessel in the groin, arm, or neck into one of the great vessels and then into the heart. Coronary arteriography requires the instillation of a contrast medium into each coronary artery.

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?

withhold food and fluids. Following a transesophageal echocardiogram in which the client's throat has been anesthetized, the nurse should withhold food and fluid until the client's gag reflex returns. There's no indication that oral airway placement would be appropriate. The client should be in the upright position, and the nurse needn't insert an NG tube.