CARDIO FUNCTION (CH. 21) PREPU
The nurse is caring for a client who has just returned from the cardiac catheterization laboratory following a coronary angioplasty. What is the nurse's priority assessment?
Check the temperature, color, and capillary refill of the affected extremity.
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
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.
A nurse is caring for a client with a central venous pressure (CVP) of 4 mm Hg. Which nursing intervention is appropriate?
Continue to monitor the client as ordered.
The nurse caring for a client who is suspected of having cardiovascular disease has a stress test ordered. The client has a co-morbidity of multiple sclerosis, so the nurse knows the stress test will be drug-induced. What drug will be used to dilate the coronary arteries?
Dobutamine
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 EXPLANATION: 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.
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?
Feet and ankles EXPLANATION: When right-sided heart failure occurs, blood accumulates in the vessels and backs up in peripheral veins, and the extra fluid enters the tissues. Particular areas for examination are the dependent parts of the body, such as the feet and ankles. Other prominent areas prone to edema are the fingers, hands, and over the sacrum. Cyanosis can be detected by noting color changes in the lips and earlobes.
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 EXPLANATION: 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 nurse is caring for a client who is scheduled for a transesophageal echocardiogram. What nursing intervention is a priority after the procedure?
Keep the head of the bed elevated 45 degrees and keep NPO until return of the gag reflex.
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
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:
Right ventricular pressure must be higher than pulmonary arterial pressure.
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 nurse is caring for a patient with a diagnosis of pericarditis. Where does the nurse understand the inflammation is located?
The thin fibrous sac encasing the heart
What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse?
contractility
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
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 nurse auscultates the apex beat at which anatomical location?
fifth intercostal space, midclavicular line
What is a harsh grating sound caused by abrasion of the pericardial surfaces during the cardiac cycle?
friction rub
The nurse auscultates the PMI (point of maximal impulse) at which anatomic location?
left midclavicular line, fifth intercostal space
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 nurse is administering a beta blocker to a patient in order to decrease automaticity. Which medication will the nurse administer?
metoprolol
What does decreased pulse pressure reflect?
reduced stroke volume EXPLANATION: 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.
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?
sinoatrial node
The nurse correctly identifies which data as an example of blood pressure and heart rate measurements in a client with postural hypotension?
supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm EXPLANATION: 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 position to a standing position. The following is an example of BP and HR measurements in a client with postural hypotension: supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm. Normal postural responses that occur when a person moves from a lying to a standing position include (1) a HR 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
The nurse receives a laboratory report indicating the client's magnesium level is 5.2 mEq/L. What symptoms is the client at risk to experience? Select all that apply.
ventricular tachycardia, headache, hypotension, irregular heartbeat
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 is administering a stool softener 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.
A nurse is preparing a client for a scheduled adenosine stress test. Which statement made by the client indicates a need for further education?
"My family is bringing me a cup of coffee to drink before the test." EXPLANATION: Caffeine must be avoided for 4 hours prior to the stress test. Caffeine acts as an adenosine receptor antagonist. If caffeine is ingested, the test must be rescheduled. It is true that the effects of the medication wear off quickly. The half-life of adenosine is less than 10 seconds. Adenosine will affect the heart like exercise, and flushing or nausea can occur.
The client asks the nurse what urine output has to do with cardiac function. What is the best response by the nurse?
"Poor urine output may indicate inadequate blood flow to the kidneys."
The nurse is assessing vital signs on a client who is 3 months status post myocardial infarction (MI). While the healthcare provider is examining the client, the client's spouse approaches the nurse and states "We are too afraid he will have another heart attack, so we just don't have sex anymore." What is the nurse's best response?
"The physiologic demands are greatest during orgasm and are equivalent to walking 3 to 4 miles per hour on a treadmill."
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
A nurse is preparing a client for cardiac catheterization. The nurse knows that which nursing intervention must be provided when the client returns to the room after the procedure?
Assess the puncture site frequently for hematoma formation or bleeding.
