Chapter 12: PrepU - Nursing Assessment: Cardiovascular and Circulatory Function

What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse? 1- contractility 2- depolarization 3- repolarization 4- diastole

1

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? 1- right ventricle 2- left ventricle 3- right atrium 4- left atrium

1

The nurse is administering a beta blocker to a patient in order to decrease automaticity. Which medication will the nurse administer? 1- Diltiazem 2- Metoprolol 3- Amiodarone 4- Propafenone

2

Following the morning assessment of an older adult patient, the nurse has documented, "Edema 3+ present to ankles and feet; dorsalis pedis and posterior tibial pulses palpable bilaterally." The nurse should recognize that this patient may be exhibiting symptoms of: 1- Heart failure 2- Angina pectoris 3- Intermittent claudication 4- Hypertension

1

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? 1- left ventricle 2- left atrium 3- right ventricle 4- right atrium

1

A 76-year-old resident of an assisted living facility who has a history of heart failure has presented to her primary care provider for a scheduled appointment. Which of the woman's statements suggests that her heart failure is worsening? 1- "The last few weeks I've found that I'm more comfortable sleeping in a chair than in my bed." 2- "I find that I have to wake up two or three times a night to go to the washroom, which never used to be the case." 3- "I find that my appetite is not what it used to be, and I have to will myself to eat enough healthy food." 4- "I pride myself in staying alert and up-to-date but lately I've forgotten a few important events."

1

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? 1- feet and ankles 2- over the sacrum 3- lips and earlobes 4- knees and elbows

1

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? 1- hypertensive heart disease 2- heart failure 3- pericarditis 4- diseased heart valves

1

A nurse is preparing a client for a scheduled adenosine stress test. Which statement made by the client indicates a need for further education? 1- "My family is bringing me a cup of coffee to drink before the test." 2- "The effects of this medication will wear off quickly." 3- "The medication will have an effect on my heart similar to exercise." 4- "I may feel some flushing or nausea with this medication."

1

A patient's gradual decline in activity tolerance and increased shortness of breath have prompted her health care provider to assess the structure and size of her heart. Which of the following diagnostic tests is most likely to yield these assessment data? 1- Echocardiography 2- Electrocardiography (ECG) 3- Cardiac catheterization 4- Angiography

1

During the assessment of a newly admitted female patient, the nurse has assessed the amplitude of the woman's temporal, dorsalis pedis, and posterior tibial pulses. The amplitude of these peripheral pulses contributes to the nurse's determination of this patient's: 1- Peripheral arterial circulation 2- Tissue perfusion in her extremities 3- Resting blood pressure 4- Risk of deep vein thrombosis (DVT)

1

The client states, "My doctor says that because I am now taking this water pill, I need to eat more foods that contain potassium. Can you give me some ideas about what foods would be good for this?" What is the appropriate response by the nurse? 1- Apricots, dried peas and beans, dates 2- Asparagus, blueberries, green beans 3- Cranberries, apples, popcorn 4- Bok choy, cooked leeks, alfalfa sprouts

1

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? 1- 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. 2- When the client is in the recumbent position, more pressure is put on the bladder, with the result of increased need to urinate. 3- The blood pressure is lower when the client is recumbent, which causes the kidneys to work harder; therefore, more urine is produced. 4- 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.

1

The critical care nurse is caring for a patient with a pulmonary artery pressure monitoring system. The nurse is aware that pulmonary artery pressure monitoring is used to assess left ventricular function (cardiac output). What else are pulmonary artery pressure monitoring systems used for? 1- To assess the patient's response to interventions such as fluid administration and drug administration 2- To obtain specimens for arterial blood gas measurements 3- They have been determined to not be clinically useful for continuous monitoring of a patient with heart failure. 4- To diagnose the etiology of chronic obstructive pulmonary disease.

1

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? 1- international normalized ratio (INR) 2- partial thromboplastic time (PTT) 3- complete blood count (CBC) 4- Sodium

1

The nurse cares for a client with clubbing of the fingers and toes. The nurse should complete which action given these findings? 1- Obtain an oxygen saturation level. 2- Assess the client's capillary refill. 3- Assess the client for pitting edema. 4- Obtain a 12-lead ECG tracing.

1

The nurse correctly identifies which data as an example of blood pressure and heart rate measurements in a client with postural hypotension? 1- 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 2- supine: BP 130/70 mm Hg, HR 80 bpm; sitting: BP 128/70 mm Hg, HR 80 bpm; standing: BP 130/68 mm Hg, HR 82 bpm 3- supine: BP 140/78 mm Hg, HR 72 bpm; sitting: BP 145/78 mm Hg, HR 74 bpm; standing: BP 144/78 mm Hg, HR 74 bpm 4- supine: BP 114/82 mm Hg, HR 90 bpm; sitting: BP 110/76 mm Hg, HR 95 bpm; standing: BP 108/74 mm Hg, HR 98 bpm

1

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? 1- Heart failure 2- Hypertensive heart disease 3- Normal functioning 4- Pericarditis

1

The nurse is admitting an older adult client with heart failure. Which education will the nurse prepare for this client prior to discharge?" 1- Try to avoid emotional stress and take part in mild physical stress only. 2- Any kind of stress is acceptable, because the aging heart has an increased ability to respond. 3- Exercise tolerance should remain the same as in younger years. 4- Continue to increase the amount of exercise, because cardiac output increases with age.

1

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? 1- Report any incident of bloody urine, stools, or both. 2- Administer calcium supplements. 3- Assess for hypokalemia. 4- Assess for clubbing of the fingers.

1

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? 1- A heart rate of more than 20 bpm above the resting rate 2- An unchanged systolic pressure 3- An increase of 10 mm Hg blood pressure reading 4- An increase of 5 mm Hg in diastolic pressure

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The nurse is assessing a patient's blood pressure. What does the nurse document as the difference between the systolic and the diastolic pressure? 1- Pulse pressure 2- Auscultatory gap 3- Pulse deficit 4- Korotkoff sound

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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? 1- Chordae tendineae 2- Atrioventricular tendons 3- Semilunar tendineae 4- Papillary tendons

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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? 1- Digoxin level 2- Cardiac output 3- Activity level 4- Dyspnea

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The nurse is caring for a patient with a diagnosis of pericarditis. Where does the nurse understand the inflammation is located? 1- The thin fibrous sac encasing the heart 2- The inner lining of the heart and valves 3- The heart's muscle fibers 4- The exterior layer of the heart

1

The nurse is conducting patient teaching about cholesterol levels in the body. When discussing the patient's elevated low-density lipoprotein (LDL) and lowered high-density lipoprotein (HDL) levels, the patient shows an understanding of the significance of these levels by stating what? 1- "Increased LDL and decreased HDL increase my risk of coronary artery disease." 2- "Increased LDL and decreased HDL decrease my risk of coronary artery disease." 3- "The decreased HDL level will increase the amount of cholesterol moved away from the artery walls." 4- "The increased LDL will decrease the amount of cholesterol deposited on the artery walls."

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The nurse is performing a focused assessment of a patient who has a complex cardiac history. The vital signs that the nurse obtains are as follows: Temperature 99.0°F (37.2°C); pulse 94 bpm; blood pressure 142/116 mm Hg; respiration 22 breaths per minute; SaO2 90% on room air. These findings should prompt the nurse to consider the possibility that this patient has: 1- Decreased cardiac output 2- Peripheral vascular disease (PVD) 3- Angina pectoris 4- An arrhythmia

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The nurse is providing discharge education for a client going home after cardiac catheterization. What information is a priority to include when providing discharge education? 1- Avoid tub baths, but shower as desired. 2- Do not ambulate until the healthcare provider indicates it is appropriate. 3- Expect increased bruising to appear at the site over the next several days. 4- Returning to work immediately is okay.

1

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? 1- Chest pain, weight gain, fatigue 2- Dizziness, rash, extra-ocular eye movements 3- Fatigue, ecchymosis, confusion 4- Petechiae, ascites, constipation

1

The nurse prepares to auscultate heart sounds. What nursing intervention will be most effective to assist with this procedure? 1- 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. 2 -Ask the client to sit on the edge of the bed and hold breath while the nurse listens. 3- Insist that the family members leave the room if they must speak to each other while the nurse is auscultating heart sounds. 4- Ask the client to take deep breaths through the mouth while the nurse auscultates heart sounds.

1

The physician orders medication to treat a client's cardiac ischemia. What is causing the client's condition? 1- reduced blood supply to the heart 2- pain on exertion 3- high blood pressure 4- indigestion

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While auscultating the heart of a pediatric client who is recovering from acute rheumatic fever, the nurse hears a murmur. This sound may indicate: 1- valve damage. 2- pericarditis. 3- cardiac tamponade. 4- atrial gallop.

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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? 1- endocardium 2- myocardium 3- pericardium 4- epicardium

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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? 1- "Have you had any episodes of dizziness or fainting?" 2- "Have you had any episodes when you are to nauseous?" 3- "Have you had any episodes of mottling in your hands?" 4- "Have you had any episodes of pain radiating into your lower extremities?"

1

You are the clinic nurse doing assessments on your clients before they have outpatient diagnostic testing done. What would you document when assessing the client's pulse? 1- Rate, quality, and rhythm 2- Pressure, rate, and rhythm 3- Rate, rhythm, and volume 4- Quality, volume, and rate

1

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 4- Assisting the patient to the bathroom after the procedure 5- Assessing vital signs every 8 hours

1,2,3

The nursing instructor is teaching nursing students about myocardial contractility and ejection fractions. What diagnostic tests can determine client ejection fractions? Select all that apply. 1- Echocardiogram 2- Cardiac catheterization 3- Magnetic resonance imaging 4- Positron emission tomography scan 5- Troponin levels

1,2,3

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? 1- Potassium 2- B-type natriuretic peptide (BNP) 3- C-reactive protein (CRP) 4- Platelet count

2

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? 1- insert an oral airway. 2- withhold food and fluids. 3- position the client on his side. 4- introduce a nasogastric (NG) tube.

2

The nurse assesses the patient and records the data collected. What would lead the nurse to anticipate that the patient will experience a decrease in cardiac output? 1- An order for the patient to receive digoxin 2- A heart rate of 54 beats per minute 3- A pulse oximetry reading of 98% 4- An increase in preload related to ambulation in the hall

2

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? 1- BP 108/60 mm Hg, ascites, and crackles 2- disorientation, 20 mL of urine over the last 2 hours 3- reduced pulse pressure and heart murmur 4- elevated jugular venous distention and postural changes in BP

2

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? 1- hemorrhage 2- catheter-related bloodstream infections 3- air embolism 4- pneumothorax

2

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? 1- congenital heart disease 2- heart failure 3- aortic stenosis 4- coronary artery disease

2

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? 1- "That's a great idea. You don't want to have a heart attack." 2- "Current research determines that the replacement of estrogen will protect a woman after she goes into menopause." 3- "Current evidence indicates that estrogen is ineffective as a cardioprotectant; estrogen is actually potentially harmful and is no longer a recommended therapy." 4- "You need to research it and determine what you want to do."

3

A nurse is reviewing laboratory values for a client diagnosed with hyperlipidemia 6 months ago. Which results indicate that the client has been following a therapeutic regimen? 1- Total cholesterol level increases from 250 mg/dl to 275 mg/dl. 2- Low density lipoproteins (LDL) increase from 180 mg/dl to 190 mg/dl. 3- High density lipoproteins (HDL) increase from 25 mg/dl to 40 mg/dl. 4- Triglycerides increase from 225 mg/dl to 250 mg/dl.

3

A patient is admitted to the emergency room after blunt chest trauma resulting from a motor vehicle accident. The nurse confirms that the patient's symptoms are consistent with the diagnosis of a dissecting aorta. Which of the following descriptions of pain is characteristic of this diagnosis? 1- Sharp and substernal, and rises from the inferior portion of the pleura 2- Stabbing and localized in the anterior chest 3- Persistent and tearing, located in the anterior chest and radiating to the shoulders 4- Stabbing and described as a persistent ache

3

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? 1- Easily heard with no palpable thrill. 2- Quiet but readily heard. 3- Loud and may be associated with a thrill sound similar to (a purring cat). 4- Very loud; can be heard with the stethoscope half-way off the chest.

3

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? 1- blood pressure in the left arm 2- pulse rate in upper extremities 3- description of the pain 4- sound of the apical pulses

3

Heparin therapy is usually considered therapeutic when the client's activated partial thromboplastin time (aPTT) is how many times normal? 1- .25 to .75 2- .75 to 1.5 3- 2.0 to 2.5 4- 2.5 to 3.0

3

In preparation for transesophageal echocardiography (TEE), the nurse must: 1- Instruct the patient to drink 1 L of water before the test 2- Heavily sedate the patient 3- Inform the patient that blood pressure (BP) and electrocardiogram (ECG) monitoring will occur throughout the test 4- Inform the patient that an access line will be initiated in the femoral artery

3

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: 1- The atrioventricular valves must open. 2- The pulmonic valve must be closed. 3- Right ventricular pressure must be higher than pulmonary arterial pressure. 4- Right ventricular pressure must decrease with systole.

3

The client is being prepared for echocardiography when he asks the nurse why he needs to have this test. What would be the nurse's best response? 1- "This test will find any congenital heart defects." 2- "This test can tell us a lot about your heart." 3- "Echocardiography is a way of determining the functioning of the left ventricle of your heart." 4- "Echocardiography will tell your doctor if you have cancer of the heart."

3

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? 1- Count the radial pulse for 20 to 25 seconds. 2- Calculate the palpated volume. 3- Count the heart rate at the apex. 4- Calculate the pauses between pulsations.

3

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? 1- Chemoreceptors 2- Sympathetic nerve fibers 3- Baroreceptors 4- Vagus nerve

3

The nurse is caring for a patient admitted with unstable angina. The laboratory results reveal that the initial troponin I level is elevated in this patient. What conclusion should the nurse draw from this fact? 1- This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours. 2- Because the entry diagnosis is unstable angina, this is a poor indicator of myocardial injury. 3- This is an accurate indicator of myocardial injury. 4- It is only an accurate indicator of skeletal muscle injury.

3

The nurse is caring for an elderly client with left-sided heart failure. When auscultating lung sounds, which adventitious sound is expected? 1- Wheezes 2- Rhonchi 3- Crackles 4- Coarseness

3

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? 1- Diminished, but cannot be obliterated with pressure. 2- Full, easy to palpate, and cannot be obliterated with pressure. 3- Difficult to palpate and is obliterated with pressure. 4- Strong and bounding and may be abnormal.

3

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 may affect the sympathetic nervous system? 1- tachycardia 2- increased contractility response to exercise 3- decreased response to beta-blockers 4- decreased time for the heart rate to return to baseline

3

The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include? 1- "You can take a tub bath or a shower when you get home." 2- "Contact your primary care provider if you develop a temperature above 102°F." 3- "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." 4- "If any discharge occurs at the puncture site, call 911 immediately."

3

The patient has a heart rate of 72 bpm with a regular rhythm. Where does the nurse determine the impulse arises from? 1- The AV node 2- The Purkinje fibers 3- The sinoatrial node 4- The ventricles

3

What does decreased pulse pressure reflect? 1- tachycardia 2- reduced distensibility of the arteries 3- reduced stroke volume 4- elevated stroke volume

3

Which area of the heart is located at the third intercostal (IC) space to the left of the sternum? 1- aortic area 2- pulmonic area 3- erb point 4- epigastric area

3

A 71-year-old woman has complained of chest pain that appears when she is doing housework or climbing stairs. The woman claims that the pain dissipates when she stops exerting herself and rests for a few minutes. The woman's history, combined with these complaints, prompted her primary care provider to order cardiac catheterization. What instructions should the nurse provide this patient in anticipation of her procedure? 1- "After the test is done, you can resume your normal activity as soon as you feel ready." 2- "You'll be put under general anesthetic for the procedure, and you'll wake up when it's done." 3- "A small amount of bleeding from your puncture site is normal for a day or two after the procedure." 4- "Make sure that you don't eat or drink before the procedure."

4

An older adult patient experienced a fall during the previous night shift, and the care team suspects that the patient may be experiencing orthostatic hypotension. When assessing this patient for postural changes in blood pressure (BP), the nurse should: 1- Record the patient's standing, sitting and lying BPs in prompt succession while assisting the patient in transitions 2- Ask the patient to begin by adopting the position that most often causes him or her to feel dizzy then assess BP in a variety of positions 3- Take BP readings when the patient is lying, sitting, and standing with a minimum period of 30 minutes between each measurement 4- Assess the patient's BP in supine, feet dangling, and then standing positions with 1 to 3 minutes of waiting between each reading.

4

For a client who has undergone peripheral arteriography, how should the nurse assess the adequacy of peripheral circulation? 1- hemodynamic monitoring 2- checking for cardiac dysrhythmias 3- observing the client for bleeding 4- checking peripheral pulses

4

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? 1- Thallium 2- Ativan 3- Diazepam 4- Dobutamine

4

The nurse is conducting a head-to-toe assessment of a patient at the beginning of a shift. The nurse has palpated the patient's radial pulse for 1 minute to determine the patient's heart rate and has detected an irregular rhythm. How should the nurse follow-up this assessment finding? 1- Continue to palpate the patient's radial pulse for one more minute in order to gauge the severity of the arrhythmia. 2- Palpate the patient's right and left radial pulses simultaneously to compare the symmetry of the patient's rate and rhythm. 3- Reposition the patient, wait 3 to 5 minutes and then reassess the patient's radial pulse. 4- Auscultate the patient's apical pulse while simultaneously palpating the patient's radial pulse.

4

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? 1- A weight gain of 4 lbs 2- A weight gain of 6 lbs 3- A weight gain of 8 lbs 4- A weight gain of 10 lbs

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