Chapter 21: Assessment of Cardiovascular Function

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 An increase of 10 mm Hg blood pressure reading An unchanged systolic pressure An increase of 5 mm Hg in diastolic pressure

A heart rate of more than 20 bpm above the resting rate Explanation: 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.

A client is being discharged after having a cardiac catheterization through the femoral artery. Which teaching will the nurse provide for the client to perform self-care at home? Select all that apply. Call 911 if there is a large amount of bleeding from the access site. Avoid bending at the waist for at least the first 24 hours. Notify the health care provider if new bruising occurs at the site. Avoid showering and take tub baths for the first two weeks. Apply pressure to the site for 10 minutes if it begins to bleed.

Avoid bending at the waist for at least the first 24 hours. Notify the health care provider if new bruising occurs at the site. Call 911 if there is a large amount of bleeding from the access site. Apply pressure to the site for 10 minutes if it begins to bleed. Explanation: After discharge from the hospital for cardiac catheterization, the client should follow specific instructions for self-care. These instructions include avoiding tub baths since the puncture site should not be submerged in water. Bending at the waist should be avoided for 24 hours. The health care provider should be notified if any bruising occurs at the puncture site since this could indicate bleeding or hematoma formation. The client should call 911 if there is a large amount of bleeding from the access site and apply pressure to the site for 10 minutes if bleeding occurs. pg 683

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

B-type natriuretic peptide (BNP) Explanation: The client's symptoms suggest heart failure. BNP is a neurohormone that's released from the ventricles when the ventricles experience increased pressure and stretch, such as in heart failure. A BNP level greater than 51 pg/ml is commonly associated with mild heart failure. As the BNP level increases, the severity of heart failure increases. Potassium levels aren't affected by heart failure. CRP is an indicator of inflammation. It's used to help predict the risk of coronary artery disease. There is no indication that the client has an increased CRP. There is no indication that the client is experiencing bleeding abnormalities, such as those seen with an abnormal platelet count. pg 674

A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). The client's blood pressure is 104/68 mm Hg. The client's pulse rate is 76 beats/minute. The nurse detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take? Document findings and check the client again in 1 hour. Encourage the client to perform isometric leg exercise to improve circulation in the legs. Slow the I.V. fluid to prevent any more swelling at the puncture site. Contact the health care provider and report the findings.

Contact the health care provider and report the findings.

A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). The client's blood pressure is 104/68 mm Hg. The client's pulse rate is 76 beats/minute. The nurse detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take? Encourage the client to perform isometric leg exercise to improve circulation in the legs. Document findings and check the client again in 1 hour. Slow the I.V. fluid to prevent any more swelling at the puncture site. Contact the health care provider and report the findings.

Contact the health care provider and report the findings. Explanation: The client is probably developing a hematoma at the puncture site. The decreased pulses, swelling, and cool temperature in the leg are all classic signs that blood flow to that extremity is compromised. The nurse should notify the health care provider immediately to preserve the blood flow in the client's leg. Documenting findings and checking the client again in 1 hour, slowing the I.V. fluid, and encouraging the client to perform isometric leg exercises aren't appropriate actions for the nurse to take at this time. pg 664

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? Thallium Ativan Diazepam Dobutamine

Dobutamine Explanation: Drugs such as adenosine (Adenocard), dipyridamole (Persantine), or dobutamine (Dobutrex) may be administered singularly or in combination by the IV route. The drugs dilate the coronary arteries, similar to the vasodilation that occurs when a person exercises to increase the heart muscle's blood supply. The other options would not dilate the coronary arteries.

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

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.

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

Have you had any episodes of dizziness or fainting?" Explanation: Ask if the client has episodes of dyspnea, dizziness, or fainting. Options B, C, and D are incorrect. Being nauseous, mottling of the hands, and pain radiating into the lower extremities are not indications of cardiac problems. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 21: Assessment of Cardiovascular Function, Common Symptoms, p. 657. Chapter 21: Assessment of Cardiovascular Function - Page 657

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. Assess the client's capillary refill. Assess the client for pitting edema. Obtain a 12-lead ECG tracing.

Obtain an oxygen saturation level. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 21: Assessment of Cardiovascular Function, Assessment of the Cardiovascular System, Physical Assessment, p. 664.

The nurse is educating a patient at risk for atherosclerosis. What nonmodifiable risk factor does the nurse identify for the patient? Stress Hyperlipidemia Positive family history Obesity

Positive family history Explanation: The health history provides an opportunity for the nurse to assess patients' understanding of their personal risk factors for coronary artery, peripheral vascular, and cerebrovascular diseases and any measures that they are taking to modify these risks. Risk factors are classified by the extent to which they can be modified by changing one's lifestyle or modifying personal behaviors. Stress, obesity, and hyperlipidemia are all risk factors that can be modified by personal behaviors. Family history is a nonmodifiable risk factor, because it cannot be changed. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 21: Assessment of Cardiovascular Function, Past Health, Family, and Social History, p. 658.

The nurse is discharging a client after a cardiac catheterization. What would the nurse include in the discharge teaching? Eat only soft foods for the next 12 hours. Restrict your intake of water until the dye is out of the body. Move around whenever the client feels like getting up. Report any numbness, tingling, or sharp pain in the extremity.

Report any numbness, tingling, or sharp pain in the extremity. Explanation: Instructions for the client and family include: Keep the extremity straight for several hours and avoid movement; Report any warm, wet feeling that may indicate oozing blood, numbness, tingling, or sharp pain in the extremity; Drink a large volume of fluid to relieve thirst and promote the excretion of the dye. There is no need to eat only soft foods after a cardiac catheterization. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 21: Assessment of Cardiovascular Function, Nursing Interventions, p. 677. Chapter 21: Assessment of Cardiovascular Function - Page 677

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? Effort to lie down to breathe Distention of the jugular vein Right-sided heart failure Blood congestion in neck veins

Right-sided heart failure

The nurse observes a client during an exercise stress test (bicycle). Which finding indicates a positive test and the need for further diagnostic testing? BP changes; 148/80 mm Hg to 166/90 mm Hg ST-segment changes on the ECG Dizziness and leg cramping Heart rate changes; 78 bpm to 112 bpm

ST-segment changes on the ECG Explanation: During the test, the following are monitored: two or more ECG leads for heart rate, rhythm, and ischemic changes; blood pressure; skin temperature; physical appearance; perceived exertion; and symptoms, including chest pain, dyspnea, dizziness, leg cramping, and fatigue. The test is terminated when the target heart rate is achieved or if the client experiences signs of myocardial ischemia. Further diagnostic testing, such as a cardiac catheterization, may be warranted if the client develops chest pain, extreme fatigue, a decrease in blood pressure or pulse rate, serious dysrhythmias or ST-segment changes on the ECG during the stress test. The other findings would not warrant stopping the test. pg 677

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? Returning to work immediately is okay. Expect increased bruising to appear at the site over the next several days. Avoid tub baths, but shower as desired. Do not ambulate until the healthcare provider indicates it is appropriate.

avoid tub baths, but shower as desired Guidelines for self-care after hospital discharge following a cardiac catheterization include showering as desired (no tub baths) and avoiding bending at the waist and lifting heavy objects. The healthcare provider will indicate when it is okay to return to work. The client should notify the healthcare provider right away if bleeding, new bruising, swelling, or pain are noted at the puncture site. The client will be able to ambulate after the puncture site has clotted.

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? air embolism pneumothorax catheter-related bloodstream infections hemorrhage

catheter-related bloodstream Explanation: 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. pg 684

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? partial thromboplastic time (PTT) international normalized ratio (INR) Sodium complete blood count (CBC)

international normalized ratio (INR) Explanation: The INR, reported with the PT, provides a standard method for reporting PT levels and eliminates the variation of PT results from different laboratories. The INR, rather than the PT alone, is used to monitor the effectiveness of warfarin. The therapeutic range for INR is 2 to 3.5, although specific ranges vary based on diagnosis. The other laboratory values are not used to evaluate the effectiveness of warfarin. 673

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? Papillary tendons Chordae tendineae Atrioventricular tendons Semilunar tendineae

Chordae tendineae

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? Apply baby powder to the client's chest prior to placing the electrodes. Once the electrodes are applied, change them every 72 hours. Clean the client's chest with alcohol prior to application of the electrodes. Clip the client's chest hair prior to applying the electrodes.

Clip the client's chest hair prior to applying the electrodes.

While the nurse is preparing a client for a cardiac catheterization, the client states that they have allergies to seafood. Which of the following medications may the nurse give prior to the procedure? Lorazepam Phenytoin Methylprednisolone Furosemide

Phenytoin Methylprednisolone Explanation: Prior to cardiac catheterization, the patient is assessed for previous reactions to contrast agents or allergies to iodine-containing substances, as some contrast agents contain iodine. If allergic reactions are of concern, antihistamines or methylprednisolone (Solu-Medrol) may be administered to the patient before angiography is performed. Furosemide, Lorazepam, and Phenytoin do not counteract allergic reactions. pg 679

The clinic nurse is assessing a client's pulse before outpatient diagnostic testing. What should the nurse document when assessing the client's pulse? Quality, volume, and rate Rate, quality, and rhythm Pressure, rate, and rhythm Rate, rhythm, and volume

Rate, quality, and rhythm

A client needs additional information about a heart condition. The client asks the nurse, "What is considered the pacemaker of the heart?" The SA node The AV node The Purkinje fibers The bundle of HIS

The SA node

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? "It is usually better to just give up sex after a heart attack." "The physiologic demands are greatest during orgasm and are equivalent to walking 3 to 4 miles per hour on a treadmill." "The medications will prevent your husband from having an erection." "Having an orgasm is very strenuous and your husband must be in excellent physical shape before attempting it."

The physiologic demands are greatest during orgasm and are equivalent to walking 3 to 4 miles per hour on a treadmill."

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

Tricuspid valve

The nurse is reviewing the results of the patient's echocardiogram and observes that the ejection fraction is 35%. The nurse anticipates that the patient will receive treatment for what condition? Myocardial infarction Heart failure Pulmonary embolism Pericarditis

heart failure

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? "When was the last time you ate or drank?" "What was your morning blood sugar reading?" "Are you allergic to shellfish?" "Are you having chest pain?"

"Are you allergic to shellfish?"

While being prepared for echocardiography, the client asks nurse why this test is necessary. What would be the nurse's best response? "This test will find any congenital heart defects." "Echocardiography will tell your doctor if you have cancer of the heart." "This test can tell us a lot about your heart." "Echocardiography is a way of determining the functioning of the left ventricle of your heart."

"Echocardiography is a way of determining the functioning of the left ventricle of your heart." Explanation: 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. Explaining the procedure is the best answer because it addresses the client's question without making the client anxious or minimizing the question. pg 680

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

"My family is bringing me a cup of coffee to drink before the test."

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 valve is located near the apex of the heart, which is on the right side." "The aortic arch causes the closure of the aortic valve to be heard best on the right side of the sternum." "The aortic valve is located near the base of the heart on the right side." "The aortic valve is located on the right side of the heart."

"The aortic arch causes the closure of the aortic valve to be heard best on the right side of the sternum."

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? Cranberries, apples, popcorn Asparagus, blueberries, green beans Bok choy, cooked leeks, alfalfa sprouts Apricots, dried peas and beans, dates

Apricots, dried peas and beans, dates Explanation: Apricots, dried peas and beans, dates, and kiwi contain high amounts of potassium. The other foods listed contain minimal amounts. pg 673

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? Chemoreceptors Baroreceptors Vagus nerve Sympathetic nerve fibers

Baroreceptors

A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). The client's blood pressure is 104/68 mm Hg. The client's pulse rate is 76 beats/minute. The nurse detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take? Document findings and check the client again in 1 hour. Slow the I.V. fluid to prevent any more swelling at the puncture site. Encourage the client to perform isometric leg exercise to improve circulation in the legs. Contact the health care provider and report the findings.

Contact the health care provider and report the findings. Explanation: The client is probably developing a hematoma at the puncture site. The decreased pulses, swelling, and cool temperature in the leg are all classic signs that blood flow to that extremity is compromised. The nurse should notify the health care provider immediately to preserve the blood flow in the client's leg. Documenting findings and checking the client again in 1 hour, slowing the I.V. fluid, and encouraging the client to perform isometric leg exercises aren't appropriate actions for the nurse to take at this time. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 21: Assessment of Cardiovascular Function, Assessment of the Skin and Extremities, p. 664.

Which finding is a priority to report to the healthcare provider? Mg++ 2 mEq/L K+ 3.1 mEq/L Ca++ 9 mg/dL Na+ 140 mEq/L

Correct response: K+ 3.1 mEq/L Explanation: All laboratory levels are within normal limits except for the K+, which is low. A low K+ level can cause ventricular tachycardia or fibrillation.

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 ventricles The Purkinje fibers The AV node

Correct response: The sinoatrial node Explanation: 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 (Weber & Kelley, 2010).

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

Obtain an oxygen saturation level.

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. Count the radial pulse for 20 to 25 seconds. Calculate the pauses between pulsations. Calculate the palpated volume.

Count the heart rate at the apex. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 21: Assessment of Cardiovascular Function, Pulse Rhythm, p. 666.

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

Crackles

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 68-year-old housewife with history of osteoporosis A 55-year-old recovering from a fall and broken femur A 72-year-old retired janitor obtaining a cardiac baseline A 48-year-old policemen with history of knee replacement 4 years ago

D. A 55-year-old recovering from a fall and broken femurAn 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.

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? Clopidogrel Enoxaparin Heparin Digoxin

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 dysrhythmia. Which of the following assessment considerations is essential when caring for this client? Dyspnea Activity level Digoxin level Cardiac output

Digoxin level Explanation: 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. pg 656

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? RBC Platelets Enzymes WBC

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. pg 672

Which area of the heart that is located at the third intercostal space to the left of the sternum? pulmonic area Erb point epigastric area aortic area

Erb point

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

Heart block explanation: 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. 651

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? Normal functioning Pericarditis Heart failure Hypertensive heart disease

Heart failure

After a physical examination, the provider diagnosed a patient with a grade 4 heart murmur. During assessment, the nurse expects to hear a murmur that is: Quiet but readily heard. Loud and may be associated with a thrill sound similar to (a purring cat). Very loud; can be heard with the stethoscope half-way off the chest. Easily heard with no palpable thrill.

Loud and may be associated with a thrill sound similar to (a purring cat Explanation: 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. pg 671

The nurse measures the pulmonary artery wedge pressure in a client with left ventricular dysfunction. Which action will the nurse take after deflating the balloon tip following pressure measurement? Lower the head of the client's bed to be at 25 degrees. Measure the client's blood pressure on both of the client's arms. Observe for return of the pulmonary artery systolic and diastolic waveforms. Ensure the transducer is positioned at the phlebostatic axis.

Observe for return of the pulmonary artery systolic and diastolic waveforms. Explanation: Pulmonary artery pressure monitoring is used in critical care for assessing left ventricular function, diagnosing the etiology of shock, and evaluating the client's response to medical interventions. After measuring the pulmonary artery wedge pressure, the nurse ensures that the balloon is deflated and that the catheter has returned to its normal position. This intervention is verified by evaluating the return of the pulmonary artery systolic and diastolic waveform displayed on the bedside monitor. The head of the bed does not need to be lowered nor does the blood pressure need to be measured on both arms after measuring the pulmonary artery wedge pressure. The transducer must be positioned at the phlebostatic axis before the measurement is taken to ensure an accurate reading. pg 685

The nurse observes a client during an exercise stress test (bicycle). Which finding indicates a positive test and the need for further diagnostic testing? BP changes; 148/80 mm Hg to 166/90 mm Hg ST-segment changes on the ECG Heart rate changes; 78 bpm to 112 bpm Dizziness and leg cramping

ST-segment changes on the ECG Explanation: During the test, the following are monitored: two or more ECG leads for heart rate, rhythm, and ischemic changes; blood pressure; skin temperature; physical appearance; perceived exertion; and symptoms, including chest pain, dyspnea, dizziness, leg cramping, and fatigue. The test is terminated when the target heart rate is achieved or if the client experiences signs of myocardial ischemia. Further diagnostic testing, such as a cardiac catheterization, may be warranted if the client develops chest pain, extreme fatigue, a decrease in blood pressure or pulse rate, serious dysrhythmias or ST-segment changes on the ECG during the stress test. The other findings would not warrant stopping the test.

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

Try to avoid emotional stress and take part in mild physical stress only.

The cardiologist has scheduled a client for drug-induced stress testing. What instructions should the nurse provide to prepare the client for this test? You will need to wear comfortable shoes to the test. You may experience an onset of dizziness during the test. You will begin exercising at a slow speed. You will receive medication via IV administration.

You will receive medication via IV administration.

The nurse is reviewing the laboratory results for a client with heart failure. Which laboratory value will the nurse report to the health care provider? magnesium 2.5 mg/dL calcium 9.8 mg/dL potassium 3.9 mEq/L sodium 148 mEq/L

sodium 148 mEq/L Explanation: Normal sodium levels are between 135 and 145 mEq/L, so the sodium value is abnormal. The remaining values are normal. Normal potassium levels range from 3.5 to 5.0 mEq/L. The normal range for calcium level is 8.5 to 10.5 mg/dL. Normal magnesium levels range from 1.8 to 3.0 mg/dL.

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? radionuclide angiography transesophageal echocardiography electrocardiography chest radiograph

transesophageal echocardiography (TEE)

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.) Assisting the patient to the bathroom after the procedure Checking the insertion site for hematoma formation Assessing vital signs every 8 hours Evaluating temperature and color in the affected extremity Assessing the peripheral pulses in the affected extremity

Checking the insertion site for hematoma formation Evaluating temperature and color in the affected extremity Assessing the peripheral pulses in the affected extremity

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 decrease with systole. The pulmonic valve must be closed. The atrioventricular valves must open. Right ventricular pressure must be higher than pulmonary arterial pressure.

Right ventricular pressure must be higher than pulmonary arterial pressure. Explanation: For the right ventricle to pump blood in need of oxygenation into the lungs via the pulmonary artery, right ventricular pressure must be higher than pulmonary arterial pressure. pg 655

hich term describes the ability of the heart to initiate an electrical impulse? excitability automaticity conductivity contractility

automaticity

critically ill client is admitted to the ICU. The health care provider decides to use intra-arterial pressure monitoring. After this intervention is performed, what assessment should the nurse prioritize? Perfusion distal to the insertion site Fluctuations in core body temperature Signs and symptoms of esophageal varices Signs and symptoms of compartment syndrome

perfusion distal to the insertion site Feedback:The radial artery is the usual site selected. However, placement of a catheter into the radial artery can further impede perfusion to an area that has poor circulation. As a result, the tissue distal to the cannulated artery can become ischemic or necrotic. Vigilant assessment is thus necessary. Alterations in temperature and the development of esophageal varices or compartment syndrome are not high risks.

A nurse is assessing a client with heart failure. When assessing hepatojugular reflux, what is the appropriate action for the nurse to take? elevate the client's head to 90 degrees. press the right upper abdomen. lay the client flat in bed. press the left upper abdomen.

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.

What does decreased pulse pressure reflect? elevated stroke volume tachycardia reduced distensibility of the arteries reduced stroke volume

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 21: Assessment of Cardiovascular Function, Assessment of the Cardiovascular System, Physical Assessment, p. 665.

Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for receiving oxygenated blood from the lungs? right ventricle left ventricle left atrium right atrium

left atrium

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 right ventricle right atrium left atrium

left ventricle Explanation: 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 positioning the client supine for 10 minutes prior to taking the initial BP and HR obtaining the supine measurements prior to the sitting and standing measurements taking the client's BP with the client sitting on the edge of the bed, feet dangling

letting 30 seconds elapse after each position change before measuring BP and HR Explanation: 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. pg 666