Chapter 21: Assessment of Cardiovascular Function

The nurse is assessing an older adult's cardiovascular system. Which assessment finding indicates to the nurse that the client is experiencing age-related changes to the conduction system? Select all that apply.

Bradycardia, exercise intolerance

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 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.

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

Depressed myocardial contractility

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 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?

Digoxin level

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

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 nursing instructor is teaching nursing students about myocardial contractility and ejection fractions. What diagnostic tests can determine client ejection fractions? Select all that apply.

Echocardiogram Cardiac catheterization Magnetic resonance imaging

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

Headache Hypotension Irregular heartbeat

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?

INR

The nurse reviews a client's lab results and notes a serum calcium level of 7.9 mg/dL. It is most appropriate for the nurse to monitor the client for what condition?

Impaired myocardial contractility

The nurse is reviewing the morning laboratory test results for a client with cardiac problems. Which finding is a priority to report to the health care provider?

K+ 3.1 mEq/L

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

Loud and may be associated with a thrill sound similar to (a purring cat).

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

Monitor BP and pulse frequently. Inspect pressure dressing for signs of bleeding. Palpate the pulse in different locations.

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?

Observe for return of the pulmonary artery systolic and diastolic waveforms.

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

The nurse is assessing a client's electrocardiogram (ECG). What phase does the nurse determine is the resting phase before the next depolarization?

Phase 4

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

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.

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 nurse is assessing heart sounds in a client with heart failure. An abnormal heart sound is detected early in diastole. How would the nurse document this?

S3

The nurse is discussing the cardiac system with a client admitted with heart failure. The client asks "What determines the heart rate?" What is the nurse's best response?

The autonomic nervous system controls the heart rate.

A client 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 nurse is teaching a client about the functionality of heart muscle. What factor may decrease a client's myocardial contractility?

acidosis

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?

baroreceptors

The nurse accompanies a client to an exercise stress test. The client can achieve the target heart rate, but the electrocardiogram indicates ST-segment elevation. Which procedure will the nurse prepare the client for next?

cardiac catheterization

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

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

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

What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse?

contractility

Age-related changes associated with the cardiac system include

decreased elasticity of the arteries

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

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?

description of the pain

The nurse is preparing a client for transesophageal echocardiography (TEE). This procedure is used for which indication?

determination of atrial thrombi

The nurse is monitoring the results of laboratory tests performed on a client admitted to the cardiac ICU with a diagnosis of myocardial infarction. Which test would the nurse expect to show elevated levels?

enzymes

The nurse is completing a cardiac assessment. Upon auscultation, the nurse hears a grating sound using the diaphragm of the stethoscope. How will the nurse best document this finding?

friction rub

The nurse cares for a client in the emergency department who has a B-type natriuretic peptide (BNP) level of 115 pg/mL. The nurse recognizes that this finding is most indicative of which condition?

heart failure

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 9 mm Hg and recognizes that this finding indicates the client is most likely experiencing which condition?

hypervolemia

The nurse provides care for a client who is diagnosed with an infarction of the posterior wall of the right atrium. Which clinical finding should the nurse anticipate relating to the infarction location?

irregular heart rate

The nurse auscultates the PMI (point of maximal impulse) at which anatomic location?

left midclavicular line at the fifth intercostal space

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

What does decreased pulse pressure reflect?

reduced stroke volume

Central venous pressure is measured in which heart chamber

right atrium

During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure?

wheezes with wet lung sounds

A 52-year-old client 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 replacement is not effective at preventing cardiovascular disease and carries some risks."

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 caring for an older adult client being seen with a cardiac issue. The client asks why they are having some of the general cardiac problems they are having. What is the best response(s) to the client's concern? Select all that apply.

"Due to the aging process, an increase in fat deposits, collagen, and elastic fibers in the sinoatrial (SA) node leads to a higher risk for cardiac arrhythmias." "Changes in cardiovascular structure and function in older adults are impacted by lifestyle and environmental factors such as smoking and lack of exercise." "Due to decreased cardiac output and delayed conduction of the heart, the aging heart requires more time to return to baseline levels after stress." "Overall deconditioning in the older adult can lead to changes in the heart muscle tissue composition, causing a decrease in cardiac output

While being prepared for echocardiography, the client asks nurse why this test is necessary. What would be the nurse's best response?

"Echocardiography is a way of determining the functioning of the left ventricle of your heart."

The nurse is doing an admission assessment on a client who is having outpatient testing done for cardiac problems. What should the nurse ask this client during their assessment?

"Have you had any episodes of dizziness or fainting?"

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 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 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

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?

Avoid tub baths, but shower as desired.