Chapter 25: Assessment of Cardiovascular Function

The nurse admits an adult female client with a medical diagnosis of "rule out MI." The client is very frightened and expresses surprise that a woman would have heart problems. What response by the nurse will be most appropriate?

"A woman's heart is smaller and has smaller arteries that become occluded more easily." Because the coronary arteries of a woman are smaller, they become occluded from atherosclerosis more easily. The resting rate, stroke volume, and ejection fraction of a woman's heart are higher than those of a man. The electrical impulses from the sinoatrial node to the atrioventricular node are not different in the genders.

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.

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?

"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. Option C is the best answer because it addresses the client's question without making him anxious or minimizing the question.

The nurse is assessing the client's cardiovascular system. The client asks the nurse why the nurse presses on the toenails. Which is the best reply by the nurse?

"I can see how quickly the blood returns to assess blood flow." The nurse presses on the toenail to assess peripheral blood flow. A decreased capillary refill time indicates a slower peripheral blood flow. Pressing toenails does not indicate any respiratory or coagulation assessments. Pain is not assessed by toenail pressing. Capillary blood flow assessments indicate blood flow.

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 physiologic demands are greatest during orgasm. The level of activity is equivalent to walking 3 to 4 miles per hour on a treadmill. Sexuality is an important quality of life, so the healthcare provider will be determining when it is safe to have intercourse. Erectile dysfunction may be a side effect of beta-blockers, but other medications may be substituted.

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.)

-Assessing the peripheral pulses in the affected extremity -Checking the insertion site for hematoma formation -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 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.

-wheezes -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 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?

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

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.

A client has undergone cardiac catheterization and will be discharged today. What information should the nurse emphasize during discharge teaching?

Avoid heavy lifting for the next 24 hours. For the next 24 hours, the patient should not bend at the waist, strain, or lift heavy objects. The patient should avoid tub baths, but can shower as desired. The patient should call the healthcare provider if she has any bleeding, swelling, new bruising, or pain from her procedure puncture site, or a temperature of 101.5 degrees Fahrenheit (38.6 degrees C) or higher.

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. 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.

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?

B-type natriuretic peptide (BNP) 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.

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 Baroreceptor sense pressure in nerve endings in the walls of the atria and major blood vessels. The baroreceptors respond accordingly to raise or lower the pressure. Chemoreceptors are sensitive to pH, CO2, and O2 in the blood. Sympathetic nerve fibers increase the heart rate. The vagus nerve slows the heart rate.

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. Options B, C, and D are distractors for the question.

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 caring for an elderly client with left-sided heart failure. When auscultating lung sounds, which adventitious sound is expected?

Crackles When the heart is pumping inefficiently, blood backs up into the pulmonary veins and lung tissue. Auscultation reveals a crackling sound. Possible wheezes and gurgles are also possibilities.

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 (Mosca, Benjamin, Berra, et al., 2011).

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.

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.

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 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. Options A, B, and C would not dilate the coronary arteries.

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.

Which area of the heart that is located at the third intercostal space to the left of the sternum?

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

The nurse is caring for a client scheduled for a cardiac stress test at 1100. When the nurse enters the client's room at 0800, the client requests toast or at least some coffee. What is the best response by the nurse?

Explain that no food or drink is allowed for 4 hours before the stress test. The client must have no food or drink, especially caffeine, for 4 hours prior to the stress test. If caffeine is ingested prior to an adenosine stress test, the test will have to be rescheduled. The client should not have any coffee or food, including toast, for 4 hours prior to the stress test.

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?

Heart failure An ejection fraction of less than 40% indicates that the patient has decreased left ventricular function and likely requires treatment for heart failure.

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

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

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.

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:

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 administering a beta blocker to a patient in order to decrease automaticity. Which medication will the nurse administer?

Metoprolol Patients may receive beta-blockers prior to the scan to control heart rate and rhythm.

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.

The nurse is assessing a patient's blood pressure. What does the nurse document as the difference between the systolic and the diastolic pressure?

Pulse pressure The difference between the systolic and the diastolic pressures is called the pulse pressure.

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?

Rate, quality, and rhythm Assess apical and radial pulses, noting rate, quality, and rhythm. Pulse quality and volume are not assessed in this instance.

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.

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. 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.

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

S3 An S3 ("DUB") is heard early in diastole during the period of rapid ventricular filling as blood flows from the atrium into a noncompliant ventricle. It is heard immediately after S2. "Lub-dub-DUB" is used to imitate the abnormal sound of a beating heart when an S3 is present.

The nurse observes a client during an exercise stress test (bicycle). Which finding indicates a positive test and the need for further diagnostic testing?

ST-segment changes on the ECG 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 uses which term for the normal pacemaker of the heart?

Sinoatrial (SA) node The sinoatrial node is the primary pacemaker of the heart. The AV node coordinates the incoming electrical impulses from the atria and, after a slight delay, relays the impulse to the ventricles. The Purkinje fibers rapidly conduct the impulses through the thick walls of the ventricles.

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. The autonomic nervous system primarily controls the heart rate. When the sympathetic branch is stimulated, heart rate increases. When the parasympathetic branch is stimulated, heart rate decreases. Stroke volume is the amount of blood pumped out of the ventricle with each contraction and depends on three factors: preload, afterload, and contractility.

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.

The client is admitted for a scheduled cardiac catheterization. On the morning of the procedure, while assessing the client's morning laboratory values, the nurse notes a blood urea nitrogen (BUN) of 34 mg/dL and a creatinine of 4.2 mg/dL. What priority reason will the nurse notify the healthcare provider?

The client is at risk for renal failure due to the contrast agent that will be given during the procedure. The contrast medium must be excreted by the kidneys. If there is already a degree of renal impairment, indicated by the increased BUN and creatinine, the risk for contrast agent-induced nephropathy and renal failure is high. Renal impairment is not usually associated with dysrhythmias. The increased BUN and creatinine do not indicate overhydration, but decreased kidney function. The BUN and creatinine levels do not interfere with coagulability or bleeding.

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. Myocardial infarction is damage to the heart and 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 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 (Weber & Kelley, 2010).

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.

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 receive medication via IV administration. Drugs such as adenosine (Adenocard), dipyridamole (Persantine), or dobutamine (Dobutrex) may be administered singularly or in combination by the IV route. Drugs may be used to stress the heart for clients with sedentary lifestyles or those with a physical disability, such as severe arthritis, that interferes with exercise testing. Drug-induced stress testing does not require the client to exercise. Instead, drugs are used to stress the heart. Clients performing exercise electrocardiography should report chest pain, dizziness, leg cramps, or weakness if they experience them during the test.

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.

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.

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

contractility Contractility is the ability of the cardiac muscle to shorten in response to an electrical impulse. Depolarization is the electrical activation of a cell caused by the influx of sodium into the cell while potassium exits the cell. Repolarization is the return of the cell to the resting state, caused by reentry of potassium into the cell while sodium exits the cell. Diastole is the period of ventricular relaxation resulting in ventricular filling.

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.

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.

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 A BNP level greater than 100 pg/mL is suggestive of heart failure. Because this serum laboratory test can be quickly obtained, BNP levels are useful for prompt diagnosis of heart failure in settings such as the emergency department. Elevations in BNP can occur from a number of other conditions such as pulmonary embolus, myocardial infarction (MI), and ventricular hypertrophy. Therefore, the healthcare provider correlates BNP levels with abnormal physical assessment findings and other diagnostic tests before making a definitive diagnosis of heart failure.

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?

heart failure The S3 heart sound is heard immediately after the S2 sound, early in diastole, as blood flows from the atrium into a noncompliant ventricle. The S3 heart sound is normal in children and young adults, but it is a significant finding suggestive of heart failure in older adults. A client with aortic stenosis commonly may have a murmur. A client with congenital heart disease may have more that one abnormal heart sound. Clients with coronary artery disease do not have S3 heart sounds.

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?

international normalized ratio (INR) 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.

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

left atrium The left atrium receives oxygenated blood from the lungs. 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 right ventricle pumps that blood to the lungs to be oxygenated.

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 client describes chest pain as sharp, substernal, of intermittent duration, and radiating to the arms and back. The client says the pain increases with inspiration and swallowing and is alleviated when sitting upright. What does the nurse suspect the client may be experiencing?

pericarditis Chest pain described as a sharp, substernal, of intermittent duration, and radiating to the arms and back that increases with inspiration and swallowing and is alleviated when sitting upright is pericarditis. Angina pectoris pain is often described as a squeezing, pressure, heaviness, tightness, or pain in the chest. Panic attack pain is not always relieved with sitting upright. A client with dissecting aorta experiences back and abdominal pain not relieved with sitting upright.

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 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.

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

wheezes with wet lung sounds If the left side of the heart fails to pump efficiently, blood backs up into the pulmonary veins and lung tissue. For abnormal and normal breath sounds, the nurse auscultates the lungs. 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. With left-sided congestive heart failure, auscultation does not reveal a high pitched sound.