Chapter 25: Assessment of Cardiovascular Function
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? A. Na+ 140 mEq/L B. Ca++ 9 mg/dL C. K+ 3.1 mEq/L D. Mg++ 2 mE/L
C 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 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? A. Chemoreceptors B. Sympathetic nerve fibers C. Baroreceptors D. Vagus nerve
C 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.
What does decreased pulse pressure reflect? A. tachycardia B. reduced distensibility of the arteries C. reduced stroke volume D. elevated stroke volume
C Decreased pulse pressure reflects reduced stroke volume and ejection velocity or obstruction to blood flow during systole. Increased pulse pressure would indicate reduced distensibility of the arteries, along with bradycardia.
The 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? A. Pulmonary embolism B. Myocardial infarction C. Pericarditis D. Heart failure
D An ejection fraction of less than 40% indicates that the patient has decreased left ventricular function and likely requires treatment for heart failure.
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? A. Chordae tendineae B. Atrioventricular tendons C. Semilunar tendineae D. Papillary tendons
A 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 nurse reviews a client's lab results and notes a serum calcium level of 7.9 mg/dL. It is mostappropriate for the nurse to monitor the client for what condition? A. Impaired myocardial contractility B. Enhanced sensitivity to digitalis C. Increased risk of heart block D. Inclination to ventricular fibrillation
A Normal serum calcium is 8.9 to 10.3 mg/dL. A reading of 7.9 is below normal. Hypocalcemia is associated with slow nodal functioning and impaired myocardial contractility, which can increase the risk of heart failure.
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? A. right ventricle B. left ventricle C. right atrium D. left atrium
A 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.
The patient has a heart rate of 72 bpm with a regular rhythm. Where does the nurse determine the impulse arises from? A. The AV node B. The Purkinje fibers C. The sinoatrial node D. The ventricles
C 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 assessing a patient's blood pressure. What does the nurse document as the difference between the systolic and the diastolic pressure? A. Pulse pressure B. Auscultatory gap C. Pulse deficit D. Korotkoff sound
A
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? A. Rate, quality, and rhythm B. Pressure, rate, and rhythm C. Rate, rhythm, and volume D. Quality, volume, and rate
A
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? A. BP 108/60 mm Hg, ascites, and crackles B. disorientation, 20 mL of urine over the last 2 hours C. reduced pulse pressure and heart murmur D. elevated jugular venous distention and postural changes in BP
B Assessment findings associated with reduced cardiac output include reduced pulse pressure, hypotension, tachycardia, reduced urine output, lethargy, or disorientation.
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? A. hemorrhage B. catheter-related bloodstream infections C. air embolism D. pneumothorax
B 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.
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? A. S1 B. S2 C. S3 D. S4
C 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? A. Dizziness and leg cramping B. BP changes; 148/80 mm Hg to 166/90 mm Hg C. ST-segment changes on the ECG D. Heart rate changes; 78 bpm to 112 bpm
C 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.
Which area of the heart is located at the third intercostal (IC) space to the left of the sternum? A. aortic area B. pulmonic area C. erb point D. epigastric area
C 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.
The nurse is performing an assessment of the patient's heart. Where would the nurse locate the apical pulse if the heart is in a normal position? A. Left 2nd intercostal space at the midclavicular line B. Right 2nd intercostal space at the midclavicular line C. Right 3rd intercostal space at the midclavicular line D. Left 5th intercostal space at the midclavicular line
D As a result of this close proximity to the chest wall, the pulsation created during normal ventricular contraction, called the apical impulse (also called the point of maximal impulse [PMI]), is easily detected. In the normal heart, the PMI is located at the intersection of the midclavicular line of the left chest wall and the fifth intercostal space (Bickley, 2009; Woods et al., 2009).
What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse? A. depolarization B. repolarization C. diastole D. contractility
D 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.
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? A. Continue to palpate the patient's radial pulse for one more minute in order to gauge the severity of the arrhythmia. B. Palpate the patient's right and left radial pulses simultaneously to compare the symmetry of the patient's rate and rhythm. C. Reposition the patient, wait 3 to 5 minutes and then reassess the patient's radial pulse. D. Auscultate the patient's apical pulse while simultaneously palpating the patient's radial pulse.
D During the initial cardiac examination, or if the pulse rhythm is irregular, the nurse assesses pulse rate for a pulse deficit, defined as the difference between the apical and the peripheral pulse rates. The pulse deficit is ascertained by simultaneously auscultating the apical pulse and palpating the radial pulse for 1 minute. The nurse should anticipate finding a pulse deficit in patients with arrhythmias, especially atrial fibrillation, atrial flutter, and ventricular arrhythmias. The nurse's original assessment finding is not enhanced by palpating longer, palpating both arms, or repositioning the patient.
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? A. heart failure B. ventricular hypertrophy C. pulmonary edema D. myocardial infarction
A 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 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? A. Heart failure B. Hypertensive heart disease C. Normal functioning D. Pericarditis
A A sound that follows S1 and S2 is called an S3 heart sound or a ventricular gallop. An S3, normal in children, often is an indication of heart failure in an adult. An extra sound before S1 is an S4 heart sound, or atrial gallop. An S4 sound often is associated with hypertensive heart disease. A friction rub may cause a rough, grating, or scratchy sound that is an indication of pericarditis or inflammation of the pericardium.
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? A. Echocardiography B. Electrocardiography (ECG) C. Cardiac catheterization D. Angiography
A An echocardiogram yields a two-dimensional rendering of the heart's structure and mechanical function. An ECG indicates the heart's electrical activity, and angiography and cardiac catheterization are used to assess the patency of the coronary arteries.
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? A. Apricots, dried peas and beans, dates B. Asparagus, blueberries, green beans C. Cranberries, apples, popcorn D. Bok choy, cooked leeks, alfalfa sprouts
A Apricots, dried peas and beans, dates, and kiwi contain high amounts of potassium. The other foods listed contain minimal amounts.
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? A. "Have you had any episodes of dizziness or fainting?" B. "Have you had any episodes when you are to nauseous?" C. "Have you had any episodes of mottling in your hands?" D. "Have you had any episodes of pain radiating into your lower extremities?"
A 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.
Which term describes the ability of the heart to initiate an electrical impulse? A. automaticity B. contractility C. conductivity D. excitability
A Automaticity is the ability of specialized electrical cells of the cardiac conduction system to initiate an electrical impulse. Contractility refers to the ability of the specialized electrical cells of the cardiac conduction system to contract in response to an electrical impulse. Conductivity refers to the ability of the specialized electrical cells of the cardiac conduction system to transmit an electrical impulse from one cell to another. Excitability refers to the ability of the specialized electrical cells of the cardiac conduction system to respond to an electrical impulse.
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. "A woman's heart is smaller and has smaller arteries that become occluded more easily." B. "A woman's resting heart rate is lower than a man's." C. "It takes longer for an electrical impulse to travel from the sinoatrial node to the atrioventricular node in a woman." D. "The stroke volume from a woman's heart is lower than from a man's heart."
A 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 cares for a client with clubbing of the fingers and toes. The nurse should complete which action given these findings? A. Obtain an oxygen saturation level. B. Assess the client's capillary refill. C. Assess the client for pitting edema. D. Obtain a 12-lead ECG tracing.
A 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.
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? A. Digoxin B. Clopidogrel C. Enoxaparin D. Heparin
A 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 prepares to auscultate heart sounds. What nursing intervention will be most effective to assist with this procedure? A. 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. B. Ask the client to sit on the edge of the bed and hold breath while the nurse listens. C. Insist that the family members leave the room if they must speak to each other while the nurse is auscultating heart sounds. D. Ask the client to take deep breaths through the mouth while the nurse auscultates heart sounds.
A During auscultation, the client remains supine and the room should be as quiet as possible while the nurse listens to heart sounds. The client should breathe normally during the examination. Sitting on the edge of the bed is not the preferred client position. The room should be quiet so asking the families to remain quiet is acceptable. The client does not need to take deep breaths during heart auscultation.
A client has undergone cardiac catheterization and will be discharged today. What information should the nurse emphasize during discharge teaching? A. Avoid heavy lifting for the next 24 hours. B. Take a tub bath, rather than a shower. C. New bruising at the puncture site is normal. D. Bend only at the waist.
A 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? A. Avoid tub baths, but shower as desired. B. Do not ambulate until the healthcare provider indicates it is appropriate. C. Expect increased bruising to appear at the site over the next several days. D. Returning to work immediately is okay.
A 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.
During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure? A. wheezes with wet lung sounds B. stridor C. high-pitched sounds D. laborious breathing
A 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.
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? A. 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. B. When the client is in the recumbent position, more pressure is put on the bladder, with the result of increased need to urinate. C. The blood pressure is lower when the client is recumbent, which causes the kidneys to work harder; therefore, more urine is produced. D. 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.
A Nocturia is common in patients with heart failure. Fluid collected in dependent areas during the day is reabsorbed into the circulation at night when the client is recumbent. The kidneys excrete more urine with the increased circulating volume. The client's sleeping position does not cause bladder constriction and increased urination. The client's blood pressure is not causing more urination. The fluid in the client's lungs does not move to the kidneys at night.
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. A heart rate of more than 20 bpm above the resting rate B. An unchanged systolic pressure C. An increase of 10 mm Hg blood pressure reading D. An increase of 5 mm Hg in diastolic pressure
A 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 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? A. international normalized ratio (INR) B. partial thromboplastic time (PTT) C. complete blood count (CBC) D. Sodium
A 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.
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? A. Digoxin level B. Cardiac output C. Activity level D. Dyspnea
A 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 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? A. Report any incident of bloody urine, stools, or both. B. Administer calcium supplements. C. Assess for hypokalemia. D. Assess for clubbing of the fingers.
A 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.
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? A. The client is at risk for renal failure due to the contrast agent that will be given during the procedure. B. These values show a risk for dysrhythmias. C. The client is overhydrated, which puts him at risk for heart failure during the procedure. D. The client is at risk for bleeding.
A 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.
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? A. endocardium B. myocardium C. pericardium D. epicardium
A The inner layer, the endocardium, is composed of a thin, smooth layer of endothelial cells. Folds of endocardium form the heart valves. The middle layer, the myocardium, consists of muscle tissue and is the force behind the heart's pumping action. The pericardium is a saclike structure that surrounds and supports the heart. The outer layer, the epicardium, is composed of fibrous and loose connective tissue.
Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for receiving oxygenated blood from the lungs? A. left atrium B. left ventricle C. right atrium D. right ventricle
A 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? A. left ventricle B. left atrium C. right ventricle D. right atrium
A 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.
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? A. Clip the client's chest hair prior to applying the electrodes. B. Apply baby powder to the client's chest prior to placing the electrodes. C. Clean the client's chest with alcohol prior to application of the electrodes. D. Once the electrodes are applied, change them every 72 hours.
A The nurse should complete the following actions when applying cardiac electrodes: (1) Clip (do not shave) hair from around the electrode site, if needed; (2) if the client is diaphoretic (sweaty), apply a small amount of benzoin to the skin, avoiding the area under the center of the electrode; (3) debride the skin surface of dead cells with soap and water and dry well (or as recommended by the manufacturer); (4) change the electrodes every 24 to 48 hours (or as recommended by the manufacturer); (5) examine the skin for irritation and apply the electrodes to different locations.
A patient 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? A. Thin fibrous sac that encases the heart. B. Inner lining of the heart and valves. C. Heart's muscle fibers. D. Exterior layer of the heart.
A The pericardium is a thin, fibrous sac that encases the heart. It is composed of two layers, the visceral and the parietal pericardium. The space between these two layers is filled with fluid.
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? A. "The physiologic demands are greatest during orgasm and are equivalent to walking 3 to 4 miles per hour on a treadmill." B. "It is usually better to just give up sex after a heart attack." C. "Having an orgasm is very strenuous and your husband must be in excellent physical shape before attempting it." D. "The medications will prevent your husband from having an erection."
A 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.
Which test used to diagnose heart disease is least invasive? A. transthoracic echocardiography B. magnetic resonance imaging C. cardiac catheterization D. coronary arteriography
A 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.
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? A. Take the blood pressure in both arms. B. Palpate a peripheral pulse. C. Auscultate the carotid artery. D. Percuss the perimeter of the heart.
B 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 discharging a client after a cardiac catheterization. What would the nurse include in the discharge teaching? A. Eat only soft foods for the next 12 hours. B. Report any numbness, tingling, or sharp pain in the extremity. C. Restrict your intake of water until the dye is out of the body. D. Move around whenever the client feels like getting up.
B 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.
A nurse is aware that the patient's heart rate is influenced by many factors. The nurse understands that the heart rate can be decreased by: A. An excess level of thyroid hormone. B. Stimulation of the vagus nerve. C. An increased level of catecholamines. D. Sympathetic nervous system stimulation.
B Parasympathetic impulses, which travel to the heart through the vagus nerve, can slow the cardiac rate. The other choices cause an increase in heart rate.
The nurse is administering a beta blocker to a patient in order to decrease automaticity. Which medication will the nurse administer? A. Diltiazem B. Metoprolol C. Amiodarone D. Propafenone
B Patients may receive beta-blockers prior to the scan to control heart rate and rhythm.
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? A. Potassium B. B-type natriuretic peptide (BNP) C. C-reactive protein (CRP) D. Platelet count
B 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.
Your client is going to have a stress test. What radionuclide would most likely be used to diagnose ischemic heart disease during this test? A. Techtonium-89-r B. Thallium-201 C. Technetium-99m D. Transamnium-105
B The radionuclide technetium-99m is used to detect areas of myocardial damage by injection before or after the test. The radionuclide thallium-201 is used to diagnose ischemic heart disease during a stress test.
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? A. Call the physician with a report. B. Assess the client. C. Assess for mechanical dysfunction. D. Reposition the client.
B 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.
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? A. Easily heard with no palpable thrill. B. Quiet but readily heard. C. Loud and may be associated with a thrill sound similar to (a purring cat). D. Very loud; can be heard with the stethoscope half-way off the chest.
C 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.
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? A. blood pressure in the left arm B. pulse rate in upper extremities C. description of the pain D. sound of the apical pulses
C If the client is experiencing chest pain, a history of its location, frequency, and duration is necessary. A description of the pain is also needed, including if it radiates to a particular area, what precipitates its onset, and what brings relief. The nurse weighs the client and measures vital signs. The nurse may measure blood pressure in both arms and compare findings. The nurse assesses apical and radial pulses, noting rate, quality, and rhythm. The nurse also checks peripheral pulses in the lower extremities.
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? A. "That's a great idea. You don't want to have a heart attack." B. "Current research determines that the replacement of estrogen will protect a woman after she goes into menopause." C. "Current evidence indicates that estrogen is ineffective as a cardioprotectant; estrogen is actually potentially harmful and is no longer a recommended therapy." D. "You need to research it and determine what you want to do."
C 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).
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? A. Total cholesterol level increases from 250 mg/dl to 275 mg/dl. B. Low density lipoproteins (LDL) increase from 180 mg/dl to 190 mg/dl. C. High density lipoproteins (HDL) increase from 25 mg/dl to 40 mg/dl. D. Triglycerides increase from 225 mg/dl to 250 mg/dl.
C The goal of treating hyperlipidemia is to decrease total cholesterol and LDL levels while increasing HDL levels. HDL levels should be greater than 35 mg/dl. This client's increased HDL levels indicate that a therapeutic regimen has been followed. Recommended total cholesterol levels are below 200 mg/dl. LDL levels should be less than 160 mg/dl, or, in clients with known coronary artery disease (CAD) or diabetes mellitus, less than 70 mg/dl. Triglyceride levels should be between 100 and 200 mg/d.
The nurse is educating a patient at risk for atherosclerosis. What nonmodifiable risk factor does the nurse identify for the patient? A. Stress B. Obesity C. Positive family history D. Hyperlipidemia
C 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.
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? A. Count the radial pulse for 20 to 25 seconds. B. Calculate the palpated volume. C. Count the heart rate at the apex. D. Calculate the pauses between pulsations.
C 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.
A nurse is caring for a dying client following myocardial infarction. The client is experiencing apnea with a falling blood pressure of 60 per palpation. Which documentation of pulse quality does the nurse anticipate? A. Bounding pulse B. Weak pulse C. Thready pulse D. A pulse deficit
C The nurse is most correct to anticipate a thready (barely palpable) pulse quality. A bounding pulse indicates a strong cardiac output. A weak pulse indicates a lower pulse quality. A pulse deficit occurs when the pulses between the apex of the heart differs from the radial pulse.
The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include? A. "You can take a tub bath or a shower when you get home." B. "Contact your primary care provider if you develop a temperature above 102°F." C. "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." D. "If any discharge occurs at the puncture site, call 911 immediately."
C 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.
In preparation for transesophageal echocardiography (TEE), the nurse must: A. Instruct the patient to drink 1 L of water before the test B. Heavily sedate the patient C. Inform the patient that blood pressure (BP) and electrocardiogram (ECG) monitoring will occur throughout the test D. Inform the patient that an access line will be initiated in the femoral artery
C The patient will have BP and ECG monitored throughout the test and must be NPO 6 hours preprocedure. The patient is sedated to make him or her comfortable, but will not be heavily sedated. Also, the patient will have an IV line initiated preprocedure.
The nurse is caring for an elderly client with left-sided heart failure. When auscultating lung sounds, which adventitious sound is expected? A. Wheezes B. Rhonchi C. Crackles D. Coarseness
C 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.
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? A. RBC B. Platelets C. Enzymes D. WBC
C 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.
The electrical conduction system of the heart has several components, all of which are instrumental in maintaining polarization, depolarization, and repolarization of cardiac tissue. Which of the conductive structures is known as the pacemaker of the heart? A. atrioventricular node B. bundle of His C. bundle branches D. sinoatrial node
D The SA node is an area of nerve tissue located in the posterior wall of the right atrium. The SA node is called the pacemaker of the heart because it initiates the electrical impulses that cause the atria and ventricles to contract. When the impulse from the SA node reaches the AV node, it is delayed a few hundredths of a second. While the ventricles fill with blood, the impulse travels from the AV node to the bundle of His, to the right and left bundle branches, and eventually to the Purkinje fibers. Then, both ventricles contract. While the ventricles fill with blood, the impulse travels from the AV node to the bundle of His, to the right and left bundle branches, and eventually to the Purkinje fibers. Then, both ventricles contract.
The nurse is preparing a client for transesophageal echocardiography (TEE). This procedure is used for which indication? A. determination of electrical activity of the heart B. evaluation of the response of the cardiovascular system to increased oxygen demands C. evaluation of myocardial perfusion at rest and after exercise D. determination of atrial thrombi
D The TEE is an important diagnostic tool for determining if atrial or ventricular thrombi are present in patients with heart failure, valvular heart disease, and dysrhythmias. The electrocardiogram (ECG) is a graphic recording of the electrical activity of the heart to determine dysrhythmias. Stress testing is used to evaluate the response of the cardiovascular system to increased demands for oxygen and nutrients. Thallium is used with exercise or pharmacologic stress testing to assess changes in myocardial perfusion at rest and after exercise.
The nurse auscultates the apex beat at which anatomical location? A. midsternum B. 5 cm to the left of the lower end of the sternum C. 2.5 cm to the left of the xiphoid process D. fifth intercostal space, midclavicular line
D The left ventricle is responsible for the apex beat or the point of maximum impulse, which is normally palpable in the left midclavicular line of the chest wall at the fifth intercostal space. The right ventricle lies anteriorly, just beneath the sternum. Use of inches to identify the location of the apex beat is inappropriate based upon variations in human anatomy. Auscultation below and to the left of the xiphoid process will detect gastrointestinal sounds, but not the apex beat of the heart.
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? A. In clients with heart valve replacement B. In geriatric clients C. In clients with an indwelling pacemaker D. In pediatric clients
D 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.
