week 2

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.

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 To determine the pulse deficit, one nurse counts 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. Pulse rhythm is the pattern of the pulsations and the pauses between them. Pulse volume is described as feeling full, weak, or thready, meaning barely palpable. The pulse quality refers to its palpated volume.

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. To determine the pulse deficit, one nurse counts 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. Pulse rhythm is the pattern of the pulsations and the pauses between them. Pulse volume is described as feeling full, weak, or thready, meaning barely palpable. The pulse quality refers to its palpated volume.

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 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.

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

determination of atrial thrombi 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 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?

disorientation, 20 mL of urine over the last 2 hours Assessment findings associated with reduced cardiac output include reduced pulse pressure, hypotension, tachycardia, reduced urine output, lethargy, or disorientation.

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.

The nurse is caring for a client who is diagnosed with an infarction of the posterior wall of the right atrium. Which assessment finding would the nurse anticipate relating to the infarction location?

Irregular heart rate The posterior wall of the right atrium is the location of the sinoatrial node (SA node), which is the pacemaker of the heart. Damage to this location may result in an irregular heart rate due to a disturbance of electrical pulse initiation. Depending on muscle damage, the client may have respiratory compromise, chest pain, and/or cyanosis.

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.

A nurse is preparing a client for a scheduled adenosine stress test. Which statement made by the client indicates a need for further education?

"My family is bringing me a cup of coffee to drink before the test." Caffeine must be avoided for 4 hours prior to the stress test. Caffeine acts as an adenosine receptor antagonist. If caffeine is ingested, the test must be rescheduled. It is true that the effects of the medication wear off quickly. The half-life of adenosine is less than 10 seconds. Adenosine will affect the heart like exercise, and flushing or nausea can occur.

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 location of the aortic arch causes the sound of the aortic valve closure to be best heard at the 2nd intercostal space on the right sternal border.

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.

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 prepares to auscultate heart sounds. What nursing intervention will be most effective to assist with this procedure?

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. 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 nurse is completing a head to toe assessment on a client diagnosed with right-sided heart failure. To assess peripheral edema, which of the following areas should be examined?

Feet and ankles When right-sided heart failure occurs, blood accumulates in the vessels and backs up in peripheral veins, and the extra fluid enters the tissues. Particular areas for examination are the dependent parts of the body, such as the feet and ankles. Other prominent areas prone to edema are the fingers, hands, and over the sacrum. Cyanosis can be detected by noting color changes in the lips and earlobes.

You are doing an admission assessment on a client who is having outpatient testing done for cardiac problems. What should you ask this client during your assessment?

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

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.

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 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 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.

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.

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 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?

Clip the client's chest hair prior to applying the electrodes. 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 nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). The client's blood pressure is 104/68 mm Hg. The client's pulse rate is 76 beats/minute. The nurse detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take?

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

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. Normal CVP ranges from 3 to 7 mm Hg. The nurse doesn't need to take any action other than to monitor the client. It isn't necessary to re-zero the equipment. Calling a health care provider and obtaining an order for a fluid bolus would be an appropriate intervention if the client has a CVP less than 3 mm Hg. Administering a diuretic would be appropriate if the client had excess fluid, as demonstrated by a CVP greater than 7 mm Hg.

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 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.

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.

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?

Digoxin Contractility is enhanced by circulating catecholamines, sympathetic neuronal activity, and certain medications, such as Lanoxin. Increased contractility results in increased stroke volume. The other medications are classified as platelet-inhibiting medications.

The nurse is caring for a geriatric client. The client is ordered Lanoxin (digoxin) tablets 0.125mg daily for a cardiac dysrhythmia. Which of the following assessment considerations is essential when caring for this client?

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 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 normal serum magnesium level is 1.5-2.5 mEq/L. Hypermagnesemia can cause nausea, headache, hypotension and irregular heartbeat. Hypomagnesemia can cause ventricular and atrial tachycardia.

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. The other options would not dilate the coronary arteries.

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 refractory period is the time when cells are resistant to electrical stimulation. Repolarization is when the ions realign themselves to wait for an electrical signal. Depolarization occurs during muscle contraction when positive ions move inside the myocardial cell membrane and negative ions move outside. Before an impulse is generated, the cells are in a polarized state.

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

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. 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 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?

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. 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.

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.

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.

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?

High density lipoproteins (HDL) increase from 25 mg/dl to 40 mg/dl 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.

A client reports chest pain. Which questions related to the client's history are most important to ask? Select all that apply.

How would you describe your symptoms? Are you allergic to any medications or foods? How did your mother die? During initial assessment, the nurse should obtain important information about the client's history that focuses on a description of the symptoms before and during admission, family medical history, prescription and nonprescription drug use, and drug and food allergies.

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 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.

The nurse is caring for a client who is scheduled for a transesophageal echocardiogram. What nursing intervention is a priority after the procedure?

Keep the head of the bed elevated 45 degrees and keep NPO until return of the gag reflex. During the recovery period, the client must have the head of the bed elevated 45 degrees to avoid aspiration. The nurse should restrict food and fluids until the return of the gag reflex and the client is fully awake and alert. There will be no puncture site after an transesophageal echocardiogram. There is no need to turn the client on the right side or watching for bleeding from the esophagus. There are no anticoagulants given during this procedure, so bloody stools or urine should not occur.

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?

Left 5th intercostal space at the midclavicular line 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).

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.

After a physical examination, the provider diagnosed a patient 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). 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.

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

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

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.

The nurse is educating a patient at risk for atherosclerosis. What nonmodifiable risk factor does the nurse identify for the patient?

Positive family history 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 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.

The clinic nurse is assessing a client's pulse before outpatient diagnostic testing. What should the nurse document when assessing the client's pulse?

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

The nurse screens a client prior to a magnetic resonance angiogram (MRA) of the heart. Which action should the nurse complete prior to the client undergoing the procedure? Select all that apply.

Remove the client's Transderm Nitro patch. Remove the client's jewelry. Offer the client a headset to listen to music during the procedure. Transdermal patches that contain a heat-conducting aluminized layer (e.g., NicoDerm, Androderm, Transderm Nitro, Transderm Scop, Catapres-TTS) must be removed before MRA to prevent burning of the skin. A client who is claustrophobic may need to receive a mild sedative before undergoing an MRA. During an MRA, the client is positioned supine on a table that is placed into an enclosed imager or tube containing the magnetic field. Clients are instructed to remove any jewelry, watches, or other metal items (e.g., ECG leads). An intermittent clanking or thumping that can be annoying is generated by the magnetic coils, so the client may be offered a headset to listen to music.

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 calcium supplements or have potassium imbalances related to the medication. The clubbing of fingers may occur with chronic pulmonary diseases.

The nurse is discharging a client after a cardiac catheterization. What would the nurse include in the discharge teaching?

Report any numbness, tingling, or sharp pain in the extremity. 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.

The nurse is caring for a client with nursing diagnosis of ineffective tissue perfusion. Which area of the heart would the nurse anticipate being compromised?

Right ventricle There are four chambers to the heart. The right and left ventricles is the heart's major pumping chamber. The right ventricle pumps to the lungs to oxygenate the blood. The left ventricle pumps blood to the tissues and cells. The pulmonary artery and aorta are not of the heart.

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.

One of the students asks what the consequences of uncorrected, left-sided heart failure would be. What would be the nursing instructor's best response?

Right-sided heart failure If uncorrected, left-sided heart failure is followed by right-sided heart failure because the circulatory system is a continuous loop. 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. If the right side of the heart fails to pump efficiently, blood becomes congested in the neck veins, and the nurse may inspect the distention of external jugular vein.

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.

A client reports recent onset of chest pain that occurs sporadically with exertion. The client also has fatigue and mild ankle swelling, which is most pronounced at the end of the day. The nurse suspects a cardiovascular disorder. What other client report increases the likelihood of a cardiovascular disorder?

Shortness of breath Common signs and symptoms of cardiovascular dysfunction include shortness of breath, chest pain, palpitations, fainting, fatigue, and peripheral edema. Insomnia seldom indicates a cardiovascular problem. Although irritability may occur if cardiovascular dysfunction leads to cerebral oxygen deprivation, this symptom more commonly reflects a respiratory or neurologic dysfunction. Lower substernal abdominal pain occurs with some GI disorders.

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:

Stimulation of the vagus nerve. 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 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 caring for a patient with a diagnosis of pericarditis. Where does the nurse understand the inflammation is located?

The thin fibrous sac encasing the heart The heart is encased in a thin, fibrous sac called the pericardium, which is composed of two layers. Inflammation of this sac is known as pericarditis.

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?

Thin fibrous sac that encases the heart. 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 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.

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.

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?

endocardium 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.

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.

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 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.

During the auscultation of a client's heart sounds, the nurse notes an S4. The nurse recognizes that an S4 is associated with which condition?

hypertensive heart disease Auscultation of the heart requires familiarization with normal and abnormal heart sounds. An extra sound just before S1 is an S4 heart sound or atrial gallop. An S4 sound often is associated with hypertensive heart disease. A sound that follows S1 and S2 is called an S3 heart sound or a ventricular gallop. An S3 heart sound is often an indication of heart failure in an adult. In addition to heart sounds, auscultation may reveal other abnormal sounds, such as murmurs and clicks, caused by turbulent blood flow through diseased heart valves.

During the auscultation of heart, what is revealed by an atrial gallop?

hypertensive heart disease Auscultation of the heart requires familiarization with normal and abnormal heart sounds. An extra sound just before S1 is an S4 heart sound, or atrial gallop. An S4 sound often is associated with hypertensive heart disease. A sound that follows S1 and S2 is called an S3 heart sound or a ventricular gallop. An S3 heart sound is often an indication of heart failure in an adult. In addition to heart sounds, auscultation may reveal other abnormal sounds, such as murmurs and clicks, caused by turbulent blood flow through diseased heart valves.

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.

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 The following steps are recommended when assessing clients for postural hypotension: (1) Position the client supine for 10 minutes before taking the initial BP and HR measurements; (2) reposition the client to a sitting position with legs in the dependent position, and wait 2 minutes to reassess both BP and HR measurements; (3) if the client is symptom free or has no significant decreases in systolic or diastolic BP, assist the client into a standing position, obtain measurements immediately and recheck in 2 minutes; (4) continue measurements every 2 minutes for a total of 10 minutes to rule out postural hypotension. Return the client to supine position if postural hypotension is detected or if the client becomes symptomatic. Document HR and BP measured in each position (e.g., supine, sitting, and standing) and any signs or symptoms that accompanied the postural changes.

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.

The nurse is reviewing the laboratory results for a client with heart failure. Which laboratory value will the nurse report to the healthcare provider?

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

Which term describes the amount of blood ejected per heartbeat?

stroke volume Stroke volume is determined by preload, afterload, and contractility of the heart. Cardiac output is the amount of blood pumped by each ventricle during a given period and is computed by multiplying the stroke volume of the heart by the heart rate. Ejection fraction is the percentage of the end-diastolic volume that is ejected with each stroke, measured at 42% to 50% in the normal heart. Afterload is defined as the pressure that the ventricular myocardium must overcome to eject blood during systole and is one of the determinants of stroke volume.

The nurse correctly identifies which data as an example of blood pressure and heart rate measurements in a client with postural hypotension?

supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm 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 position to a standing position. The following is an example of BP and HR measurements in a client with postural hypotension: supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm. Normal postural responses that occur when a person moves from a lying to a standing position include (1) a HR 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.

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.

Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes no active gag reflex. What nursing action is a priority?

withhold food and fluids. Following a transesophageal echocardiogram in which the client's throat has been anesthetized, the nurse should withhold food and fluid until the client's gag reflex returns. There's no indication that oral airway placement would be appropriate. The client should be in the upright position, and the nurse needn't insert an NG tube.