ATI Health Asses 2.0: Cardiovascular

Auscultating Heart Sounds

!. Elevate head of bed 30 degreed and instruct client to breathe normally 2. Visualize the anatomy of the heart 3. Place stethoscope to the right sternal border at the second intercostal space 4. Place the stethoscope close to the sternal border at the fourth intercostal space 5. Auscultate the apical pulse 1 minute

4 Heart Sounds Location

1. Aortic valve is located in the second intercostal space, right to the sternal border 2. Pulmonic valve is located at the second intercostal space just left to the sternal border 3. Tricuspid valve is located at the fourth intercostal space just to the left of the lower sternal border 4. The mitral valve is where the APEX or the PMI is heard. Located at the fifth intercostal space in the midclavicular area

A nurse is preparing to conduct a cardiovascular assessment on a client. Which of the following actions should the nurse plan to take? (select all that apply) 1. Auscultate the apical pulse 2. Ask the client if they experience shortness of breath 3. Check the color of the client's skin 4. Auscultate bowel motility 5. Inspect the extremities for the presence of edema

1. Auscultate the apical pulse 2. Ask the client if they experience shortness of breath 3. Check the color of the client's skin 5. Inspect the extremities for the presence of edema Rationale: Auscultating the rate and rhythm of the apical pulse is part of the assessment. Shortness of breath can be an indication of alterations in the cardiovascular system that result in fluid in the lungs. The nurse should inspect the skin, presence of pallor, cyanosis, or a grey color is an unexpected finding. The nurse should inspect for edema during the assessment.

A nurse is teaching a client about behaviors that promote cardiovascular health. Which of the following client statements indicate an understanding of that teaching? (select all that apply) 1. I am going to start walking several time a week 2. I plan to join a support group to help me stop smoking 3. If my HDL cholesterol levels are high it can hurt my heart 4. I will be sure to have my blood pressure checked at least every year 5. Eating more low fiber foods and processed carbohydrates will make my heart healthier

1. I am going to start walking several time a week 2. I plan to join a support group to help me stop smoking 4. I will be sure to have my blood pressure checked at least every year Rationale: The CDC recommends 150 minute per week of activity. Smoking increases the risk for developing cardiovascular disease. Monitoring BP is a component of screenings for cardiovascular health issues.

A nurse is inspecting and palpating the neck vessels of a client. Which of the following findings should the nurse report to the provider? (select all that apply) 1. Visible pulsations observed in the carotid area on both sides of the neck. 2. Full, bounding pulse noted bilaterally in the carotid arteries upon palpation 3. Distention of the jugular vein on one side of the neck 4. Flattening of the jugular veins when the client sits upright 5. The left carotid artery pulse is weak

2. Full, bounding pulse noted bilaterally in the carotid arteries upon palpation 3. Distention of the jugular vein on one side of the neck 5. The left carotid artery pulse is weak Rationale: A full and BOUNDING pulse in the carotid arteries upon palpitation is an unexpected finding. Distention of one or both jugular veins may be an indicator of R sided heart failure or an obstruction A weak pulse can indicate a blockage or narrowing of the artery.

A nurse is caring for a client who has a peripheral venous ulcer. Which of the following actions should the nurse take? (select all that apply) 1. Instruct the client to apply warm heat for pain 2. Instruct the client to sit with their legs uncrossed 3. Encourage the client to avoid tobacco products 4. Instruct the client to cleanse the area with mild soap 5. Instruct the client to wear shoes when ambulating

2. Instruct the client to sit with their legs uncrossed 3. Encourage the client to avoid tobacco products 4. Instruct the client to cleanse the area with mild soap 5. Instruct the client to wear shoes when ambulating Rationale: Client should avoid heating pads and hot water to avoid burns or further injury to the extremity.

A nurse is auscultating heart sounds in a group of clients. Which of the following should the nurse identify as an expected variation? A. An adolescent who has an S3 heart sound B. An older adult who has a heart rate of 48/ min C. A young adult who has an irregular apical pulse D. A middle adult who has a murmer

A. An adolescent who has an S3 heart sound Rationale: In children and young adults it is an expected variation to hear S3 sound.

A nurse has completed a cardiovascular assessment on a client. Which of the following findings should the nurse report to the provider. A. Capillary refill of 3 seconds B. +2 Radial pulse C. Fingernail with 160 degree curvature D. Oxygen saturation of 98%

A. Capillary refill of 3 seconds Rationale: Capillary refill should be less than or equal to 2 seconds

A nurse is preparing to perform a cardiovascular assessment on a client. The client asks, "Why do you need to use a penlight?" Which of the following responses should the nurse make? A. The penlight will allow me to look at the pulses in your neck B. The penlight will allow me to locate your pedal pulse C. The penlight will be used to check your skin turgor D. The penlight will be used to evaluate the effort that you use to breathe

A. The penlight will allow me to look at the pulses in your neck Rationale: Focused lighting will enhance visualizations of the blood vessels in the neck to check for pulsations and distention.

A nurse is assessing a client's jugular veins and carotid arteries. The nurse should assist the client into which of the following positions? A. Place the client in a high-fowlers position B. Have the client lay supine with the head of their bed at a 45 degree angle C. Have the client seated with their chin touching their chest D. Place the client in a left lateral position

B. Have the client lay supine with the head of their bed at a 45 degree angle Rationale: Having the client supine with the head of their bed at 35-45 angle assists the nurse in visualizing the pulsation of the carotid arteries and the jugular vein.

A nurse is preparing to teach a client who has a BMI of 32 about a heart-healthy diet. Which of the following dietary recommendations should the nurse include? A. Increase intake of red meat B. Limit sodium intake to less than 3,000 mg/day C. Increase intake of foods high in trans fat D. Drink whole milk

B. Limit sodium intake to less than 3,000 mg/day Rationale: A heart healthy diet aims to reduce the client's sodium intake to no more than 2-3 g/day. Excess sodium can lead to hypertension, which is a risk factor for cardiovascular disease.

A nurse is completing a medical history on a client. Which of the following findings indicated the client has a family history of cardiovascular disease? A. Parent who experienced a pulmonary embolism B. Sibling who has hypertension C. Cousin who has diabetes mellitus D. Child who has epilepsy

B. Sibling who has hypertension Rationale: Hypertension can have a negative impact on cardiovascular health. An immediate family member such as a sibling who has hypertension increases the likelihood the client will develop it due to genetics.

A nurse is assessing a client who reports an increase in their stress level related to the demands of their job. Which of the following interventions should the nurse recommend for the client to reduce their stress? A. Instruct client to vary the time they go to sleep each night. B. Have the client check their BP daily C. Discuss the benefits of meditation with the client D. Have the client limit their exercise program until the stress has decreased

C. Discuss the benefits of meditation with the client Rationale: The nurse can provide the client with information about meditation, which is a stress reduction activity. The nurse may also discuss stress reducing activities such as yoga or hobbies.

A nurse is caring for a client who has a foot ulcer. Which of the following findings should the nurse identify as consistent with peripheral venous disease. A. Loss of hair on the lower leg B. Cool skin temperature in the lower leg C. Palpable dorsalis pedal pulse D. Regular, even wound border

C. Palpable dorsalis pedal pulse Rationale: The pedal pulse remain present in clients who have peripheral venous disease. Absent pedal pulses are consistent with arterial insufficiency

A nurse is assessing the anterior chest of a client. Which of the following findings should the nurse report to the provider? A. The point of maximal impulse located at the fifth intercostal space. B. Symmetrical chest movements during inhalation and expiration. C. Absent visible pulsations in the area of the point of maximal impulse. D. A forceful chest movement at the midclavicular line in the fourth intercostal space.

D. A forceful chest movement at the midclavicular line in the fourth intercostal space. Rationale: a forceful thrusting movement of the chest at the point of maximal impulse is termed a heave or lift. This is associated with enlarged left ventricle.