ATI Health Assess - Cardiovascular
Which of the following is an extra or unexpected heart sound? (SATA)
S3 S4 Murmur
A nurse is teaching a client about behaviors that promote cardiovascular health. Which of the following client statements indicate an understanding of the teaching? (SATA)
"I am going to start walking several times a week." "I plan to join a support group to help me stop smoking." "I will be sure to have my BP checked at least every year."
Which of the following client report indicates a medical emergency?
"I have a tight feeling in my chest." *any report of chest pain is considered a medical emergency
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?
"The penlight will allow me to look at the pulses in your neck." Rationale: Focused lighting, such as from a penlight, will enhance visualization of the blood vessels in the neck to check for pulsations and distention.
What is the correlating scale rating for mild pitting edema that is barely noticeable?
+1
Which of the following ratings should you assign to a bounding carotid pulse?
+4
In what order does blood flow through the heart valves?
1. Tricuspid Valve 2. Pulmonic Valve 3. Mitral Valve 4. Aortic Valve (T, P, M, A) Blood flow through the tricuspid valve from the right atria, and into the right ventricle. The right ventricle contracts and forces blood through the pulmonic valve to lungs. The blood returns from the lungs to the left atria. The blood flows from the left atria through the mitral valve to the left ventricle. The left ventricle contracts and forced through the aortic valve to the aorta and to the rest of the body.
A nurse is assessing the anterior chest of a client. Which of the following findings should the nurse reports to the provider?
A forceful chest movement at the midclavicular line in the 4th intercostal space.
A nurse is auscultating heart sounds in a group of clients. Which of the following should the nurse identify as an expected variation.
An adolescent who has an S3 heart sound.
A nurse is preparing to conduct a cardiovascular assessment on a client. Which of the following actions should the nurse plan to take? (SATA).
Auscultate the apical pulse. Ask the client if they experience shortness of breath. Check the color of the client's skin. Inspect the extremities for the presence of edema.
Which of the following are the risk factors for heart disease? (SATA)
BMI greater than 30 Smoking tobacco Family history of hypertension Type 2 diabetes
A nurse has completed a cardiovascular assessment on a client. Which of the following findings should the nurse report to the provider?
Capillary refill of 3 seconds. Rationale: Capillary refill should be less than or equal to 2 seconds.
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?
Discuss the benefits of meditation with the client.
A nurse is auscultating a client's heart sounds. What is the correct order of performance?
Elevate the head of the bead 30' and instruct the client to breathe normally. Visualize the anatomy of the heart. Place the stethoscope to the right sternal border at the second intercostal space. Place the stethoscope close to the sternal border at the fourth intercostal space. Auscultate the apical pulse for 1 min.
A nurse is inspecting and palpating the neck vessels of a client. Which of the following findings should the nurse report to the provider? (SATA)
Full, bounding pulse noted bilaterally in the carotid arteries upon palpation. Distention of the jugular vein on one side of the neck. The left carotid artery pulse is weak.
A nurse is assessing a client's jugular veins and carotid arteries. The nurse should assist the client into which of the following positions?
Have the client lay supine with the head of their bed at a 45' angle.
A nurse is caring for a client who has a peripheral venous ulcer. Which of the following actions should the nurse take? (SATA)
Instruct the client to sit with their legs uncrossed. Encourage the client to avoid tobacco products. Instruct the client to cleanse the area with mild soap. Instruct the client to wear shoes when ambulating.
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?
Limit sodium intake to less than 3,000 mg/day.
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?
Palpable dorsalis pedal pulse. Rationale: The pedal pulses remain present in clients who have peripheral venous disease. Absent pedal pulses are consistent with arterial insufficiency.
A nurse is completing a medical history on a client. Which of the following finding indicates that the client has a family history of cardiovascular disease.
Sibling who has hypertension.
Which of the following are signs of peripheral arterial disease (PAD)?
Ulcer on the toes leg pain that occurs with activity decreased or absent pulses
Which of the following should the nurse include when documenting objective findings? (SATA)
Vital signs Inspection results
Which of the following are nursing interventions for chest pain? (SATA)
apply oxygen Provide continuous ECG monitoring Obtain IV access
Which of the following conditions is associated with jugular venous distention?
heart failure
