CARDIO: CH 25 Assessment of the Cardio Function (HINKLE)
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. Chapter 25: Assessment of Cardiovascular Function - Page 678
The nurse cares for a client with diabetes who is scheduled for a cardiac catheterization. Prior to the procedure, it is most important for the nurse to ask which question? "Are you having chest pain?" "When was the last time you ate or drank?" "What was your morning blood sugar reading?" "Are you allergic to shellfish?"
"Are you allergic to shellfish?" Radiopaque contrast agents are used to visualize the coronary arteries. Some contrast agents contain iodine, and the client is assessed before the procedure for previous reactions to contrast agents or allergies to iodine-containing substances (e.g., seafood). If the client has a suspected or known allergy to the substance, antihistamines or methylprednisolone may be administered before the procedure. Although the other questions are important to ask the client, it is most important to ascertain if the client has an allergy to shellfish. Chapter 25: Assessment of Cardiovascular Function - Page 702
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 replacement is not effective at preventing cardiovascular disease and carries some risks." 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 to prevent cardiovascular disease. However, hormone replacement therapy has not been shown to be harmful for all women, and it may be a good choice for some women seeking to reduce symptoms of menopause. Chapter 25: Assessment of Cardiovascular Function - Page 678
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. Chapter 25: Assessment of Cardiovascular Function - Page 705
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 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. Chapter 25: Assessment of Cardiovascular Function - Page 702
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 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. Chapter 25: Assessment of Cardiovascular Function - Page 702
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?" "Have you had any episodes when you are to nauseous?" "Have you had any episodes of mottling in your hands?" "Have you had any episodes of pain radiating into your lower extremities?"
"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. Chapter 25: Assessment of Cardiovascular Function - Page 680
A nurse is preparing a client for an exercise stress test the following morning. Which client statement indicates a need for additional teaching?
"I won't eat or drink anything after midnight tonight." The client requires additional teaching if he states that he'll fast from midnight until the test. Clients need to abstain from eating and drinking for only 4 hours before the test. The client should refrain from smoking for several hours before the test. Although the physician may direct the client to avoid certain medications, it's more likely that the physician will direct the client to take all his normal medications. The client must sign a consent form before the test. Chapter 25: Assessment of Cardiovascular Function - Page 699
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 aortic valve is located near the apex of the heart, which is on the right side." "The aortic valve is located near the base of the heart on the right side." "The aortic valve is located on the right side of the heart."
"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. Chapter 25: Assessment of Cardiovascular Function - Page 677
The nurse assesses a client with increasing shortness of breath and peripheral edema. The healthcare provider inserts a triple lumen catheter and orders a transduced central venous pressure (CVP). What CVP reading does the nurse suspect will correlate with the client's symptoms?
8 mmHg The normal CVP reading is 2-6 mmHg. A reading of 0 mmHg indicates hypovolemia. A reading of 8 mmHg, which is high, correlates with hypervolemia and the client's symptoms of fluid overload with increasing shortness of breath and edema. Chapter 25: Assessment of Cardiovascular Function - Page 677
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 72-year-old retired janitor obtaining a cardiac baseline A 55-year-old recovering from a fall and broken femur
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. Chapter 25: Assessment of Cardiovascular Function - Page 699
The nurse is assisting the client to manage the cardiovascular risk factors of hyperlipidemia and hypertension. The client asks the nurse what type of a diet would be best to follow. What is the best response by the nurse? A diet high in trans fats and potassium A diet with high sodium, fruits, vegetables A diet low in sodium, fat, cholesterol A diet with restricted fruits and fluids
A diet low in sodium, fat, cholesterol Diets that are restricted in sodium, fat, and cholesterol are commonly prescribed to manage the cardiovascular risk factors of hypertension and hyperlipidemia. The lowered sodium, fat, and cholesterol diets aid with decreasing water retention and fatty substances. Cardiovascular risk factors do not involve potassium levels and limiting fruits and fluids. Cardiovascular risks factors are lowered by eating fruits and vegetables to lower cholesterol levels. Chapter 25: Assessment of Cardiovascular Function - Page 682
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
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. Chapter 25: Assessment of Cardiovascular Function - Page 687
The nurse observes that a patient has 2+ pitting edema in the lower extremities. What does the nurse know that the presence of pitting edema indicates regarding fluid retention? A weight gain of 4 lbs A weight gain of 6 lbs A weight gain of 10 lbs A weight gain of 8 lbs
A weight gain of 10 lbs Pitting edema, in which indentations in the skin remain after even slight compression with the fingertips (Fig. 29-2), is generally obvious after retention of at least 4.5 kg (10 lb) of fluid (4.5 L). Chapter 25: Assessment of Cardiovascular Function - Page 823
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? Bok choy, cooked leeks, alfalfa sprouts Apricots, dried peas and beans, dates Cranberries, apples, popcorn Asparagus, blueberries, green beans
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. Chapter 25: Assessment of Cardiovascular Function - Page 694
A client is experiencing an irregular heartbeat. The client asks the nurse how a heartbeat occurs. The nurse explains the conduction system of the heart beginning with the sinoatrial node (SA node). Place the conduction sequence of the heart in order beginning with the SA node. Use all options. 1Bundle branches 2Bundle of His 3Purkinje fibers 4AV node 5Atrial cell stimulation
Atrial cell stimulation AV node Bundle of His Bundle branches Purkinje fibers Chapter 25: Assessment of Cardiovascular Function - Page 675
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. Chapter 25: Assessment of Cardiovascular Function - Page 705
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.
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. Chapter 25: Assessment of Cardiovascular Function - Page 705
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. Chapter 25: Assessment of Cardiovascular Function - Page 695
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 chemoreceptors sympathetic nerve fibers vagus nerve
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 taking a health history from a client admitted with the medical diagnosis of cardiovascular disease (CVD). Which symptoms correlate with the client's diagnosis? Chest pain, weight gain, fatigue
Chest pain, weight gain, fatigue Chest pain, weight gain, fatigue, dizziness, ascites, and confusion are all symptoms of CVD. . Chapter 25: Assessment of Cardiovascular Function - Page 679
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. Chapter 25: Assessment of Cardiovascular Function - Page 675
The nurse is performing a skin assessment for a client and observes a blue tinge in the buccal mucosa and tongue. What condition does the nurse correlate this finding with? Peripheral vasoconstriction. Congenital heart disease.
Congenital heart disease. Cyanosis is due to serious cardiac disorders. A bluish tinge in the tongue and buccal mucosa are signs of central cyanosis caused by venous blood passing through the pulmonary circulation without being oxygenated. In the absence of pulmonary edema and cardiogenic shock, this sign is indicative of congenital heart disease. Refer to Table 12-3 in the text. Chapter 25: Assessment of Cardiovascular Function - Page 686
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. Chapter 25: Assessment of Cardiovascular Function - Page 686
A nurse is caring for a client with a central venous pressure (CVP) of 4 mm Hg. Which nursing intervention is appropriate? Re-zero the equipment and take another reading. Continue to monitor the client as ordered.
Continue to monitor the client as ordered. Normal CVP ranges from 2 to 6 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 2 mm Hg. Administering a diuretic would be appropriate if the client had excess fluid, as demonstrated by a CVP greater than 6 mm Hg. (Note: normal values can vary by reference source.) Chapter 25: Assessment of Cardiovascular Function - Page 822
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. Chapter 25: Assessment of Cardiovascular Function - Page 688
A cardiac patient with a magnesium lab result of 2.5 mEq/L would most likely evidence which of the following? Ventricular arrhythmias Depressed myocardial contractility
Depressed myocardial contractility The normal magnesium level is 1.3 to 2.2 mEq/L. An elevated magnesium level can depress myocardial contractility and excitability, which can lead to heart block or asystole. Chapter 25: Assessment of Cardiovascular Function - Page 694
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? Diminished, but cannot be obliterated with pressure. Difficult to palpate and is obliterated with pressure.
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. Chapter 25: Assessment of Cardiovascular Function - Page 688
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. Chapter 25: Assessment of Cardiovascular Function - Page 678
A client is being scheduled for a stress test. The client is unable to exercise during the test. The nurse would include information about which medication used for pharmacologic stress testing? Cardiolite Dipyridamole Lanoxin Thallium 201
Dipyridamole If the patient is unable to exercise, a pharmacologic stress test is performed by injecting a vasodilating agent, dipyridamole or adenosine, to mimic the physiologic effects of exercise. The stress test may be combined with an echocardiogram or radionuclide imaging techniques to examine myocardial function during exercise and rest. Digoxin would not be used for stress testing. Thallium 201 and Cardiolite are radioisotopes used in myocardial perfusion scanning. Chapter 25: Assessment of Cardiovascular Function - Page 699
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 polarization During depolarization During repolarization During the refractory period
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. Chapter 25: Assessment of Cardiovascular Function - Page 718
The nursing instructor is teaching nursing students about myocardial contractility and ejection fractions. What diagnostic tests can determine client ejection fractions? Select all that apply. Positron emission tomography scan Echocardiogram Cardiac catheterization Magnetic resonance imaging
Echocardiogram Cardiac catheterization Magnetic resonance imaging Echocardiogram, cardiac catheterization, and magnetic resonance imaging can provide ejection fraction estimates. The positron emission tomography scan reveals areas of decreased blood flow in the heart. Troponin levels are cardiac markers and do not measure ejection fractions. Chapter 25: Assessment of Cardiovascular Function - Page 678
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. Chapter 25: Assessment of Cardiovascular Function - Page 683
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? rbc wbc enzyme platelets
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. Chapter 25: Assessment of Cardiovascular Function - Page 693
Which symptom is an early warning sign of acute coronary syndrome (ACS) and heart failure (HF)? fatigue
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. Chapter 25: Assessment of Cardiovascular Function - Page 680
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
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. Chapter 25: Assessment of Cardiovascular Function - Page 694
The nurse is assessing an older adult client's electrocardiogram (ECG). What age related change to the conduction system may the nurse observe? murmur heart block
Heart block Age-related changes to the conduction system may include bradycardia and heart block. Age-related changes to the heart valves include the presence of a murmur or thrill. Chapter 25: Assessment of Cardiovascular Function - Page 679
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?
Heart failure 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. Chapter 25: Assessment of Cardiovascular Function - Page 690
A client is admitted to the hospital with weakness. What nursing assessment indicates postural hypotension? Systolic pressure did not change with the change in position. Heart rate decreased from 85 to 75 bpm at the same time that the systolic pressure increased from 120 to 135 mm Hg. Heart rate increased from 85 to 110 bpm. Diastolic pressure went from 80 to 110 mm Hg.
Heart rate increased from 85 to 110 bpm A sign of postural hypotension is the increase in the heart rate from 5 to 20 bpm with the change in position from lying, sitting and standing. Therefore, an increase of 25 bpm is indicative of hypotension. With postural hypotension, the systolic and diastolic blood pressure will decrease with standing and heart rate will increase. Chapter 25: Assessment of Cardiovascular Function - Page 687
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. Low density lipoproteins (LDL) increase from 180 mg/dl to 190 mg/dl. Total cholesterol level increases from 250 mg/dl to 275 mg/dl. Triglycerides increase from 225 mg/dl to 250 mg/dl.
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. Chapter 25: Assessment of Cardiovascular Function - Page 682
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. Chapter 25: Assessment of Cardiovascular Function - Page 679
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. Chapter 25: Assessment of Cardiovascular Function - Page 694
The critical care nurse is caring for clients in an emergency department. When caring for a variety of clients, when is the presence of a third heart sound normal? In clients with heart valve replacement In pediatric clients In clients with an indwelling pacemaker In geriatric clients
In pediatric clients When caring for a variety of clients, it is important to consider that a third heart sound is normal in children. In adults, a third heart sound may signify heart failure. There is no correlation between third heart sounds with heart valve replacement and an indwelling pacemaker. Chapter 25: Assessment of Cardiovascular Function - Page 691
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
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. Chapter 25: Assessment of Cardiovascular Function - Page 718
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 Respiratory compromise Cyanosis Chronic chest pain
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. Chapter 25: Assessment of Cardiovascular Function - Page 718
A nurse is performing a cardiac assessment on an elderly client. Which finding warrants further investigation? Orthostatic hypotension Increased PR interval Irregularly irregular heart rate Fourth heart sound (S4)
Irregularly irregular heart rate An irregularly irregular heart rate indicates atrial fibrillation and should be investigated further. It's normal for an elderly client to have a prolonged systole, which causes an S4 heart sound. It's also normal for an elderly client to have slowed conduction, causing an increased PR interval. As a person ages, it's normal for baroreceptors in the body to decrease their response to changes in body position, which can cause orthostatic hypotension. Chapter 25: Assessment of Cardiovascular Function - Page 693
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. Chapter 25: Assessment of Cardiovascular Function - Page 694
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). Chapter 25: Assessment of Cardiovascular Function - Page 689
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. Chapter 25: Assessment of Cardiovascular Function - Page 692
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 furosemide lorazepam phenytoin
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 caring for a client in the cardiac intensive care unit (CICU) after a myocardial infarction (MI). Which drug will the nurse administer that will decrease contractility? Metoprolol Dopamine Digoxin Dobutamine
Metoprolol Contractility is depressed by beta-adrenergic blocking medications. The other choices all enhance contractility. Chapter 25: Assessment of Cardiovascular Function - Page 678
Which assessments should a nurse perform when caring for a client following a cardiac catheterization? Select all that apply. Palpate the insertion site for tenderness. Inspect the color in every extremity. Monitor BP and pulse frequently. Palpate the pulse in different locations. Inspect pressure dressing for signs of bleeding.
Monitor BP and pulse frequently. Inspect pressure dressing for signs of bleeding. Palpate the pulse in different locations. After a cardiac catheterization, the nurse monitors BP and pulse frequently to detect complications, checks the dressing over the insertion site frequently for signs of bleeding, palpates the pulse in various locations, and checks the color and temperature in the affected extremity to confirm that blood is circulating well. Chapter 25: Assessment of Cardiovascular Function - Page 703
The client's heart rate is observed to be 140 bpm on the monitor. The nurse knows to monitor the client for what condition? Myocardial ischemia
Myocardial ischemia As heart rate increases, diastolic time is shortened, which may not allow adequate time for myocardial perfusion. As a result, clients are at risk for myocardial ischemia (inadequate oxygen supply) during tachycardias (heart rate greater than 100 bpm), especially clients with coronary artery disease.
The nurse is caring for a client with ECG changes consistent with a myocardial infarction. Which of the following diagnostic test does the nurse anticipate to confirm heart damage? Chest radiography Nuclear cardiology
Nuclear cardiology Nuclear cardiology uses a radionuclide to detect areas of myocardial damage. Chest radiography and fluoroscopy determine the size and position of the heart and condition of the lungs. Serum blood work notes elevations in enzymes suggesting muscle damage.
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. Chapter 25: Assessment of Cardiovascular Function - Page 687
The nurse cares for a client with clubbing of the fingers and toes. The nurse should complete which action given these findings? Assess the client for pitting edema. Obtain an oxygen saturation level. Obtain a 12-lead ECG tracing. Assess the client's capillary refill.
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. Chapter 25: Assessment of Cardiovascular Function - Page 687
The nurse is assessing a patient's electrocardiogram (ECG). What phase does the nurse determine is the resting phase before the next depolarization? Phase 2 Phase 3 Phase 4 Phase 1
Phase 4 Phase 4 is considered the resting phase before the next depolarization. In phase 1, early cellular repolarization begins as potassium exits the intracellular space. Phase 2 is called the plateau phase because the rate of repolarization slows. Calcium ions enter the intracellular space. Phase 3 marks the completion of repolarization and return of the cell to its resting state. Chapter 25: Assessment of Cardiovascular Function - Page 676
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. Chapter 25: Assessment of Cardiovascular Function - Page 687
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. Chapter 25: Assessment of Cardiovascular Function - Page 688
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 jewelry. Position the client on the stomach for the procedure. Remove the client's Transderm Nitro patch. Sedate the client prior to the procedure. Offer the client a headset to listen to music during the procedure.
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. Chapter 25: Assessment of Cardiovascular Function - Page 702
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? Assess for clubbing of the fingers. Assess for hypokalemia. Administer calcium supplements. Report any incident of bloody urine, stools, or both.
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. Chapter 25: Assessment of Cardiovascular Function - Page 683
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 Pulmonary artery Right atrium Aorta
Right ventricle There are four chambers to the heart. The right and left ventricles are 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. Chapter 25: Assessment of Cardiovascular Function - Page 673
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. Chapter 25: Assessment of Cardiovascular Function - Page 677
A client in the ICU has a central venous pressure (CVP) line placed. The CVP reading is 10 mm Hg. To what condition does the nurse correlate the CVP reading?
Right-sided heart failure Normal CVP is 2 to 8 mm Hg. A CVP greater that 8 mm Hg indicates hypervolemia or right-sided heart failure. A CVP less than 2 mm Hg indicates a reduction in preload or hypovolemia. Chapter 25: Assessment of Cardiovascular Function - Page 706
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? Distention of the jugular vein Blood congestion in neck veins Effort to lie down to breathe Right-sided heart failure
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. Chapter 25: Assessment of Cardiovascular Function - Page 822
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. Chapter 25: Assessment of Cardiovascular Function - Page 691
The nurse is performing an assessment for an older adult client with reports of chest pain. What assessment finding correlates with a potential age-related change?
S4 sound With age, the heart rate will decrease, and heart block can occur with changes in the conduction system. Auscultation may reveal the presence of an S4 sound. Pulse pressure will widen, and the systolic pressure will increase because of stiffening of the blood vessels. The heart rate should decrease. Chapter 25: Assessment of Cardiovascular Function - Page 691
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? atrioventricular node sinoatrial node
SA node 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. Chapter 25: Assessment of Cardiovascular Function - Page 675
The nurse is reviewing the laboratory results for a client with heart failure. Which laboratory value will the nurse report to the health care provider? sodium 148 mEq/L potassium Calcium Magnesium
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. Chapter 25: Assessment of Cardiovascular Function - Page 694
The nurse is discussing the cardiac system with a client admitted with heart failure. The client asks "What determines the heart rate?" What is the nurse's best response?
The autonomic nervous system controls the heart rate. The autonomic nervous system primarily controls the heart rate. When the sympathetic branch is stimulated, heart rate increases. When the parasympathetic branch is stimulated, heart rate decreases. Stroke volume is the amount of blood pumped out of the ventricle with each contraction and depends on three factors: preload, afterload, and contractility. Chapter 25: Assessment of Cardiovascular Function - Page 819
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 need for medication. The client and family understands the discharge instructions. The client and family understands the client's CV diagnosis. The client and family understands the need to restrict activity for 72 hours.
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. Chapter 25: Assessment of Cardiovascular Function - Page 705
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. Chapter 25: Assessment of Cardiovascular Function - Page 683
The nurse is performing an assessment for an older adult client with reports of chest pain. What assessment finding correlates with a potential age-related change? A heart rate of 92 beats/minute A progressive decrease in systolic blood pressure The presence of an S4 sound A shortened pulse pressure
The presence of an S4 sound With age, the heart rate will decrease, and heart block can occur with changes in the conduction system. Auscultation may reveal the presence of an S4 sound. Pulse pressure will widen, and the systolic pressure will increase because of stiffening of the blood vessels. The heart rate should decrease. Chapter 25: Assessment of Cardiovascular Function - Page 691
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). Chapter 25: Assessment of Cardiovascular Function - Page 675
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. Chapter 25: Assessment of Cardiovascular Function - Page 673
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? Bounding pulse Thready pulse Weak pulse A pulse deficit
Thready pulse 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. Chapter 25: Assessment of Cardiovascular Function - Page 762
The nurse is admitting an older adult client with heart failure. Which education will the nurse prepare for this client prior to discharge?" Try to avoid emotional stress and take part in mild physical stress only. Continue to increase the amount of exercise, because cardiac output increases with age. Any kind of stress is acceptable, because the aging heart has an increased ability to respond. Exercise tolerance should remain the same as in younger years.
Try to avoid emotional stress and take part in mild physical stress only. Stressful physical and emotional conditions may have adverse effects on the aged person's heart. Stress is not tolerated by older adults with heart failure. Exercise regimes need to be tailored to the older adult's ability. Cardiac output does not increase with age. Chapter 25: Assessment of Cardiovascular Function - Page 705
The nurse is admitting an older adult client with heart failure. Which education will the nurse prepare for this client prior to discharge?"
Try to avoid emotional stress and take part in mild physical stress only.. Stressful physical and emotional conditions may have adverse effects on the aged person's heart. Stress is not tolerated by older adults with heart failure. Exercise regimes need to be tailored to the older adult's ability. Cardiac output does not increase with age. Chapter 25: Assessment of Cardiovascular Function - Page 705
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 need to wear comfortable shoes to the test. You will receive medication via IV administration.
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. Chapter 25: Assessment of Cardiovascular Function - Page 700
Which term describes the ability of the heart to initiate an electrical impulse? automaticity conductivity contractility excitability
automaticity 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. Chapter 25: Assessment of Cardiovascular Function - Page 675
The nurse accompanies a client to an exercise stress test. The client can achieve the target heart rate, but the electrocardiogram indicates ST-segment elevation. Which procedure will the nurse prepare the client for next? cardiac catheterization transesophageal echocardiogram Telemetry monitoring pharmacologic stress test
cardiac catheterization An elevated ST-segment means an evolving myocardial infarction. A cardiac catheterization would be the logical next step. Telemetry monitoring will only provide dysrhythmia detection. A transesophageal echocardiogram is a diagnostic test to assess cardiac function. The pharmacologic stress test is diagnostic and will determine heart function. Chapter 25: Assessment of Cardiovascular Function - Page 699
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? pneumothorax catheter-related bloodstream infections air emboli
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. Chapter 25: Assessment of Cardiovascular Function - Page 706
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. Chapter 25: Assessment of Cardiovascular Function - Page 688
The nurse is preparing a client for transesophageal echocardiography (TEE). This procedure is used for which indication? determination of electrical activity of the heart determination of atrial thrombi
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. Chapter 25: Assessment of Cardiovascular Function - Page 702
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? elevated jugular venous distention and postural changes in BP BP 108/60 mm Hg, ascites, and crackles disorientation, 20 mL of urine over the last 2 hours reduced pulse pressure and heart murmur
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. Chapter 25: Assessment of Cardiovascular Function - Page 685
Age-related changes associated with the cardiac system include which conditions? Select all that apply. endocardial fibrosis increased size of the left atrium increase in the number of SA node cells
endocardial fibrosis increased size of the left atrium Age-related changes associated with the cardiac system include endocardial fibrosis, increased size of the left atrium, decreased number of SA node cells, and myocardial thickening. Chapter 25: Assessment of Cardiovascular Function - Page 679
Age-related changes associated with the cardiac system include endocardial fibrosis increased size of the left atrium myocardial thinning increase in the number of SA node cells
endocardial fibrosis. Age-related changes associated with the cardiac system include: endocardial fibrosis, increased size of the left atrium, a decreasing number of SA node cells, and myocardial thickening. Chapter 25: Assessment of Cardiovascular Function - Page 679
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 myocardium pericardium epicardium
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. Chapter 25: Assessment of Cardiovascular Function - Page 673
Which area of the heart that is located at the third intercostal space to the left of the sternum?
erb point
The nurse is performing an assessment for an older adult client and auscultates an S3 heart sound. What condition does the nurse determine may correlate with this finding? heart failure
heart failure The S3 heart sound is heard immediately after the S2 sound, early in diastole, as blood flows from the atrium into a noncompliant ventricle. The S3 heart sound is normal in children and young adults, but it is a significant finding suggestive of heart failure in older adults. A client with aortic stenosis commonly may have a murmur. A client with congenital heart disease may have more that one abnormal heart sound. Clients with coronary artery disease do not have S3 heart sounds. Chapter 25: Assessment of Cardiovascular Function - Page 690
The nurse is explaining vasovagal syncope to a client. What does the nurse associate the temporary loss of consciousness with for the client? increase fluid intake heart rate 48 vertigo blood pressure 190/50 standing
heart rate 48 Parasympathetic hyperactivity leading to sudden hypotension secondary to bradyarrhythmia causes vasovagal syncope; bradyarrhythmia leads to cerebral ischemia, which in turn leads to syncope. Vasovagal syncope isn't caused by vestibular dysfunction such as vertigo, hypertension, or vascular fluid shifting. Chapter 25: Assessment of Cardiovascular Function - Page 704
The nurse is monitoring a client experiencing a decrease in cardiac output. What medical conditions will lead to a decrease in preload? hemorrhage, sepsis, and anaphylaxis
hemorrhage, sepsis, and anaphylaxis Preload is the volume in the left ventricle at the end of diastole. It's also referred to as end-diastolic volume. Preload is reduced by any condition that reduces circulating volume, such as hemorrhage, sepsis, and anaphylaxis. Hemorrhage reduces circulating volume by the loss of volume from the intravascular space. Sepsis and anaphylaxis reduce circulating volume by increased capillary permeability. Diuresis, vasodilation, and third spacing also reduce preload. Preload increases with fluid overload and heart failure. Chapter 25: Assessment of Cardiovascular Function - Page 677-678
The nurse is monitoring a client experiencing a decrease in cardiac output. What medical conditions will lead to a decrease in preload? hemorrhage, sepsis, and anaphylaxis myocardial infarction, fluid overload, and diuresis
hemorrhage, sepsis, and anaphylaxis Preload is the volume in the left ventricle at the end of diastole. It's also referred to as end-diastolic volume. Preload is reduced by any condition that reduces circulating volume, such as hemorrhage, sepsis, and anaphylaxis. Hemorrhage reduces circulating volume by the loss of volume from the intravascular space. Sepsis and anaphylaxis reduce circulating volume by increased capillary permeability. Diuresis, vasodilation, and third spacing also reduce preload. Preload increases with fluid overload and heart failure. Chapter 25: Assessment of Cardiovascular Function - Page 677-678
A client's chart indicates an S4 heart sound, and is scheduled for a cardiac workup. The nurse is aware that this client may have which cardiac condition? hypertensive heart disease diseased heart valves
hypertensive heart disease An S4 sound is often associated with hypertensive heart disease. An S3, although normal in children, is often an indication of heart failure in an adult. A friction rub may cause a rough, grating, or scratchy sound that is indicative of pericarditis. Murmurs and clicks caused by turbulent blood flow through diseased heart valves. Chapter 25: Assessment of Cardiovascular Function - Page 691
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? diseased heart valves hypertensive heart disease
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. Chapter 25: Assessment of Cardiovascular Function - Page 691
The nurse cares for a client in the ICU who is being monitored with a central venous pressure (CVP) catheter. The nurse records the client's CVP as 8 mm Hg and recognizes that this finding indicates the client is experiencing which condition? excessive blood loss left-sided heart failure overdiuresis hypervolemia
hypervolemia The normal CVP is 2 to 6 mm Hg. A CVP greater than 6 mm Hg indicates an elevated right ventricular preload. Many problems can cause an elevated CVP, but the most common is hypervolemia (excessive fluid circulating in the body) or right-sided HF. In contrast, a low CVP (<2 mm Hg) indicates reduced right-ventricular preload, which is most often from hypovolemia. Chapter 25: Assessment of Cardiovascular Function - Page 706
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)
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. Chapter 25: Assessment of Cardiovascular Function - Page 694
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
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 angina panic attack dissecting aorta
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. Chapter 25: Assessment of Cardiovascular Function - Page 681
A nurse is caring for a client taking diltiazem for arrhythmias. The nurse knows that diltiazem helps decrease arrhythmias by working during which phase of the cardiac action potential? Phase 3 Phase 1 Phase 2 Phase 0
phase 0 Diltiazem, a calcium channel blocker, blocks the influx of calcium into the cells during phase 0 of the cardiac action potential. This action causes the sinoatrial node and atrioventricular (AV) node to slow their response times, which results in slowed AV conduction, decreased ventricular depolarization, and arrhythmias. Diltiazem doesn't work during phase 1, 2, or 3 of the cardiac action potential. Chapter 25: Assessment of Cardiovascular Function - Page 677
A nurse is assessing a client with heart failure. When assessing hepatojugular reflux, what is the appropriate action for the nurse to take?
press the right upper abdomen. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a client has positive hepatojugular reflux. Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree, not 90-degree, angle. Chapter 25: Assessment of Cardiovascular Function - Page 693
When the balloon on the distal tip of a pulmonary artery catheter is inflated and the pressure is measured, the measurement obtained is referred to as the cardiac output. pulmonary artery pressure. pulmonary artery wedge pressure. central venous pressure.
pulmonary artery wedge pressure. When the balloon is inflated, the tip of the catheter floats into smaller branches of the pulmonary artery until it can no longer be passed. The pressure is recorded, reflecting left-atrial pressure and left-ventricular end-diastolic pressure. Central venous pressure is measured in the right atrium. Pulmonary artery pressure is measured when the balloon tip is not inflated. Cardiac output is determined through thermodilution, which involves injection of fluid into the pulmonary artery catheter. Chapter 25: Assessment of Cardiovascular Function - Page 709
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. Chapter 25: Assessment of Cardiovascular Function - Page 687
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... Chapter 25: Assessment of Cardiovascular Function - Page 687
Central venous pressure is measured in which heart chamber? right atrium left atrium left ventricle right ventricle
right atrium Rationale: 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. Chapter 25: Assessment of Cardiovascular Function - Page 688
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
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 left ventricle right atrium left atrium
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. Chapter 25: Assessment of Cardiovascular Function - Page 673
*Which term describes the amount of blood ejected per heartbeat? cardiac output stroke volume ejection fraction afterload
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. Chapter 25: Assessment of Cardiovascular Function - Page 677
An obese client describes symptoms of palpitations, chronic fatigue, and dyspnea on exertion to the cardiologist. Upon completing the examination, the cardiologist schedules a procedure to confirm the suspected diagnosis. What diagnostic procedure would the nurse expect to be prescribed? electrocardiography transesophageal echocardiography radionuclide thallium-201 Chest radiography and fluoroscopy
transesophageal echocardiography TEE involves passing a tube with a small transducer internally from the mouth to the esophagus to obtain images of the posterior heart and its internal structures from the esophagus, which lies behind the heart. TEE provides superior views that are not possible using standard transthoracic echocardiography. Clients whose chests are rotund or who are obese are candidates for TEE. Chest radiography and fluoroscopy determine the size and position of the heart and condition of the lungs. The radionuclide technetium-99m is used to detect areas of myocardial damage. The radionuclide thallium-201 is used to diagnose ischemic heart disease during a stress test. Electrocardiography (ECG) is the graphic recording of the electrical currents generated by the heart muscle. Chapter 25: Assessment of Cardiovascular Function - Page 702
1.The nurse is auscultating a client's heart sounds and notes a murmur at the left fourth intercostal space. At which cardiac valve would the nurse document this murmur? aortic valve pulmonic valve tricuspid valve mitral valve
tricuspid valve Rationale: the tricuspid valve is at the left fourth intercostal space and lateral to the sternum. Mitral valve: is heard at the left fifth intercostal space and midclavicular line. Aortic valve: heard at the right second intercostal space, lateral to the sternum Pulmonic valve: heard at the left second intercostal space, lateral to the sternum
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. Chapter 25: Assessment of Cardiovascular Function - Page 692
