Ch. 25 Ass. of cardio fx
S4 sound is caused by what?
Resistance in blood flow due to ventricular hypertrophy caused by HTN, CAD, cardiomyopathies, aortic stenosis, and numerous conditions p. 691
Hepatojugular reflex?
Test to determine R HF. Pt is positioned to detect jugular venous pulse, by pressing over RUQ for 30-60sec and if positive there will be a 1cm or more in jugular venous pressure p. 693
Second intercostal space to the right of the sternum?
Aortic area p. 689
Hypernatremia?
Can result from fluid deficit, not enough water or dehydration p. 694
Hyperkalemia?
Heart block, asystole, ventricular dysrhythmias p. 694
S4 is heard when?
Late diastole p. 691
L 5th intercostal space at the midclavicular line?
Mitral apical area p. 689
Where is S4 ausculatated?
Over L ventricle with the bell over the apical area p. 691
Left sided S3 is heard where?
Over apical pulse in L lateral position p. 691
S1 increases when?
Tachycardia and mitral stenosis p. 690
Valve between L ventricle and pulmonary artery is?
aortic valve p. 675
S3 is heard when?
early diastole p. 691
Valve between R ventricle and pulmonary artery is?
pulmonic valve p. 675
Tricuspid valve separates what?
right atrium and right ventricle p. 675
Hypomagnesia?
Caused by diuretics or digitalis toxicity, causes atrial or ventricular tachycardia p. 694
Bicuspid valve separates what?
left atrium and left ventricle p. 675
S3 can indicate what?
HF p. 691
Fourth and fifth intercostal space to the L sternum?
Tricuspid area p. 689
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? BP 108/60 mm Hg, ascites, and crackles disorientation, 20 mL of urine over the last 2 hours reduced pulse pressure and heart murmur elevated jugular venous distention and postural changes in BP
disorientation, 20 mL of urine over the last 2 hours Explanation: Assessment findings associated with reduced cardiac output include reduced pulse pressure, hypotension, tachycardia, reduced urine output, lethargy, or disorientation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 685.
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? 0 mmHg 2 mmHg 6 mmHg 8 mmHg
8 mmHg Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Effect of Heart Rate on Cardiac Output, p. 677.
Papillary muscles and chordae tendenae maintain what?
Closure of valves p. 675
Crackles indicate what?
HF, atelectasis associated with bed rest, splinting from ischemic pain, effects of analgesia, sedative, anesthetics p. 692
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. Ventricular tachycardia Atrial tachycardia Headache Hypotension Irregular heartbeat
Headache Hypotension Irregular heartbeat Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 694.
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 Enhanced sensitivity to digitalis Increased risk of heart block Inclination to ventricular fibrillation
Impaired myocardial contractility Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Table 25-4 Common Serum Laboratory Tests and Implications for Patients With Cardiovascular Disease, p. 694.
Hypokalemia?
Life threatening ventricular tachycardia or ventricular fibrillation p. 694
Where is R sided S4 heard?
Over tricuspid area with pt in supine p. 691
S2 (dub) is produced by closure of?
Pulmonic and aortic valves p. 690
What is heard at the second intercostal space L to the sternum?
Pulmonic area p. 689
Elevated BUN indicates what?
Reduced renal perfusion from decreased C.O. or intravascular fluid deficit p. 694
Hypocalcemia indicates what?
Slow nodal function and impair myocardial contractility increasing HF risk p. 694
Wheezing indication?
Small airways by interstitial pulmonary edema, beta blockers, non-cardioselective beta-adrenergic blocking agents (propanolol) p. 693
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." "I'll likely be able to take my regular medications before the test." "I won't smoke for 2 to 3 hours before the test." "I'll have to sign a consent form before the test."
"I won't eat or drink anything after midnight tonight." Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Nursing Interventions, p. 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 on the right side of the heart." "The aortic valve is located near the base of the heart on the right side."
"The aortic arch causes the closure of the aortic valve to be heard best on the right side of the sternum." Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Effect of Heart Rate on Cardiac Output, p. 677.
S1 & S2 are produced by closure of what?
AV valves and semilunar valves p. 690
A patient had a cardiac catheterization and is now in the recovery area. What nursing interventions should be included in the plan of care? (Select all that apply.) Assessing the peripheral pulses in the affected extremity Checking the insertion site for hematoma formation Evaluating temperature and color in the affected extremity Assisting the patient to the bathroom after the procedure Assessing vital signs every 8 hours
Assessing the peripheral pulses in the affected extremity Checking the insertion site for hematoma formation Evaluating temperature and color in the affected extremity Explanation: The nurse should observe the catheter access site for bleeding or hematoma formation and assess peripheral pulses in the affected extremity (dorsalis pedis and posterior tibial pulses in the lower extremity, radial pulse in the upper extremity) every 15 minutes for 1 hour, every 30 minutes for 1 hour, and hourly for 4 hours or until discharge. Blood pressure and heart rate should also be assessed during these same time intervals, not every 8 hours. The nurse should evaluate temperature, color, and capillary refill of the affected extremity during these same time intervals. The patient should maintain bed rest for 2 to 6 hours after the procedure. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Nursing Interventions, p. 704.
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? Potassium B-type natriuretic peptide (BNP) C-reactive protein (CRP) Platelet count
B-type natriuretic peptide (BNP) Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Brain (B-Type) Natriuretic Peptide, p. 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? Chemoreceptors Sympathetic nerve fibers Baroreceptors Vagus nerve
Baroreceptors Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Effect of Heart Rate on Cardiac Output, p. 677.
Hypermagnesia?
Commonly caused by cathartics or antacid overuse and can cause depression on contraction & excitability causing heart block or asystole p. 694
A nurse is caring for a client with a central venous pressure (CVP) of 4 mm Hg. Which nursing intervention is appropriate? Call the health care provider and obtain an order for a fluid bolus. Re-zero the equipment and take another reading. Call the physician and obtain an order for a diuretic. Continue to monitor the client as ordered.
Continue to monitor the client as ordered. Explanation: 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.) Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Central Venous Pressure Monitoring, p. 706.
Bladder distention?
Decreased urine output may indicate a cardiac issue p. 693
Ascites cause?
Develops in pts w/ R sided failure or biventricular HF. Abnormally high chamber pressures impede return of venous blood the liver becomes engorged with excessive w/ venous blood (hepatosplenomegaly) due to pressure in portal system rising, fluid shifts from vascular bed to abdominal cavity p. 693
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. Full, easy to palpate, and cannot be obliterated with pressure. Difficult to palpate and is obliterated with pressure. Strong and bounding and may be abnormal.
Difficult to palpate and is obliterated with pressure. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Pulse Amplitude, p. 688.
Hypercalcemia?
Digitalis toxicity or thiazide overuse, cause heart block or sudden death from ventricular fibrillation p. 694
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 Cardiac output Activity level Dyspnea
Digoxin level Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Gerontologic Considerations, p. 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? Dipyridamole Lanoxin Thallium 201 Cardiolite
Dipyridamole Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Pharmacologic Stress Testing, p. 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? Thallium Ativan Diazepam Dobutamine
Dobutamine Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Pharmacologic Stress Testing, p. 699.
Below xiphoid process?
Epigastric area p. 689
Third intercostal space L to the sternum sound?
Erb point p. 689
PTT pr aPTT or PT measures what?
Extrinsic pathway, anticoagulation levels such as heparin or warfarin p. 694
Hyponatremia?
HF or thiazide p. 694
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 Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Computed Tomography, p. 701.
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? Digoxin Dopamine Dobutamine Metoprolol
Metoprolol Explanation: Contractility is depressed by beta-adrenergic blocking medications. The other choices all enhance contractility. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Effect of Stroke Volume on Cardiac Output, p. 678.
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 0 Phase 1 Phase 2 Phase 3
Phase 0 Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Refractory Periods, p. 677.
Hemoptysis?
Pink, frothy sputum (blood) which indicates acute pulmonary edema p. 692
Abdominal distention?
Protuberant abdomen w/ bulging flanks indicates ascites. p. 693
Cough can indicate what?
Pulmonary congestion from HF p. 692
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: The atrioventricular valves must open. The pulmonic valve must be closed. Right ventricular pressure must be higher than pulmonary arterial pressure. Right ventricular pressure must decrease with systole.
Right ventricular pressure must be higher than pulmonary arterial pressure. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Cardiac Hemodynamics, p. 677.
The nurse observes a client during an exercise stress test (bicycle). Which finding indicates a positive test and the need for further diagnostic testing? Dizziness and leg cramping BP changes; 148/80 mm Hg to 166/90 mm Hg ST-segment changes on the ECG Heart rate changes; 78 bpm to 112 bpm
ST-segment changes on the ECG Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 699.
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: An excess level of thyroid hormone. Stimulation of the vagus nerve. An increased level of catecholamines. Sympathetic nervous system stimulation.
Stimulation of the vagus nerve. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Effect of Heart Rate on Cardiac Output, p. 677.
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. Preload controls the heart rate. Stroke volume controls the heart rate. Force of contractility controls the heart rate.
The autonomic nervous system controls the heart rate. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Etiology, p. 819.
Which valves close during the "lub" sound aka S1 sound?
Tricuspid and mitral valve p. 690
Right sided S3 is heard over what?
Tricuspid valve w/ pt supine p. 691
INR measures what?
Used with PT to measure effectiveness of warfarin? p. 694
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. You will need to wear comfortable shoes to the test. You will begin exercising at a slow speed. You may experience an onset of dizziness during the test.
You will receive medication via IV administration. Explanation: 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. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 700.
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? hemorrhage catheter-related bloodstream infections air embolism pneumothorax
catheter-related bloodstream infections Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 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. rhythm. volume. quality.
deficit. Explanation: 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. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 688.
Which area of the heart is located at the third intercostal (IC) space to the left of the sternum? aortic area pulmonic area erb point epigastric area
erb point Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 689.
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 ventricular hypertrophy pulmonary edema myocardial infarction
heart failure Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 695.
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 pectoris panic attack dissecting aorta
pericarditis Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Table 25-2 Assessing Chest Pain, p. 681.
A nurse is assessing a client with heart failure. When assessing hepatojugular reflux, what is the appropriate action for the nurse to take? elevate the client's head to 90 degrees. press the right upper abdomen. press the left upper abdomen. lay the client flat in bed.
press the right upper abdomen. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Abdomen, p. 693.
During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure? wheezes with wet lung sounds stridor high-pitched sounds laborious breathing
wheezes with wet lung sounds Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Lungs, p. 692.
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." "A woman's resting heart rate is lower than a man's." "It takes longer for an electrical impulse to travel from the sinoatrial node to the atrioventricular node in a woman." "The stroke volume from a woman's heart is lower than from a man's heart."
"A woman's heart is smaller and has smaller arteries that become occluded more easily." Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Gender Considerations, p. 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 allergic to shellfish?" "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?" Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Cardiac Catheterization, p. 702.
Your client is being prepared for echocardiography when they ask you why they need to have this test. What would be your best response? "This test will find any congenital heart defects." "This test can tell us a lot about your heart." "Echocardiography is a way of determining the functioning of the left ventricle of your heart." "Echocardiography will tell your doctor if you have cancer of the heart."
"Echocardiography is a way of determining the functioning of the left ventricle of your heart." Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Echocardiography, p. 702.
While being prepared for echocardiography, the client asks nurse why this test is necessary. What would be the nurse's best response? "This test will find any congenital heart defects." "This test can tell us a lot about your heart." "Echocardiography is a way of determining the functioning of the left ventricle of your heart." "Echocardiography will tell your doctor if you have cancer of the heart."
"Echocardiography is a way of determining the functioning of the left ventricle of your heart." Explanation: 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. Explaining the procedure is the best answer because it addresses the client's question without making the client anxious or minimizing the question. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Echocardiography, p. 702.
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." "I'll likely be able to take my regular medications before the test." "I won't smoke for 2 to 3 hours before the test." "I'll have to sign a consent form before the test."
"I won't eat or drink anything after midnight tonight." Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Nursing Interventions, p. 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 on the right side of the heart." "The aortic valve is located near the base of the heart on the right side."
"The aortic arch causes the closure of the aortic valve to be heard best on the right side of the sternum." Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Effect of Heart Rate on Cardiac Output, p. 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? 0 mmHg 2 mmHg 6 mmHg 8 mmHg
8 mmHg Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Effect of Heart Rate on Cardiac Output, p. 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 48-year-old policemen with history of knee replacement 4 years ago A 68-year-old housewife with history of osteoporosis 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 Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Pharmacologic Stress Testing, p. 699.
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 An unchanged systolic pressure An increase of 10 mm Hg blood pressure reading An increase of 5 mm Hg in diastolic pressure
A heart rate of more than 20 bpm above the resting rate Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Postural (Orthostatic) Blood Pressure Changes, p. 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 8 lbs A weight gain of 10 lbs
A weight gain of 10 lbs Explanation: 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). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Right-Sided Heart Failure, p. 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? Apricots, dried peas and beans, dates Asparagus, blueberries, green beans Cranberries, apples, popcorn Bok choy, cooked leeks, alfalfa sprouts
Apricots, dried peas and beans, dates Explanation: Apricots, dried peas and beans, dates, and kiwi contain high amounts of potassium. The other foods listed contain minimal amounts. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Table 25-4 Common Serum Laboratory Tests and Implications for Patients With Cardiovascular Disease, p. 694.
A nurse is preparing a client for cardiac catheterization. The nurse knows that which nursing intervention must be provided when the client returns to the room after the procedure? Withhold analgesics for at least 6 hours after the procedure. Assess the puncture site frequently for hematoma formation or bleeding. Inform the client that he or she may experience numbness or pain in the leg. Restrict fluids for 6 hours after the procedure.
Assess the puncture site frequently for hematoma formation or bleeding. Explanation: Because the diameter of the catheter used for cardiac catheterization is large, the puncture site must be checked frequently for hematoma formation and bleeding. The nurse should administer analgesics as ordered and needed. If the femoral artery was accessed during the procedure, the client should be instructed to report any leg pain or numbness, which may indicate arterial insufficiency. Fluids should be encouraged to eliminate dye from the client's system. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Nursing Interventions, p. 704.
A patient had a cardiac catheterization and is now in the recovery area. What nursing interventions should be included in the plan of care? (Select all that apply.) Assessing the peripheral pulses in the affected extremity Checking the insertion site for hematoma formation Evaluating temperature and color in the affected extremity Assisting the patient to the bathroom after the procedure Assessing vital signs every 8 hours
Assessing the peripheral pulses in the affected extremity Checking the insertion site for hematoma formation Evaluating temperature and color in the affected extremity Explanation: The nurse should observe the catheter access site for bleeding or hematoma formation and assess peripheral pulses in the affected extremity (dorsalis pedis and posterior tibial pulses in the lower extremity, radial pulse in the upper extremity) every 15 minutes for 1 hour, every 30 minutes for 1 hour, and hourly for 4 hours or until discharge. Blood pressure and heart rate should also be assessed during these same time intervals, not every 8 hours. The nurse should evaluate temperature, color, and capillary refill of the affected extremity during these same time intervals. The patient should maintain bed rest for 2 to 6 hours after the procedure. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Nursing Interventions, p. 704.
A client is being discharged after having a cardiac catheterization through the femoral artery. Which teaching will the nurse provide for the client to perform self-care at home? Select all that apply. Avoid showering and take tub baths for the first two weeks. Avoid bending at the waist for at least the first 24 hours. Notify the health care provider if new bruising occurs at the site. Call 911 if there is a large amount of bleeding from the access site. Apply pressure to the site for 10 minutes if it begins to bleed.
Avoid bending at the waist for at least the first 24 hours. Notify the health care provider if new bruising occurs at the site. Call 911 if there is a large amount of bleeding from the access site. Apply pressure to the site for 10 minutes if it begins to bleed. Explanation: After discharge from the hospital for cardiac catheterization, the client should follow specific instructions for self-care. These instructions include avoiding tub baths since the puncture site should not be submerged in water. Bending at the waist should be avoided for 24 hours. The health care provider should be notified if any bruising occurs at the puncture site since this could indicate bleeding or hematoma formation. The client should call 911 if there is a large amount of bleeding from the access site and apply pressure to the site for 10 minutes if bleeding occurs.
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. Take a tub bath, rather than a shower. New bruising at the puncture site is normal. Bend only at the waist.
Avoid heavy lifting for the next 24 hours. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Chart 25-6, p. 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. Do not ambulate until the healthcare provider indicates it is appropriate. Expect increased bruising to appear at the site over the next several days. Returning to work immediately is okay.
Avoid tub baths, but shower as desired. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Chart 25-6 Patient Education, p. 705.
The nurse is assessing an older adult's cardiovascular system. Which assessment finding indicates to the nurse that the client is experiencing age-related changes to the conduction system? Select all that apply. Murmur Bradycardia Presence of an S4 Exercise intolerance Point of maximum impulse displaced to the left
Bradycardia Exercise intolerance Explanation: An age-related change to the conduction system of the cardiovascular system includes bradycardia. This is caused by a slower sinoatrial node rate of impulse discharge that slows conduction across the atrioventricular node and ventricular conductive system. Bradycardia can contribute to exercise intolerance, so this is also a potential sign of age-related change to the conduction system. Changes to the cardiac valves causes abnormal blood flow across the valves which may lead to the development of murmurs. Age-related changes to the left ventricle, not the conduction system, can cause the development of an S4 and displacement of the point of maximum impulse to the left.
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? Congenital heart disease. Blood leaking outside the blood vessels. Intermittent arteriolar vasoconstriction. Peripheral vasoconstriction.
Congenital heart disease. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Table 25-3 Common Assessment Findings Associated With Cardiovascular Disease, p. 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? Document findings and check the client again in 1 hour. Slow the I.V. fluid to prevent any more swelling at the puncture site. Contact the health care provider and report the findings. Encourage the client to perform isometric leg exercise to improve circulation in the legs.
Contact the health care provider and report the findings. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Assessment of the Skin and Extremities, p. 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 mostappropriate action for the nurse to take? Document findings and check the client again in 1 hour. Slow the I.V. fluid to prevent any more swelling at the puncture site. Contact the health care provider and report the findings. Encourage the client to perform isometric leg exercise to improve circulation in the legs.
Contact the health care provider and report the findings. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Assessment of the Skin and Extremities, p. 686.
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 radial pulse for 20 to 25 seconds. Calculate the palpated volume. Count the heart rate at the apex. Calculate the pauses between pulsations.
Count the heart rate at the apex. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Pulse Rhythm, p. 688.
A cardiac patient with a magnesium lab result of 2.5 mEq/L would most likely evidence which of the following? Atrial tachycardia Ventricular arrhythmias Depressed myocardial contractility Increased cardiac excitability.
Depressed myocardial contractility Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Table 25-4 Common Serum Laboratory Tests and Implications for Patients With Cardiovascular Disease, p. 694.
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 Cardiac output Activity level Dyspnea
Digoxin level Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Gerontologic Considerations, p. 678.
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? Thallium Ativan Diazepam Dobutamine
Dobutamine Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Pharmacologic Stress Testing, p. 699.
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 Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Types of Dysrhythmias, p. 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. Echocardiogram Cardiac catheterization Magnetic resonance imaging Positron emission tomography scan Troponin levels
Echocardiogram Cardiac catheterization Magnetic resonance imaging Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Effect of Stroke Volume on Cardiac Output, p. 678.
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 Platelets Enzymes WBC
Enzymes Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Cardiac Biomarker Analysis, p. 693.
Which area of the heart that is located at the third intercostal space to the left of the sternum? aortic area pulmonic area Erb point epigastric area
Erb point Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 689.
The nurse is assessing an older adult client's electrocardiogram (ECG). What age related change to the conduction system may the nurse observe? Heart block Murmur Thrills Tachycardia
Heart block Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Table 25-1 Age-Related Changes of the Cardiac System, p. 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 Hypertensive heart disease Normal functioning Pericarditis
Heart failure Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Abnormal Heart Sounds, p. 690.
A client is admitted to the hospital with weakness. What nursing assessment indicates postural hypotension? Heart rate increased from 85 to 110 bpm. Systolic pressure did not change with the change in position. Diastolic pressure went from 80 to 110 mm Hg. 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. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Postural (Orthostatic) Blood Pressure Changes, p. 687.
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? Do you have any children? How did your mother die?
How would you describe your symptoms? Are you allergic to any medications or foods? How did your mother die? Explanation: 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. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 679.
In which client does the nurse consider the presence of an S3 heart sound to be normal? In a client who is in elementary school In older adult clients In a client with an indwelling pacemaker In a client who is diagnosed with heart failure
In a client who is in elementary school Explanation: A heart sound that follows S1 and S2 is called an S3 heart sound, or a ventricular gallop. Although an abnormal finding for many clients, this finding is considered normal in many pediatric clients, including a school-age client. In adults, the presence of S3 may signify heart failure, so this is not considered normal. Additionally, S3 is not considered normal for older adult clients nor for a client who has an indwelling pacemaker. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, S3--Third Heart Sound, p. 691.
The nurse provides care for a client who is diagnosed with an infarction of the posterior wall of the right atrium. Which clinical finding should the nurse anticipate relating to the infarction location? Jugular vein distention Peripheral edema Irregular heart rate Fever
Irregular heart rate Explanation: 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. Jugular vein distension and peripheral edema are anticipated for the client who is experiencing heart failure, not myocardial infarction (MI). Although fever can increase the client's heart rate, this is not an expected finding with an MI. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Normal Sinus Rhythm, p. 718.
The nurse provides care for a client who is diagnosed with an infarction of the posterior wall of the right atrium. Which clinicalfinding should the nurse anticipate relating to the infarction location? Jugular vein distention Peripheral edema Irregular heart rate Fever
Irregular heart rate Explanation: 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. Jugular vein distension and peripheral edema are anticipated for the client who is experiencing heart failure, not myocardial infarction (MI). Although fever can increase the client's heart rate, this is not an expected finding with an MI. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Normal Sinus Rhythm, p. 718.
A nurse is performing a cardiac assessment on an elderly client. Which finding warrants further investigation? Fourth heart sound (S4) Increased PR interval Orthostatic hypotension Irregularly irregular heart rate
Irregularly irregular heart rate Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Gerontologic Considerations, p. 693.
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: Easily heard with no palpable thrill. Quiet but readily heard. Loud and may be associated with a thrill sound similar to (a purring cat). Very loud; can be heard with the stethoscope half-way off the chest.
Loud and may be associated with a thrill sound similar to (a purring cat). Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Chart 25-3 Characteristics of Heart Murmurs, p. 692.
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 2nd intercostal space at the midclavicular line Right 2nd intercostal space at the midclavicular line Right 3rd intercostal space at the midclavicular line Left 5th intercostal space at the midclavicular line
Left 5th intercostal space at the midclavicular line Explanation: 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). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Heart Inspection and Palpation, p. 689.
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 Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Computed Tomography, p. 701.
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? Digoxin Dopamine Dobutamine Metoprolol
Metoprolol Explanation: Contractility is depressed by beta-adrenergic blocking medications. The other choices all enhance contractility. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Effect of Stroke Volume on Cardiac Output, p. 678.
Which assessments should a nurse perform when caring for a client following a cardiac catheterization? Select all that apply. Monitor BP and pulse frequently. Inspect pressure dressing for signs of bleeding. Palpate the pulse in different locations. Inspect the color in every extremity. Palpate the insertion site for tenderness.
Monitor BP and pulse frequently. Inspect pressure dressing for signs of bleeding. Palpate the pulse in different locations. Explanation: 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. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 703.
The nurse is assessing a patient's electrocardiogram (ECG). What phase does the nurse determine is the resting phase before the next depolarization? Phase 1 Phase 2 Phase 3 Phase 4
Phase 4 Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Cardiac Action Potential, p. 676.
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 A pulmonary embolism Right-sided heart failure A stroke
Myocardial ischemia Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Coronary Arteries, p. 675.
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? Fluoroscopy Nuclear cardiology Serum blood work Chest radiography
Nuclear cardiology Explanation: 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 tissue damage. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Radionuclide Imaging, p. 700.
The nurse measures the pulmonary artery wedge pressure in a client with left ventricular dysfunction. Which action will the nurse take after deflating the balloon tip following pressure measurement? Lower the head of the client's bed to be at 25 degrees. Measure the client's blood pressure on both of the client's arms. Ensure the transducer is positioned at the phlebostatic axis. Observe for return of the pulmonary artery systolic and diastolic waveforms.
Observe for return of the pulmonary artery systolic and diastolic waveforms. Explanation: Pulmonary artery pressure monitoring is used in critical care for assessing left ventricular function, diagnosing the etiology of shock, and evaluating the client's response to medical interventions. After measuring the pulmonary artery wedge pressure, the nurse ensures that the balloon is deflated and that the catheter has returned to its normal position. This intervention is verified by evaluating the return of the pulmonary artery systolic and diastolic waveform displayed on the bedside monitor. The head of the bed does not need to be lowered nor does the blood pressure need to be measured on both arms after measuring the pulmonary artery wedge pressure. The transducer must be positioned at the phlebostatic axis before the measurement is taken to ensure an accurate reading.
You are working on a telemetry unit. Your client was admitted with a cardiac event and is now on a cardiac monitor. You know a cardiac monitor reveals the heart's electrical but not its mechanical activity. How would you assess the mechanical activity of the client's heart? Take the blood pressure in both arms. Palpate a peripheral pulse. Auscultate the carotid artery. Percuss the perimeter of the heart.
Palpate a peripheral pulse. Explanation: A cardiac monitor reveals the heart's electrical but not its mechanical activity. The healthcare provider must palpate a peripheral pulse or auscultate the apical heart rate to obtain this information. You cannot obtain information on the mechanical activity of the heart by taking the client's blood pressure, auscultating the carotid artery, or attempting to percuss the perimeter of the heart. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Pulse Rate, p. 688.
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 0 Phase 1 Phase 2 Phase 3
Phase 0 Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Refractory Periods, p. 677.
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 Auscultatory gap Pulse deficit Korotkoff sound
Pulse pressure Explanation: The difference between the systolic and the diastolic pressures is called the pulse pressure. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Pulse Pressure, p. 687.
A client with cardiovascular disease is scheduled for transesophageal echocardiography (TEE). Which information in the health history increases the client's risk of developing a complication from the procedure? Follows a low-sodium diet Stopped smoking 5 years ago Radiation to the chest 4 years ago Takes metoprolol orally each day
Radiation to the chest 4 years ago Explanation: Transesophageal echocardiography (TEE) provides clearer images than those produced through a transthoracic echocardiogram because ultrasound waves pass through less tissue. During a TEE, a transducer is inserted into the mouth and the client is asked to swallow several times until it is positioned in the esophagus. Complications are uncommon during TEE however if they do occur, they can be severe and are caused by sedation and impaired swallowing. The client must be assessed before the TEE for a history of dysphagia or radiation therapy to the chest which increases the likelihood of complications. A low-sodium diet, smoking cessation, and beta blockers do not increase the risk of complications after a TEE.
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. Sedate the client prior to the procedure. Position the client on the stomach for the procedure. Remove the client's jewelry. 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. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 702. Chapter 25: Assessment of Cardiovascular Function - Page 702
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 atrium Pulmonary artery Right ventricle Aorta
Right ventricle Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Heart Chambers, p. 673.
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 Hypovolemia Left-sided heart failure Reduction in preload
Right-sided heart failure Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Central Venous Pressure Monitoring, p. 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 Effort to lie down to breathe Right-sided heart failure Blood congestion in neck veins
Right-sided heart failure Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Left-Sided Heart Failure, p. 822.
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 Effort to lie down to breathe Right-sided heart failure Blood congestion in neck veins
Right-sided heart failure Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Left-Sided Heart Failure, p. 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? S1 S2 S3 S4
S3 Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, S 3 —Third Heart Sound, p. 691.
The nurse observes a client during an exercise stress test (bicycle). Which finding indicates a positive test and the need for further diagnostic testing? Dizziness and leg cramping BP changes; 148/80 mm Hg to 166/90 mm Hg ST-segment changes on the ECG Heart rate changes; 78 bpm to 112 bpm
ST-segment changes on the ECG Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 699.
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: An excess level of thyroid hormone. Stimulation of the vagus nerve. An increased level of catecholamines. Sympathetic nervous system stimulation.
Stimulation of the vagus nerve. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Effect of Heart Rate on Cardiac Output, p. 677.
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 client's CV diagnosis. The client and family understands the need for medication. The client and family understands the need to restrict activity for 72 hours. The client and family understands the discharge instructions.
The client and family understands the discharge instructions. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Nursing Interventions, p. 705.
x 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 client's CV diagnosis. The client and family understands the need for medication. The client and family understands the need to restrict activity for 72 hours. The client and family understands the discharge instructions.
The client and family understands the discharge instructions. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Nursing Interventions, p. 705.
The nurse notes that a client has an elevated homocysteine level. For which reason will the nurse suggest that the blood test be repeated? The client follows a lacto-ovo-vegetarian diet. The client ate breakfast before the test. The client takes medication for type 2 diabetes. The client was treated for heart failure two months ago.
The client ate breakfast before the test. Explanation: Homocysteine, an amino acid, is linked to the development of atherosclerosis because it can damage the endothelial lining of arteries and promote thrombus formation. Therefore, an elevated blood level of homocysteine is thought to indicate a high risk for CAD. A 12-hour fast is necessary before drawing a blood sample for an accurate serum measurement. Since the client ate breakfast before the test, it should be repeated to obtain an accurate level. A diet low in folate, vitamin B6, and vitamin B12 are associated with elevated homocysteine levels however there is no evidence that a lacto-ovo-vegetarian diet causes these vitamin deficiencies. Medication for type 2 diabetes and treatment for heart failure months ago are not identified as impacting the homocysteine level.
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? Mitral valve Tricuspid valve Aortic valve Pulmonic valve
Tricuspid valve Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Abnormal Heart Sounds, p. 690.
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 Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, S4 —Fourth Heart Sound, p. 691.
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 Weak pulse Thready pulse A pulse deficit
Thready pulse Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Acute Coronary Syndrome and Myocardial Infarction, p. 762.
A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often at rest in the absence of precipitating factors. How would the nurse best describe this type of anginal pain? Stable angina Variant angina Unstable angina Nonanginal pain
Variant angina
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. You will need to wear comfortable shoes to the test. You will begin exercising at a slow speed. You may experience an onset of dizziness during the test.
You will receive medication via IV administration. Explanation: 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. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 700.
The nurse is teaching a client about the functionality of heart muscle. What factor may decrease a client's myocardial contractility? acidosis alkalosis sympathetic activity administration of digoxin
acidosis Explanation: Contractility is depressed by hypoxemia, acidosis, and certain medications, such as beta-adrenergic blocking medications. Contractility is enhanced by sympathetic neuronal activity and specific medications like digoxin. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Effect of Stroke Volume on Cardiac Output, p. 678.
Which term describes the ability of the heart to initiate an electrical impulse? automaticity contractility conductivity excitability
automaticity Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 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 telemetry monitoring transesophageal echocardiogram pharmacologic stress test
cardiac catheterization Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Exercise Stress Testing, p. 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? hemorrhage catheter-related bloodstream infections air embolism pneumothorax
catheter-related bloodstream infections Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 706.
Age-related changes associated with the cardiac system include decreased size of the left atrium. endocardial fibrosis. increase in the number of SA node cells. myocardial thinning.
endocardial fibrosis. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Table 25-1, p. 679.
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. rhythm. volume. quality.
deficit. Explanation: 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. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 688.
The nurse is preparing a client for transesophageal echocardiography (TEE). This procedure is used for which indication? determination of atrial thrombi determination of electrical activity of the heart evaluation of the response of the cardiovascular system to increased oxygen demands evaluation of myocardial perfusion at rest and after exercise
determination of atrial thrombi Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Transesophageal Echocardiography, p. 702.
Which area of the heart is located at the third intercostal (IC) space to the left of the sternum? aortic area pulmonic area erb point epigastric area
erb point Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 689.
Which symptom is an early warning sign of acute coronary syndrome (ACS) and heart failure (HF)? hypotension fatigue change in level of consciousness weight gain
fatigue Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 680.
A client with a history of right-sided heart failure lives in a long-term care facility. In the daily assessment, the nurse is required to record the level of this client's peripheral edema. Which would be the main area for examination? feet and ankles over the sacrum lips and earlobes knees and elbows
feet and ankles Explanation: Edema occurs when blood is not pumped efficiently or plasma protein levels are inadequate to maintain osmotic pressure. When blood has nowhere else to go, the extra fluid enters the tissues. Particular areas for examination are the dependent parts of the body, such as the feet and ankles. The area over, not below, the sacrum is another area prone to edema. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 686.
What is a harsh grating sound caused by abrasion of the pericardial surfaces during the cardiac cycle? murmur opening snap ejection click friction rub
friction rub Explanation: During pericarditis, a harsh, grating sound that can be heard in both systole and diastole is called a friction rub. A murmur is created by the turbulent flow of blood. A cause of the turbulence may be a critically narrowed valve. An opening snap is caused by high pressure in the left atrium with abrupt displacement of a rigid mitral valve. An ejection click is caused by very high pressure within the ventricle, displacing a rigid and calcified aortic valve. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 691.
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 ventricular hypertrophy pulmonary edema myocardial infarction
heart failure Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 695.
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? congenital heart disease heart failure aortic stenosis coronary artery disease
heart failure Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Abnormal Heart Sounds, p. 690.
The nurse is explaining vasovagal syncope to a client. What does the nurse associate the temporary loss of consciousness with for the client? vertigo increase fluid intake blood pressure 190/50 standing heart rate 48
heart rate 48 Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Nursing Interventions, p. 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 myocardial infarction, fluid overload, and diuresis fluid overload, sepsis, and vasodilation third spacing, heart failure, and diuresis
hemorrhage, sepsis, and anaphylaxis Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Effect of Stroke Volume on Cardiac Output, pp. 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 heart failure pericarditis diseased heart valves
hypertensive heart disease Explanation: 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. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 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? heart failure hypertensive heart disease turbulent blood flow diseased heart valves
hypertensive heart disease Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, S4--Fourth Heart Sound, p. 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? hypervolemia excessive blood loss overdiuresis left-sided heart failure
hypervolemia Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 706.
Age-related changes associated with the cardiac system include which conditions? Select all that apply. increased size of the left atrium endocardial fibrosis increase in the number of SA node cells myocardial thinning
increased size of the left atrium endocardial fibrosis Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Table 25-1, p. 679.
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) partial thromboplastic time (PTT) complete blood count (CBC) Sodium
international normalized ratio (INR) Explanation: 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 left ventricle right atrium right ventricle
left atrium Explanation: 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. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 673.
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 positioning the client supine for 10 minutes prior to taking the initial BP and HR taking the client's BP with the client sitting on the edge of the bed, feet dangling obtaining the supine measurements prior to the sitting and standing measurements
letting 30 seconds elapse after each position change before measuring BP and HR Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Chart 25-2, p. 687.
The physician orders medication to treat a client's cardiac ischemia. What is causing the client's condition? reduced blood supply to the heart pain on exertion high blood pressure indigestion
reduced blood supply to the heart Explanation: Ischemia is reduced blood supply to body organs. Cardiac ischemia is caused by reduced blood supply to the heart muscle. It may lead to a myocardial infarction. Chest pain is a symptom of ischemia. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 675.
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 pectoris panic attack dissecting aorta
pericarditis Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Table 25-2 Assessing Chest Pain, p. 681.
A nurse is assessing a client with heart failure. When assessing hepatojugular reflux, what is the appropriate action for the nurse to take? elevate the client's head to 90 degrees. press the right upper abdomen. press the left upper abdomen. lay the client flat in bed.
press the right upper abdomen. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Abdomen, p. 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 central venous pressure. pulmonary artery pressure. pulmonary artery wedge pressure. cardiac output.
pulmonary artery wedge pressure. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 709.
Central venous pressure is measured in which heart chamber? right atrium left atrium left ventricle right ventricle
right atrium Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 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 left ventricle right atrium left atrium
right ventricle Explanation: 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. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 673.
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 3.9 mEq/L calcium 9.8 mg/dL magnesium 2.5 mg/dL
sodium 148 mEq/L Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Table 25-4 Common Serum Laboratory Tests and Implications for Patients With Cardiovascular Disease, p. 694.
Which term describes the amount of blood ejected per heartbeat? cardiac output ejection fraction stroke volume afterload
stroke volume Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 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? transesophageal echocardiography chest radiograph radionuclide angiography electrocardiography
transesophageal echocardiography Explanation: 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. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 25: Assessment of Cardiovascular Function, p. 702.
