Chapter 21 assessment of cardiovascular function NCLEX Questions

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? a. "When was the last time you ate or drank?" b. "Are you allergic to shellfish?" c. "What was your morning blood sugar reading?" d. "Are you having chest pain?"

"b. Are you allergic to shellfish?" Rationale: 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.

The nurse is calculating a cardiac client's pressure. if the client's blood pressure is 122/76, what is the clients pulse pressure? a. 46 mm Hg b. 99 mm Hg c. 198 mm Hg d. 76 mm Hg

a. 46 mm Hg Rationale: Pulse pressure is the difference between the systole and diastolic pressure.

Age-related changes associated with the cardiac system include: a. endocardial fibrosis. b. myocardial thinning. c. increase in the number of SA node cells. d. decreased size of the left atrium.

a. endocardial fibrosis. Rationale: 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.

A client has had a myocardial infraction and has been diagnosed as having damage to the layer of the heart responsible for the pumping action. this client experienced damage to which area of the heart? a. endocardium b. pericardium c. myocardium d. visceral pericardium

c. myocardium Rationale: The middle layer of the heart, or myocardium, is made up of muscle fibers and is responsible for the pumping action.

During the auscultation of heart, what is revealed by an atrial gallop? a. turbulent blood flow b. heart failure c. diseased heart valves d. hypertensive heart disease

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

The nurse cares for a client prescribed warfarin orally. The nurse reviews the client's prothrombin time (PT) level to evaluate the effectiveness of the medication. Which laboratory values should the nurse also evaluate? a. Sodium b. partial thromboplastic time (PTT) c. complete blood count (CBC) d. international normalized ratio (INR)

d. international normalized ratio (INR) Rationale: 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.

The nurse is caring for a client who is undergoing an exercise stress test. prior to reaching the target heart rate, the client develops chest pain. what is the nurse's most appropriate response? a. administer sublingual nitroglycerin to allow the client to finish the test. b. initiate cardiopulmonary resuscitation. c. administer analgesia and slow the test d. stop the test and monitor the client closely

d. stop the test and monitor the client closely. Rationale: The client is may experience signs of myocardial ischemia would necessitate stopping the test.

A client is admitted to a cardiac unit with the diagnosis of syncope. orthostatic blood pressures are ordered every 8 hours. which blood pressure readings would best indicate that the nurse should notify the health care provider of a positive finding? a. supine 146/70, sitting 132/68, standing 130/66 b. supine 110/62, sitting 108/58, standing 106/56 c. supine 128/72, sitting 118/70, standing 110/66 d. supine 138/76, sitting 132/66, standing 122/52

d. supine 138/76, sitting 132/66, standing 122/52 Rationale: Postural orthostatic hypotension is a significant drop in blood pressure (systolic: 20mm Hg Diastolic: 10 mm Hg) with in 3 minutes of moving from lying or sitting to a standing position to indicate a positive result.

The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include? a. "Contact your primary care provider if you develop a temperature above 102°F." b. "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." c. "If any discharge occurs at the puncture site, call 911 immediately." d. "You can take a tub bath or a shower when you get home.

"b. Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." Rationale: The nurse should instruct the client to follow these guidelines: For the next 24 hours, do not bend at the waist, strain, or lift heavy objects if the artery of the groin was used; contact the primary provider if swelling, new bruising or pain from the procedure puncture site, or a temperature of 101°F or more occur. If bleeding occurs, lie down (groin approach) and apply firm pressure to the puncture site for 10 minutes. Notify the primary provider as soon as possible and follow instructions. If there is a large amount of bleeding, call 911. The client should not drive to the hospital.

The nurse is conducting client teaching about cholesterol levels. when discussing the client's elevated LDL and lower HDL levels, the client shows an understanding of the significance of these levels by making what statement? a. increased LDL and decreased HDL increase the risk of coronary artery disease. b. increased LDL has the potential to decrease my risk of heart disease. c. the decreased HDL level will increase the amount of cholesterol moved away from the artery wall d. the increased LDL will decrease the amount of cholesterol deposited on the artery walls."

a. Increased LDL and decreased HDL increase the risk of coronary artery disease. Rationale: Elevated LDL levels and decreased HDL levels are associated with a greater incidence of coronary artery disease.

The nurse observes a client during an exercise stress test (bicycle). Which finding indicates a positive test and the need for further diagnostic testing? a. ST-segment changes on the ECG b. BP changes; 148/80 mm Hg to 166/90 mm Hg c. Dizziness and leg cramping d. Heart rate changes; 78 bpm to 112 bpm

a. ST-segment changes on the ECG Rationale: 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.

The nurse working on a cardiac care unit is caring for a client whose stroke volume has increased. the nurse is aware that afterload influences a client's stroke volume. the nurse recognizes that which factor increases afterload? a. arterial vasoconstriction b. venous vasoconstriction c. arterial vasodilation d. venous vasodilation

a. arterial vasoconstriction Rationale: Afterload, or resistance to ejection of blood from the ventricle, is one determinant of stroke volume. there is a inverse relationship between afterload and stroke volume. Arterial vasoconstriction increases afterload, which leads to decreased stroke volume

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? a. hypervolemia b. overdiuresis c. excessive blood loss d. left-sided heart failure

a. hypervolemia Rationale: 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.

A client has been admitted to the intensive care unit (ICU) after an ischemic stroke, and a central venous pressure (CVP) monitoring line was placed. the nurse notes a low CVP. which condition is the most likely reason for a low CVP? a. hypovolemia b. myocardial infraction c. left side heart failure d. aortic valve regurgitation

a. hypovolemia Rationale: CVP is a measurement of the pressure in the vena cava or right atrium. a low CVP indicates a reduces right ventricular preload, most often from hypovolemia.

The nurse auscultates the PMI (point of maximal impulse) at which anatomic location? a. left midclavicular line, fifth intercostal space b. 3 cm to the right of the sternum c. 2.5 cm to the left of the xiphoid process d. 5 cm to the left of the lower end of the sternum

a. left midclavicular line, fifth intercostal space. Rationale: The left ventricle is responsible for the apical impulse or the point of maximum impulse, which is normally palpable in the left midclavicular line of the chest wall at the fifth intercostal space. The right ventricle lies anteriorly, just beneath the sternum. Use of inches to identify the location of the PMI is inappropriate based on variations in human anatomy. Auscultation below and to the left of the xiphoid process will detect gastrointestinal sounds, but not the PMI.

What does decreased pulse pressure reflect? a. reduced stroke volume b. reduced distensibility of the arteries c. elevated stroke volume d. tachycardia

a. reduced stroke volume Rationale: Decreased pulse pressure reflects reduced stroke volume and ejection velocity or obstruction to blood flow during systole. Increased pulse pressure would indicate reduced distensibility of the arteries, along with bradycardia.

A nurse is describing the process by which blood is ejected into circulation as the chamber of the heart become smaller. the instructor categorizes this as what action? a. systole b. diastole c. repolarization d. ejection fraction

a. systole Rationale: Systole is the action of the chamber of the heart becoming smaller and ejecting blood.

A client with complex cardiac history is scheduled for a transthoracic echocardiography. what should the nurse teach the client in anticipation of his diagnostic procedure? a. test is noninvasive, and nothing will be inserted into the client's body. b. the client's pain will be managed aggressively during the procedure c. the test will provide a detailed profile of the heart's electrical activity. d. the client will remain on bed rest for 1-2 hours after the test.

a. test is noninvasive, and nothing will be inserted into the client's body. Rationale: before transthoracic echocardiography, the nurse informs the client about the test, explaining that it is painless.

The nurse is caring for a client admitted with angina who is scheduled for cardiac catheterization. the client is anxious and asks the reason for this test. the nurse should explain that cardiac catheterization is most commonly done for which purpose? a. to assess how blocked or open a client's coronary arteries are b. to detect how efficiently a client's heart muscles contracts c. to evaluate cardiovascular response to stress d. to evaluate the cardiac electrical activity

a. to assess how blocked or open a client's coronary arteries are. Rationale: Cardiac catheterization is usually use to assess coronary patency to determine whether revascularization procedures are necessary.

The critical care nurse is caring for a client with a pulmonary artery pressure monitoring system. in addition to assessing left ventricular function, what is an additional function of a pulmonary artery pressure monitoring system? a. to assess the client's response to fluid and drug administration b. to obtain specimens for arterial blood gas measurements c. to dislodge pulmonary emboli d. to diagnose the etiology of chronic obstructive pulmonary disease

a. to assess the client's response to fluid and drug administration. Rationale: pulmonary artery pressure monitoring is an important tool used in critical care for assessing left ventricular function (cardiac output), diagnosing the etiology of shock, and evaluating the client's response to medical interventions, such as fluid administration and vasoactive medication.

Which area of the heart that is located at the third intercostal space to the left of the sternum? a. aortic area b. Erb point c. pulmonic area d. epigastric area

b. Erb point (2nd pulmonic area) Rationale: Erb point is located at the third intercostal space to the left of the sternum. The aortic area is located at the second intercostal space to the right of the sternum. The pulmonic area is at the second intercostal space to the left of the sternum. The epigastric area is located below the xiphoid process.

The nurse cares for a client with clubbing of the fingers and toes. The nurse should complete which action given these findings? a. Obtain an oxygen saturation level. b. Obtain a 12-lead ECG tracing. c. Assess the client's capillary refill. d. Assess the client for pitting edema.

b. Obtain an oxygen saturation level. Rationale: Clubbing of the fingers and toes indicates chronic hemoglobin desaturation (decreased oxygen supply) and is associated with congenital heart disease. The nurse should assess the client's O2 saturation level and intervene as directed. The other assessments are not indicated.

The nurse 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. a. Sedate the client prior to the procedure. b. Remove the client's Transderm Nitro patch. c. Offer the client a headset to listen to music during the procedure. d. Remove the client's jewelry. e. Position the client on the stomach for the procedure.

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

The nurse uses which term for the normal pacemaker of the heart? a. Atrioventricular (AV) node b. Sinoatrial (SA) node c. Purkinje fibers d. Bundle of His

b. Sinoatrial (SA) node Rationale: The sinoatrial node is the primary pacemaker of the heart. The AV node coordinates the incoming electrical impulses from the atria and, after a slight delay, relays the impulse to the ventricles. The Purkinje fibers rapidly conduct the impulses through the thick walls of the ventricles

While auscultating a client's heart sounds, the nurse hears an extra heart sound immediately after the second heart sound (S2). an audible S3 would be considered an expected finding in which client? a. a 47 yr old client b. a 20 yr old client c. a client who has undergone valve replacement D. a client who takes a beta-adrenergic blocker

b. a 20 yr old client Rationale: S3 represents a normal finding in children and adults up to 35 or 40 years of age. it is called a physiologic S3.

The nurse is caring for a client who has a history of heart disease. what factor should the nurse identify as possibly contributing to a decrease in cardiac output? a. a change in position from standing to sitting b. a heart rate of 54 bpm c. a pulse oximetry reading of 94% d. an increase in preload related to ambulation

b. a heart rate of 54 BPM Rationale: Cardiac output is computed by multiplying the stroke volume by the heart rate. cardiac output can be affected by changes in either stroke volume or heart rate, such as a rate of 54 bpm.

For a client who has undergone peripheral arteriography, how should the nurse assess the adequacy of peripheral circulation? a. checking for cardiac dysrhythmias b. checking peripheral pulses c. observing the client for bleeding d. hemodynamic monitoring

b. checking peripheral pulses Rationale: Peripheral arteriography is used to diagnose occlusive arterial disease in smaller arteries. The nurse observes the client for bleeding and cardiac dysrhythmias and assesses the adequacy of peripheral circulation by frequently checking the peripheral pulses. Hemodynamic monitoring is used to assess the volume and pressure of blood in the heart and vascular system.

What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse? a. repolarization b. contractility c. diastole d. depolarization

b. contractility Rationale: Contractility is the ability of the cardiac muscle to shorten in response to an electrical impulse. Depolarization is the electrical activation of a cell caused by the influx of sodium into the cell while potassium exits the cell. Repolarization is the return of the cell to the resting state, caused by reentry of potassium into the cell while sodium exits the cell. Diastole is the period of ventricular relaxation resulting in ventricular filling.

A client has been scheduled for cardiovascular computed tomography (CT) with contrast. to prepare the client for this test, what action should the nurse perform? a. keep the client NPO for at least 6 hours prior to the test. b. establish peripheral IV access. c. limit the client's activity for 2 hours before the test d. teach the client to perform incentive spirometry

b. establish peripheral IV access. Rationale: An IV is necessary if contrast is to be used to enhance the images of the CT.

The nurse's assessment of an older adult client reveals the following data: lying bp: 144/82 sitting: 121/69 standing: 98/56 the nurse should identify the priority nursing diagnosis of a risk for which outcome in the client's plan of care? a. ineffective breathing pattern related to hypotension b. falls related to orthostatic hypotension c. ineffective role performance related to hypotension d. imbalanced fluid balance related to hemodynamic variability

b. falls related to orthostatic hypotension. Rationale: Orthostatic hypotension creates a significant risk for falls due to the dizziness and lightheadedness that accompany it.

Which symptom is an early warning sign of acute coronary syndrome (ACS) and heart failure (HF)? a. change in level of consciousness b. fatigue c. hypotension d. weight gain

b. fatigue Rationale: Fatigue is an early warning symptom of ACS, heart failure, and valvular disease. Other signs and symptoms of cardiovascular disease are hypotension, change in level of consciousness, and weight gain.

The nurse cares for a client in the emergency department who has a B-type natriuretic peptide (BNP) level of 115 pg/mL. The nurse recognizes that this finding is most indicative of which condition? a. ventricular hypertrophy b. heart failure c. pulmonary edema d. myocardial infarction

b. heart failure Rationale: 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.

A brain (B-type) natriuretic peptide (BNP) sample has been drawn from an older adult client who has been experiencing vital fatigue and shortness of breath. this test will allow the care team to investigate the possibility of what diagnosis? a. pleurisy b. heart failure c. valve dysfunction d. cardiomyopathy

b. heart failure Rationale: The level of BNP in the blood increase as the ventricular walls expand from increasing pressure, making it a helpful diagnostic, monitoring, and prognostic tool in the setting of HF.

The critical care nurse is caring for a client with a central venous pressure CVP monitoring system. the nurse notes that the client's CVP is increasing. this may indicate: a. psychosocial stress b. hypervolemia c. dislodgment of the catheter d. hypomagnesemia

b. hypervolemia Rationale: CVP is a useful hemodynamic parameter to observe when managing an unstable client's fluid volume status. an increasing pressure may be caused by hypervolemia or by a condition, such as heart failure, that results in decreased myocardial contractility.

The health care provider has ordered a high sensitivity C-reactive protein (hs-CRP) drawn on a client. the results of this test will allow the nurse to evaluate the role of what process that is implicated in the development of atherosclerosis? a. immunosuppression b. inflammation c. infection d. hemostasis

b. inflammation Rationale: High sensitivity CRP is a protein produced by the liver in response to systemic inflammation.

During a shift assessment, the nurse is identifying the client's point of maximum impulse (PMI). Where will the nurse best palpate the PMI? a. Left midclavicular line of the chest at the level of the nipple b. Left midclavicular line of the chest at the fifth intercostal space c. Midline between the xiphoid process and the left nipple d. Two to three centimeters to the left of the sternum

b. left midclavicular line of the chest at the fifth intercostal space Rationale: The left ventricle is responsible for the apical beat or the PMI, which is normally palpated in the left midclavicular line of the chest wall at fifth intercostal space.

The physical therapist notifies the nurse that a client with coronary artery disease (CAD) experienced a significant increase in heart rate during physical therapy. the nurse recognizes that an increase in heart rate in a client with CAD may result in which outcome? a. development of an atrial-septal defect b. myocardial ischemia c. formation of a pulmonary embolism d. release of potassium ions from cardiac cells

b. myocardial ischemia Rationale: Unlike other arteries, the coronary arteries are perfused during diastole. an increase in HR shorten diastole and can decrease myocardial perfusion. clients w/CAD can develop myocardial ischemia.

The nurse correctly identifies which data as an example of blood pressure and heart rate measurements in a client with postural hypotension? a. supine: BP 140/78 mm Hg, HR 72 bpm; sitting: BP 145/78 mm Hg, HR 74 bpm; standing: BP 144/78 mm Hg, HR 74 bpm b. supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm c. supine: BP 114/82 mm Hg, HR 90 bpm; sitting: BP 110/76 mm Hg, HR 95 bpm; standing: BP 108/74 mm Hg, HR 98 bpm d. supine: BP 130/70 mm Hg, HR 80 bpm; sitting: BP 128/70 mm Hg, HR 80 bpm; standing: BP 130/68 mm Hg, HR 82 bpm

b. supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm Rationale: Postural (orthostatic) hypotension is a sustained decrease of at least 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP within 3 minutes of moving from a lying or sitting position to a standing position. The following is an example of BP and HR measurements in a client with postural hypotension: supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm. Normal postural responses that occur when a person moves from a lying to a standing position include (1) a HR increase of 5 to 20 bpm above the resting rate; (2) an unchanged systolic pressure, or a slight decrease of up to 10 mm Hg; and (3) a slight increase of 5 mm Hg in diastolic pressure.

A resident of a long-term care facility has reported chest pain to the nurse. what aspect of the resident's pain would be most suggestive of angina as the cause? a. the pain is worse when the resident inhales deeply b. the pain occurs immediately following physical exertion c. the pain is worse when the resident coughs d. the pain is most severe when the resident moves the upper body

b. the pain occurs immediately following physical exertion. Rationale: Chest pain associated with angina is often precipitated by physical exertion.

The nurse is doing discharge teaching with a client who has coronary artery disease. the client asks why they have to take an aspirin every day if they don't have any pain. which rationale for this intervention would be best? a. to help restore the normal function of the heart b. to help prevent blockages that can cause chest pain or heart attacks c. to help the blood penetrate the heart more freely d. to help the blood carry more oxygen than it would otherwise

b. to help prevent blockages that can cause chest pain or heart attacks. Rationale:

During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure? a. laborious breathing b. wheezes with wet lung sounds c. high-pitched sounds d. stridor

b. wheezes with wet lung sounds Rationale: 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.

The nurse prepares to apply ECG electrodes to a male client who requires continuous cardiac monitoring. Which action should the nurse complete to optimize skin adherence and conduction of the heart's electrical current? a. Clean the client's chest with alcohol prior to application of the electrodes. b. Once the electrodes are applied, change them every 72 hours. c. Clip the client's chest hair prior to applying the electrodes. d. Apply baby powder to the client's chest prior to placing the electrodes.

c. Clip the client's chest hair prior to applying the electrodes. Rationale: The nurse should complete the following actions when applying cardiac electrodes: (1) Clip (do not shave) hair from around the electrode site, if needed; (2) if the client is diaphoretic (sweaty), apply a small amount of benzoin to the skin, avoiding the area under the center of the electrode; (3) debride the skin surface of dead cells with soap and water and dry well (or as recommended by the manufacturer); (4) change the electrodes every 24 to 48 hours (or as recommended by the manufacturer); (5) examine the skin for irritation and apply the electrodes to different locations.

A student nurse prepares to assess a client for postural blood pressure changes. Which action indicates the student nurse needs further education? a. taking the client's BP with the client sitting on the edge of the bed, feet dangling. b. obtaining the supine measurements prior to the sitting and standing measurements. c. letting 30 seconds elapse after each position change before measuring BP and HR. d. positioning the client supine for 10 minutes prior to taking the initial BP and HR.

c. Letting 30 seconds elapse after each position change before measuring BP and HR. Rationale: 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.

The nurse is performing an intake assessment on a client with a new diagnosis of coronary artery disease. what would be the most important determination to make during this intake assessment? a. whether the client and involved family members understand the role of genetics in the etiology of the disease b. whether the client and involved family members understand dietary changes and the role of nutrition c. whether the client and involved family member are able to recognize symptoms of an acute cardiac problem and respond appropriately. d. whether the client and involved family members understand the importance of social support and community agencies.

c. Whether the client and involved family member are able to recognize symptoms of an acute cardiac problem and respond appropriately. Rationale: Involved family members are able to recognize symptoms of an acute cardiac problem, such as acute coronary syndrome (ACS) or HF, and seek timely treatment for these symptoms

A lipid profile has been ordered for a client who has been experiencing cardiac symptoms. when should the lipid profile be drawn in order to maximize the accuracy of results? a. as a close to end of the day as possible b. after a meal high in fat c. after a 12 hour fast d. thirty minutes after a normal meal

c. after a 12 fast Rationale: Although cholesterol levels remain relatively constant over 24 hours, the blood specimen for a lipid profile should be obtained after a 12 hour fast.

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? a. air embolism b. pneumothorax c. catheter-related bloodstream infections d. hemorrhage

c. catheter-related bloodstream infections Rationale: 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.

For both outpatients and inpatients scheduled for diagnostic procedures of the cardiovascular system, the nurse performs a thorough initial assessment to establish accurate baseline data. Which data is necessary to collect if the client is experiencing chest pain? a. sound of the apical pulses b. blood pressure in the left arm c. description of the pain d. pulse rate in upper extremities

c. description of the pain Rationale: If the client is experiencing chest pain, a history of its location, frequency, and duration is necessary. A description of the pain is also needed, including if it radiates to a particular area, what precipitates its onset, and what brings relief. The nurse weighs the client and measures vital signs. The nurse may measure blood pressure in both arms and compare findings. The nurse assesses apical and radial pulses, noting rate, quality, and rhythm. The nurse also checks peripheral pulses in the lower extremities.

The nurse 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? a. reduced pulse pressure and heart murmur b. BP 108/60 mm Hg, ascites, and crackles c. disorientation, 20 mL of urine over the last 2 hours d. elevated jugular venous distention and postural changes in BP

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

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: a. central venous pressure. b. cardiac output. c. pulmonary artery wedge pressure. d. pulmonary artery pressure.

c. pulmonary artery wedge pressure. Rationale: 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.

Which term describes the amount of blood ejected per heartbeat? a. ejection fraction b. cardiac output c. stroke volume d. afterload

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

The nurse is caring for a client admitted with unstable angina. the laboratory result for the initial troponin 1 is elevated in this client. the nurse should recognize what implication of this assessment finding? a. this is only an accurate indicator of myocardial damage when it reaches its peak in24 hours b. because the client has a history of unstable angina, this is a poor indicator of myocardial injury c. this is an accurate indicator of myocardial injury. d. this result indicates muscle injury but does not specify the source

c. this is an accurate indicator of myocardial injury. Rationale: Troponin 1, which is specific to cardiac muscle, is elevated within hours after myocardial injury.

The cardiac care nurse is reviewing the conduction system of the heart. the nurse is aware that electrical conduction of the heart usually originates in the sinoatrial (SA) node and then proceeds in which sequence? a. bundle of His to atrioventricular (AV) node to purkinje fibers b. AV node to purkinje fibers to bundle of His c. bundle of His to purkinje fibers to AV node d. AV node to bundle of His to purkinje fibers

d. Av node to bundle of His to purkinje fibers Rationale: The normal electrophysiological conduction route is SA node to the AV node to bundle of his to purkinje fibers.

Which term describes the ability of the heart to initiate an electrical impulse? a. contractility b. excitability c. conductivity d. automaticity

d. automaticity. Rationale: 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.

What is a harsh grating sound caused by abrasion of the pericardial surfaces during the cardiac cycle? a. ejection click b. opening snap c. murmur d. friction rub

d. friction rub Rationale: 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.

A client is brought into the emergency department (ED) by a family member, who tells the nurse that the client grabbed their chest and reported substernal chest pain. the care team recognizes that need to monitor the clients cardiac function closely while interventions are performed. which form of monitoring should the nurse anticipate? a. left-side heart catheterization b. cardiac telemetry c. transesophageal echocardiography d. hardwire continuous electrocardiogram

d. hardwire continuous electrocardiogram (ECG) monitoring. Rationale: Two types of continuous ECG monitoring techniques are used in health care setting: Hardwire cardiac monitoring(emergent) and cardiac catheterization (non emergent).