Chapter 22: Introduction to the Cardiovascular System Prep - U med surg

The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include?

"Do not bend at the waist, strain, or lift heavy objects for the next 24 hours."

The nurse 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 heart rate of 54 bpm

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.

A patient has been placed on telemetry following treatment for a non-ST wave elevation myocardial infarction (NSTEMI). Which of the patient's following statements indicates that the nurse should perform further patient teaching?

"If I get chest pain or shortness of breath, it will show up on my telemetry monitor."

The nurse is conducting client teaching about cholesterol levels. When discussing the client's elevated LDL and lowered HDL levels, the client shows an understanding of the significance of these levels by making what statement?

"Increased LDL and decreased HDL increase my risk of coronary artery disease."

A 71-year-old woman has complained of chest pain that appears when she is doing housework or climbing stairs. The woman claims that the pain dissipates when she stops exerting herself and rests for a few minutes. The woman's history, combined with these complaints, prompted her primary care provider to order cardiac catheterization. What instructions should the nurse provide this patient in anticipation of her procedure?

"Make sure that you don't eat or drink before the procedure."

The nurse is calculating a cardiac client's pulse pressure. If the client's blood pressure is 122/76 mm Hg, what is the client's pulse pressure?

46 mm Hg

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

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 sinoartrial (SA) node and then proceeds in which sequence?

AV node to bundle of His to Purkinje fibers

A lipid profile has been ordered for a client who has been experiencing cardiac symptoms. When should a lipid profile be drawn in order to maximize the accuracy of results?

After a 12-hour fast

The nurse is caring for a client on a monitored telemetry unit. During morning assessment, the nurse notes abnormal ECG waves on the telemetry monitor. Which action would the nurse do first?

Assess the client.

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?

Assess the puncture site frequently for hematoma formation or bleeding.

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

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.

Bradycardia Exercise intolerance

The nurse is caring for a patient who has undergone peripheral arteriography. How should the nurse assess the adequacy of peripheral circulation?

By checking peripheral pulses

A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). The client's blood pressure is 104/68 mm Hg. The client's pulse rate is 76 beats/minute. The nurse detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take?

Contact the health care provider and report the findings.

Which area of the heart that is located at the third intercostal space to the left of the sternum?

Erb point

The nurse's assessment of an older adult client reveals the following data: Lying BP 144/82 mm Hg; sitting BP 121/69 mm Hg; standing BP 98/56 mm Hg. The nurse should identify the priority nursing diagnosis of a risk for which outcome in the client's plan of care?

Falls related to orthostatic hypotension

A client has had a myocardial infarction 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?

Myocardium

While auscultating heart sounds, the nurse hears "lub-dub-dee" and recognizes that this would be characterized as which heart sound?

S3

The critical care nurse is caring for a client who has been experiencing bradycardia after cardiovascular surgery. The nurse knows that the heart rate is determined by myocardial cells with the fastest inherent firing rate. Under normal circumstances where are these cells located?

SA node

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.

Heart disease is the leading cause of adult death in the United States. Cardiac disease causes alteration in function, and eventual tissue necrosis and death. What is the function of the cardiovascular system?

eliminate CO and cellular wastes

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:

hypervolemia.

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)

The physician orders medication to treat a client's cardiac ischemia. What is causing the client's condition?

reduced blood supply to the heart

What does decreased pulse pressure reflect?

reduced stroke volume

A patient's gradual decline in activity tolerance and increased shortness of breath have prompted her health care provider to assess the structure and size of her heart. Which of the following diagnostic tests is most likely to yield these assessment data?

Echocardiography

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?

Heart failure

Following the morning assessment of an older adult patient, the nurse has documented, "Edema 3+ present to ankles and feet; dorsalis pedis and posterior tibial pulses palpable bilaterally." The nurse should recognize that this patient may be exhibiting symptoms of:

Heart failure

The nurse is reviewing the results of the patient's echocardiogram and observes that the ejection fraction is 35%. The nurse anticipates that the patient will receive treatment for what condition?

Heart failure

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?

Inflammation

During a shift assessment, the nurse is identifying the client's point of maximum impulse (PMI). Where should the nurse best palpate the PMI?

Left midclavicular line of the chest at the fifth intercostal space

The heart has valves between the atrium and the ventricles. What valve separates the left atrium and ventricle?

Mitral

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?

Myocardial ischemia

While assessing a client with coronary artery disease following a coronary arteriography, the nurse observes that the client has cool toes, an absent distal peripheral pulse, and a rapid pulse. Which intervention would be most appropriate?

Notify the physician immediately.

A critically ill client is admitted to the ICU. The health care provider decides to use intra-arterial pressure monitoring. After this intervention is performed, what assessment should the nurse prioritize?

Perfusion distal to the insertion site

A critical care nurse is caring for a client with a hemodynamic monitoring system in place. For what complications should the nurse assess? Select all that apply.

Pneumothorax Infection Air embolism

The nurse is educating a patient at risk for atherosclerosis. What nonmodifiable risk factor does the nurse identify for the patient?

Positive family history

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

A student nurse is caring for a client with suspected cardiovascular disease. The nursing instructor asks the student what side effects a client may experience when undergoing a cardiac magnetic resonance imaging (MRI) test. What should the student respond?

Rapid heart rate

The nurse is assessing heart sounds in a patient with heart failure. An abnormal heart sound is detected early in diastole. How would the nurse document this?

S3

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:

Stimulation of the vagus nerve.

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?

The pain occurs immediately following physical exertion.

A patient tells the nurse, "I was straining to have a bowel movement and felt like I was going to faint. I took my pulse and it was so slow." What does the nurse understand occurred with this patient?

The patient had a vagal response.

The patient has a heart rate of 72 bpm with a regular rhythm. Where does the nurse determine the impulse arises from?

The sinoatrial node

A client with a complex cardiac history is scheduled for transthoracic echocardiography. What should the nurse teach the client in anticipation of this diagnostic procedure?

The test is noninvasive, and nothing will be inserted into the client's body.

The nurse is caring for a patient with a diagnosis of pericarditis. Where does the nurse understand the inflammation is located?

The thin fibrous sac encasing the heart

A patient recently diagnosed with pericarditis asks the nurse to explain what area of the heart is involved. How does the nurse best describe the pericardium to the client?

Thin fibrous sac that encases the heart.

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?

Thready pulse

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?

To assess how blocked or open a client's coronary arteries are

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 the best?

To help prevent blockages that can cause chest pain or heart attacks

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?

Tricuspid valve

When assessing a patient with left-sided heart failure, what would be noted on auscultation of lungs?

Wheezes with wet lung sounds

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?

Whether the client and involved family members are able to recognize symptoms of an acute cardiac problem and respond appropriately

For a client who has undergone peripheral arteriography, how should the nurse assess the adequacy of peripheral circulation?

checking peripheral pulses

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.

Before conducting diagnostic procedures of the cardiovascular system, which baseline data are necessary to collect from a client who is experiencing chest pain?

description of the pain

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?

description of the pain

Within the heart, several structures and several layers all play a part in protecting the heart muscle and maintaining cardiac function. The inner layer of the heart is composed of a thin, smooth layer of cells, the folds of which form heart valves. What is the name of this layer of cardiac tissue?

endocardium

Which area of the heart is located at the third intercostal (IC) space to the left of the sternum?

erb point

The nurse auscultates the apex beat at which anatomical location?

fifth intercostal space, midclavicular line

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

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

Age-related changes associated with the cardiac system include which conditions? Select all that apply.

increased size of the left atrium endocardial fibrosis

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

Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for pumping blood to all the cells and tissues of the body?

left ventricle

Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for receiving deoxygenated blood from the venous system?

right atrium

The electrical conduction system of the heart has several components, all of which are instrumental in maintaining polarization, depolarization, and repolarization of cardiac tissue. Which of the conductive structures is known as the pacemaker of the heart?

sinoatrial node

During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure?

wheezes with wet lung sounds

Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes no active gag reflex. What nursing action is a priority?

withhold food and fluids.