Honan-Chapter 12: Nursing Assessment: Cardiovascular and Circulatory Function
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? "After the test is done, you can resume your normal activity as soon as you feel ready." "You'll be put under general anesthetic for the procedure, and you'll wake up when it's done." "A small amount of bleeding from your puncture site is normal for a day or two after the procedure." "Make sure that you don't eat or drink before the procedure."
"Make sure that you don't eat or drink before the procedure." Explanation: Fasting is required for cardiac catheterization. Activity is resumed slowly after the procedure, which is not performed under general anesthetic. Bleeding from the puncture site requires prompt intervention.
A 76-year-old resident of an assisted living facility who has a history of heart failure has presented to her primary care provider for a scheduled appointment. Which of the woman's statements suggests that her heart failure is worsening? "The last few weeks I've found that I'm more comfortable sleeping in a chair than in my bed." "I find that I have to wake up two or three times a night to go to the washroom, which never used to be the case." "I find that my appetite is not what it used to be, and I have to will myself to eat enough healthy food." "I pride myself in staying alert and up-to-date but lately I've forgotten a few important events."
"The last few weeks I've found that I'm more comfortable sleeping in a chair than in my bed." Explanation: Orthopnea is the term used to indicate the need to sit upright or stand to avoid dyspnea. Thus, patients with worsening heart failure will report that they sleep upright in a chair instead of in bed, increase the number of pillows used, and awaken from sleep with sudden onset of dyspnea. Cognitive changes, nocturia, and anorexia may accompany a decline in cardiac function but orthopnea is more clearly suggestive of an exacerbation of heart failure.
The nurse is conducting a head-to-toe assessment of a patient at the beginning of a shift. The nurse has palpated the patient's radial pulse for 1 minute to determine the patient's heart rate and has detected an irregular rhythm. How should the nurse follow-up this assessment finding? Continue to palpate the patient's radial pulse for one more minute in order to gauge the severity of the arrhythmia. Palpate the patient's right and left radial pulses simultaneously to compare the symmetry of the patient's rate and rhythm. Reposition the patient, wait 3 to 5 minutes and then reassess the patient's radial pulse. Auscultate the patient's apical pulse while simultaneously palpating the patient's radial pulse.
Auscultate the patient's apical pulse while simultaneously palpating the patient's radial pulse. Explanation: During the initial cardiac examination, or if the pulse rhythm is irregular, the nurse assesses pulse rate for a pulse deficit, defined as the difference between the apical and the peripheral pulse rates. The pulse deficit is ascertained by simultaneously auscultating the apical pulse and palpating the radial pulse for 1 minute. The nurse should anticipate finding a pulse deficit in patients with arrhythmias, especially atrial fibrillation, atrial flutter, and ventricular arrhythmias. The nurse's original assessment finding is not enhanced by palpating longer, palpating both arms, or repositioning the patient.
A patient with cardiovascular disease is being treated with Norvasc, a calcium channel blocking agent. The nurse is aware that calcium channel blockers have a variety of effects. What is one of the therapeutic effects? Decrease sinoatrial node and atrioventricular node conduction and decrease workload of the heart Prevent platelet aggregation and subsequent thrombosis Reduce myocardial oxygen consumption by blocking beta-adrenergic stimulation to the heart Reduce myocardial oxygen consumption thus decreasing ischemia and relieving pain
Decrease sinoatrial node and atrioventricular node conduction and decrease workload of the heart Explanation: Calcium channel blocking agents decrease sinoatrial node automaticity and atrioventricular node conduction resulting in a slower heart rate and a decrease in the strength of the heart muscle contraction. These effects decrease the workload of the heart. They are also used to prevent and treat vasospasm. Antiplatelet and anticoagulation medications are administered to prevent platelet aggregation and subsequent thrombosis that impede blood flow. Beta-blockers reduce myocardial consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced myocardial contractility (force of contraction) to balance the myocardium oxygen needs and supply. Nitrates reduce myocardial oxygen consumption, which decreases ischemia and relieves pain by dilating the veins and in higher doses, the arteries.
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.
A 70-year-old man has been diagnosed with angina pectoris and subsequently prescribed nitroglycerin spray to be used sublingually when he experiences chest pain. This drug will achieve relief of the patient's chest pain by: Blocking sympathetic stimulation of the heart and reducing oxygen demand Increasing contractility and consequent cardiac output Blocking the a-delta pain fibers in the myocardium Dilating the blood vessels and reducing preload
Dilating the blood vessels and reducing preload Explanation: Nitroglycerin is administered to reduce myocardial oxygen consumption, which decreases ischemia and relieves pain. Nitroglycerin dilates primarily the veins and, in higher doses, also the arteries. Dilation of the veins causes venous pooling of blood throughout the body. As a result, less blood returns to the heart, and filling pressure (preload) is reduced. Nitrates do not block sympathetic stimulation or pain transmission. As well, nitrates do not have the ability to increase cardiac contractility.
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.
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? Pulmonary embolism Myocardial infarction Pericarditis Heart failure
Heart failure Explanation: An ejection fraction of less than 40% indicates that the patient has decreased left ventricular function and likely requires treatment for heart failure.
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.
After a physical examination, the provider diagnosed a patient with a grade 4 heart murmur. When auscultating a murmur, what does the nurse expect to hear? 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.
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 may have had a myocardial infarction. The patient had a vagal response. The patient was anxious about being constipated. The patient may have an abdominal aortic aneurysm.
The patient had a vagal response. Explanation: When straining during defecation, the patient bears down (the Valsalva maneuver), which momentarily increases pressure on the baroreceptors. This triggers a vagal response, causing the heart rate to slow and resulting in syncope in some patients. Straining during urination can produce the same response. Myocardial infarction is damage to the heart and clients will experience pain or shortness of breath. Anxiety causes the heart rate to increase. The client with an abdominal aortic aneurysm will experience back or abdominal pain, not a decrease in heart rate.
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 The inner lining of the heart and valves The heart's muscle fibers The exterior layer of the heart
The thin fibrous sac encasing the heart Explanation: The heart is encased in a thin, fibrous sac called the pericardium, which is composed of two layers. Inflammation of this sac is known as pericarditis.
The critical care nurse is caring for a patient with a pulmonary artery pressure monitoring system. The nurse is aware that pulmonary artery pressure monitoring is used to assess left ventricular function (cardiac output). What else are pulmonary artery pressure monitoring systems used for? To assess the patient's response to interventions such as fluid administration and drug administration To obtain specimens for arterial blood gas measurements They have been determined to not be clinically useful for continuous monitoring of a patient with heart failure. To diagnose the etiology of chronic obstructive pulmonary disease.
To assess the patient's response to interventions such as fluid administration and drug administration Explanation: 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 patient's response to medical interventions such as fluid administration and response to vasoactive medications. Pulmonary artery monitoring is preferred for the patient with heart failure over central venous pressure monitoring. Arterial catheters are useful when arterial blood gas measurements and blood samples need to be obtained frequently.
The nurse is caring for a client after cardiac surgery. What laboratory result will lead the nurse to suspect possible renal failure? an hourly urine output of 50 to 70 mL a urine specific gravity reading of 1.021 a serum BUN of 70 mg/dL a serum creatinine of 1.0 mg/dL
a serum BUN of 70 mg/dL Explanation: These four laboratory results should always be assessed after cardiac surgery. Serum osmolality (N = >800 mOsm/kg) should also be included. A BUN reading of greater than 21 mg/dL is abnormal; a reading of greater than 60 mg/dL is indicative of renal failure. Urine output needs to be greater than 30 mL/hr. Normal urine specific gravity is 1.005-1.030. Normal serum creatinine values are between 0.5-1.2 mg/dL.
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.
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? blood pressure in the left arm pulse rate in upper extremities description of the pain sound of the apical pulses
description of the pain Explanation: 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.
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.
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.
The nurse auscultates the apex beat at which anatomical location? midsternum 5 cm to the left of the lower end of the sternum 2.5 cm to the left of the xiphoid process fifth intercostal space, midclavicular line
fifth intercostal space, midclavicular line Explanation: The left ventricle is responsible for the apex beat 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 apex beat is inappropriate based upon variations in human anatomy. Auscultation below and to the left of the xiphoid process will detect gastrointestinal sounds, but not the apex beat of the heart.
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.
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.
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.
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.
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.
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.
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.
The nurse correctly identifies which data as an example of blood pressure and heart rate 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 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 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 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
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 Explanation: 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.
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.
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.
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.
The nurse is auscultating a client's heart sounds and notes a murmur at the left fourth intercostal space and lateral to the sternum. 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.
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.
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 Electrocardiography (ECG) Cardiac catheterization Angiography
Echocardiography Explanation: An echocardiogram yields a two-dimensional rendering of the heart's structure and mechanical function. An ECG indicates the heart's electrical activity, and angiography and cardiac catheterization are used to assess the patency of the coronary arteries.
The clinic nurse is assessing a client's pulse before outpatient diagnostic testing. What should the nurse document when assessing the client's pulse? Rate, quality, and rhythm Pressure, rate, and rhythm Rate, rhythm, and volume Quality, volume, and rate
Rate, quality, and rhythm Explanation: Assess apical and radial pulses, noting rate, quality, and rhythm. Pulse pressure and volume are not assessed in this instance.
The nurse is caring for a client who is diagnosed with an infarction of the posterior wall of the right atrium. Which assessment finding would the nurse anticipate relating to the infarction location? Respiratory compromise Chronic chest pain Irregular heart rate Cyanosis
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. Depending on muscle damage, the client may have respiratory compromise, chest pain, and/or cyanosis.
The nurse is reviewing the morning laboratory test results for a client with cardiac problems. Which finding is a priority to report to the healthcare provider? Na+ 140 mEq/L Ca++ 9 mg/dL K+ 3.1 mEq/L Mg++ 2 mEq/L
K+ 3.1 mEq/L Explanation: All laboratory levels are within normal limits except for the K+, which is low. A low K+ level can cause ventricular tachycardia or fibrillation.
The nurse cares for a client with clubbing of the fingers and toes. The nurse should complete which action given these findings? Obtain an oxygen saturation level. Assess the client's capillary refill. Assess the client for pitting edema. Obtain a 12-lead ECG tracing.
Obtain an oxygen saturation level. Explanation: 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 uses which term for the normal pacemaker of the heart? Sinoatrial (SA) node Atrioventricular (AV) node Purkinje fibers Bundle of His
Sinoatrial (SA) node Explanation: 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.
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.
What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse? contractility depolarization repolarization diastole
contractility Explanation: 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.
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.
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 left atrium right ventricle right atrium
left ventricle Explanation: The left ventricle pumps blood to all the cells and tissues of the body. The left atrium receives oxygenated blood from the lungs. The right ventricle pumps blood to the lungs to be oxygenated. The right atrium receives deoxygenated blood from the venous system.
The client is being prepared for echocardiography when he asks the nurse why he needs to have this test. What would be the nurse's best response? "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. Option C is the best answer because it addresses the client's question without making him anxious or minimizing the question.
The nurse assesses the patient and records the data collected. What would lead the nurse to anticipate that the patient will experience a decrease in cardiac output? An order for the patient to receive digoxin A heart rate of 54 beats per minute A pulse oximetry reading of 98% An increase in preload related to ambulation in the hall
A heart rate of 54 beats per minute Explanation: 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 beats per minute. An increase in preload will lead to an increase in stroke volume. Digoxin will increase contractility of the heart and ultimately increase stroke volume. A pulse oximetry reading of 98% does not indicate hypoxemia, as hypoxia can decrease contractility.
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
A man was just admitted after experiencing chest pain and shortness of breath. Blood tests were sent while he was in the emergency department, and the nurse is evaluating the results. An elevation in which one of the following blood tests indicates that he is having an acute myocardial infarction? A. Troponin B. Cholesterol C. Brain natriuretic peptide (BNP) D. C-reactive protein (CRP)
A. Troponin RATIONALE Troponin is a protein that rises after myocardial injury. The remaining responses are not related to myocardial cell injury.
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.
A 45-year-old woman who has a history of diabetes, hypertension, and cigarette smoking walks into the emergency room with shortness of breath, indigestion, and diaphoresis. She should be evaluated immediately for: A. Community-acquired pneumonia B. Acute coronary syndrome C. Pulmonary embolus D. Aortic dissection
B. Acute coronary syndrome RATIONALE Patients with diabetes develop neuropathies that diminish the perception of pain, which can mask the pain associated with acute myocardial infarction. Because this woman has diabetes, she is more likely to present with atypical acute myocardial infarction symptoms rather than experiencing chest pain or pressure. Despite her younger age, she has multiple cardiac risk factors that put her at high risk for having an acute myocardial infarction. An ECG should be done immediately to determine if she is having an acute myocardial infarction, before assessing her for other medical problems.
After which of the following diagnostic tests will the patient need to remain on bedrest for 2 to 6 hours? A. Exercise stress test B. Cardiac catheterization C. Myocardial perfusion imaging D. Traditional echocardiography
B. Cardiac catheterization RATIONALE Cardiac catheterization is an invasive procedure that involves insertion of catheters into a large vein and an artery. Bed rest for 2 to 6 hours is necessary to ensure that hemostasis is achieved. The other diagnostic tests are noninvasive and do not place the patient at risk for bleeding; therefore, they do not require postprocedure bed rest.
Which of the following signs or symptoms are indications for performing an ankle-brachial index (ABI)? A. Irregular, superficial ulcer along the medial malleolus B. 4+ pitting edema to lower extremities C. Intermittent claudication D. Pulse deficit greater than 20 mm Hg
C. Intermittent claudication RATIONALE Intermittent claudication is a symptom associated with peripheral arterial disease. The ABI is a test that evaluates arterial perfusion to the lower extremities and is used to quantify the severity of peripheral arterial disease. An irregular, superficial ulcer along the medial malleolus is due to chronic venous insufficiency, pitting edema is a nonspecific finding caused by certain medications and many other medical conditions, and a pulse deficit is the difference between the systolic and diastolic blood pressures.
The nurse is caring for a client with a damaged tricuspid valve. The nurse knows that the tricuspid valve is held in place by which of the following? Chordae tendineae Atrioventricular tendons Semilunar tendineae Papillary tendons
Chordae tendineae Explanation: Attached to the mitral and tricuspid valves are cordlike structures known as chordae tendineae, which in turn attach to papillary muscles, two major muscular projections from the ventricles. Options B, C, and D are distractors for the question.
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.
The nurse is caring for an elderly client with left-sided heart failure. When auscultating lung sounds, which adventitious sound is expected? Wheezes Rhonchi Crackles Coarseness
Crackles Explanation: When the heart is pumping inefficiently, blood backs up into the pulmonary veins and lung tissue. Auscultation reveals a crackling sound. Possible wheezes and gurgles are also possibilities.
The nurse is performing a cardiac examination of a patient who has HF. When auscultating over the apical area, the nurse hears an extra sound between S1 and S2. This sound may be caused by: A. S3, indicating worsening HF B. S4, indicating the sound of blood moving into a noncompliant left ventricle C. A diastolic murmur, suggesting aortic regurgitation D. A systolic murmur, indicating a mitral valve regurgitation
D. A systolic murmur, indicating a mitral valve regurgitation RATIONALE A leaky mitral valve causes regurgitation of blood back into the left atrial during systole that creates the murmur or vibration during systole. All of the other responses are abnormal sounds heard during diastole (between S2 and S1).
A nurse is assessing a new patient who is diagnosed with peripheral arterial disease. The nurse cannot feel the pulse in the patient's left foot. What could the nurse use to assess the blood flow in the patient's left foot? An ultrasound machine A stethoscope A fetoscope Doppler ultrasound
Doppler ultrasound Explanation: When pulses cannot be reliably palpated, a Doppler ultrasound device may be used to hear (insonate) the blood flow in vessels. This hand-held device emits a continuous signal through the patient's tissues. The signals are reflected by ("echo off") the moving blood cells and are received by the device. The filtered-output Doppler signal is then transmitted to a loudspeaker or headphones, where it can be heard for interpretation. A regular ultrasound machine cannot assess blood flow in the patient's foot, neither can a stethoscope or a fetoscope, which is used to assess the heartbeat of a fetus.
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.
The nurse is aware of the importance of synchronization of the atrial and ventricular events in the maintenance of normal cardiac function. What are the physiologic characteristics of the nodal and Purkinje cells that provide this synchronization? Select all that apply. Loop connectivity Excitability Automaticity Conductivity Independence
Excitability Automaticity Conductivity Explanation: Three physiologic characteristics of two types of specialized electrical cells, the nodal cells and the Purkinje cells, provide this synchronization: automaticity (the ability to initiate an electrical impulse), excitability (the ability to respond to an electrical impulse), and conductivity (the ability to transmit an electrical impulse from one cell to another). Loop connectivity is a distracter for this question. Independence of the cells has nothing to do with the synchronization described in the scenario.
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.
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.
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.
During the assessment of a newly admitted female patient, the nurse has assessed the amplitude of the woman's temporal, dorsalis pedis, and posterior tibial pulses. The amplitude of these peripheral pulses contributes to the nurse's determination of this patient's: Peripheral arterial circulation Tissue perfusion in her extremities Resting blood pressure Risk of deep vein thrombosis (DVT)
Peripheral arterial circulation Explanation: The pulse quality or amplitude is indicative of the blood pressure in an artery and is used to assess peripheral arterial circulation. This is related to, but not synonymous with, tissue perfusion. This assessment cannot be used to ascertain blood pressure. Peripheral pulses in the lower extremities diminish when occluded by thrombosis, but assessment of peripheral pulses cannot ascertain an individual's risk of DVT.
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.
The nurse is educating a patient at risk for atherosclerosis. What nonmodifiable risk factor does the nurse identify for the patient? Stress Obesity Positive family history Hyperlipidemia
Positive family history Explanation: The health history provides an opportunity for the nurse to assess patients' understanding of their personal risk factors for coronary artery, peripheral vascular, and cerebrovascular diseases and any measures that they are taking to modify these risks. Risk factors are classified by the extent to which they can be modified by changing one's lifestyle or modifying personal behaviors. Stress, obesity, and hyperlipidemia are all risk factors that can be modified by personal behaviors. Family history is a nonmodifiable risk factor, because it cannot be changed.
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 TAKE ANOTHER QUIZ
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.
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.
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
Thrombolytic therapy is being prepared for administration to an older adult patient who has presented to the emergency department with an ST-segment elevation MI (STEMI). The nurse recognizes that the primary goal of this intervention is: To restore the flow of blood through the coronary arteries To restore function to infarcted myocardial cells To relieve the patient's symptoms of chest pain and dyspnea To prevent the rupture of atheromas
To restore the flow of blood through the coronary arteries Explanation: The purpose of thrombolytics is to dissolve and lyse the thrombus in a coronary artery (thrombolysis), allowing blood to flow through the coronary artery again (reperfusion), minimizing the size of the infarction, and preserving ventricular function. Thrombolytics are not primarily a pain-control measure, and function cannot be restored to infarcted cardiac cells.
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.
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.
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 atrioventricular node bundle of His bundle branches
sinoatrial node Explanation: The SA node is an area of nerve tissue located in the posterior wall of the right atrium. The SA node is called the pacemaker of the heart because it initiates the electrical impulses that cause the atria and ventricles to contract. When the impulse from the SA node reaches the AV node, it is delayed a few hundredths of a second. While the ventricles fill with blood, the impulse travels from the AV node to the bundle of His, to the right and left bundle branches, and eventually to the Purkinje fibers. Then, both ventricles contract. While the ventricles fill with blood, the impulse travels from the AV node to the bundle of His, to the right and left bundle branches, and eventually to the Purkinje fibers. Then, both ventricles contract.
