Question 1

While assessing a patient who has just arrived in the emergency department, the nurse notes a pulse deficit. The nurse will anticipate that the patient may require

Accepted Answer

Pulse deficit is a difference between simultaneously obtained apical and radial pulses and indicates that there may be cardiac dysrhythmias that would be detected with ECG monitoring. Frequent BP monitoring, coronary arteriograms, and echocardiograms are used for diagnosis of other cardiovascular disorders but would not be as helpful in determining the reason for the pulse deficit.

Question 2

When admitting a patient for a coronary arteriogram and angiogram, the assessment information that will be most important for the nurse to communicate to the health care provider is that the

Accepted Answer

The contrast dye used for the procedure is iodine based, so patients who have shellfish allergies will require treatment with medications such as corticosteroids and antihistamines before the arteriogram. The other information is also communicated to the health care provider but will not require a change in the usual pre-arteriogram orders or medications.

Question 3

When performing an assessment of a newly admitted patient, the nurse notes a thrill along the left sternal border. To obtain more information about the cause of the thrill, which action will the nurse take next?

Accepted Answer

Both thrills and murmurs are caused by turbulent blood flow, such as occurs when blood flows through a damaged valve. Relevant information includes the quality of the murmur, where in the cardiac cycle the murmur is heard, and where on the thorax the murmur is heard best. The other information is also important in the cardiac assessment but will not provide information that is relevant to the thrill.

Question 4

The nurse is monitoring a patient with possible coronary artery disease who is undergoing exercise (stress) testing on a treadmill. The symptom that has the most immediate implications for the patient's care during the exercise testing is

Accepted Answer

ECG changes associated with coronary ischemia (such as T-wave inversions and ST segment depression) indicate that the myocardium is not getting adequate oxygen delivery and that the exercise test should be immediately terminated. Increases in BP and HR are normal responses to aerobic exercise. Shortness of breath is also normal as the intensity of exercise increases during the stress testing.

Question 5

A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that

Accepted Answer

A sensation of warmth or flushing is common when the iodine-based contrast material is injected, which can be anxiety-producing unless it has been discussed with the patient. The catheter is inserted in an artery (typically the femoral artery) and advanced to the openings for the coronary arteries at the aortic root. Dysrhythmias may occur during the procedure, but most patients are discharged a few hours after the coronary arteriogram or angiogram is completed. The patient is not required to be completely immobile during the procedure.

Question 6

The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to

Accepted Answer

The patient is instructed to keep a diary describing daily activities while Holter monitoring is being accomplished to help correlate any rhythm disturbances with patient activities. Patients are taught that they should not take a shower or bath during Holter monitoring and that they should continue with their usual daily activities. The recorder stores the information about the patient's rhythm until the end of the testing, when it is removed and the data are analyzed.

Question 7

During a physical examination of a patient, the nurse palpates the PMI in the sixth intercostal space lateral to the midclavicular line. The most appropriate action for the nurse to take next will be to

Accepted Answer

The PMI should be felt at the intersection of the 5th intercostal space and the midclavicular line. A PMI located outside these landmarks indicates possible cardiac enlargement, such as with left ventricular hypertrophy. Cardiac enlargement is not necessarily associated with coronary or carotid artery disease.

Question 8

During physical examination of a thin 72-year-old patient, the nurse observes pulsation of the abdominal aorta in the epigastric area just below the xiphoid process. The nurse teaches the patient that this is

Accepted Answer

Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals. More data would be needed to support a diagnosis of aortic sclerosis, aortic aneurysm, or hypertension.

Question 9

The RN is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student nurse

Accepted Answer

The carotid pulses should never be palpated at the same time to avoid vagal stimulation, dysrhythmias, and decreased cerebral blood flow. The other assessment techniques also need to be corrected; however, they are not dangerous to the patient.

Question 10

While assessing a patient with heart failure, the nurse notes that the patient has jugular venous distension (JVD) when lying flat in bed. The nurse's next action will be to

Accepted Answer

When assessing for and documenting JVD, the nurse should document the angle at which the patient is positioned. When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but not clinically significant) finding. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant. The nurse may use a ruler to determine the level of JVD above the heart if the JVD persists when the patient is at 30 to 45 degree angle or more. JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure increases. Comparison of the volume and pressure of the jugular veins is not included in jugular vein assessment.

Question 11

The nurse is obtaining a health history for a new patient with possible coronary artery disease. Which question would the nurse use when obtaining subjective data related to the patient's health perception-health management functional health pattern?

Accepted Answer

The health perception-health management functional pattern includes information related to what the patient knows about coronary heart disease risk factors and actions the patient is taking to decrease risk. Any patient history of streptococcal infections or sore throat would also be included in this functional pattern, but this patient has possible coronary artery disease, not rheumatic heart disease. Information about discomfort caused by activity would be included in the activity-exercise pattern. The data about symptoms in response to stress would be documented in the coping-stress tolerance functional pattern.

Question 12

When auscultating over the patient's abdominal aorta, the nurse hears a humming sound. The nurse documents this finding as a

Accepted Answer

A bruit is the sound created by turbulent blood flow in an artery. Thrills are palpable vibrations felt when there is turbulent blood flow through the heart or in a blood vessel. Heaves are sustained lifts over the precordium that can be observed or palpated. A murmur is the sound caused by turbulent blood flow through the heart.

Question 13

The nurse hears a murmur between the S₁ and S₂ heart sounds at the patient's left 5th intercostal space and midclavicular line. The best way to record this information is

Accepted Answer

The S₁ sound is created by closure of the mitral and tricuspid valves and signifies the onset of ventricular systole. S₂ is caused by the closure of the aortic and pulmonic valves and signifies the onset of diastole. A murmur occurring between these two sounds is a systolic murmur. The mitral area is the intersection of the left 5th intercostal space and the midclavicular line. The aortic area is located at the 2nd intercostal space along the right sternal border. Erb's point is located at the 3rd intercostal space along the left sternal border. The tricuspid area is located at the 5th intercostal space along the left sternal border.

Question 14

Which information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI) will be most important to report to the health care provider before the MRI?

Accepted Answer

MRI is contraindicated for patients with implanted metallic devices such as pacemakers. The other information will also be reported to the health care provider but does not impact on whether or not the patient can have an MRI.

Question 15

The nurse has received the laboratory results for a patient who developed chest pain 2 hours ago and may be having a myocardial infarction. The most important laboratory result to review will be

Accepted Answer

Cardiac troponins start to elevate 1 hour after myocardial injury and are specific to myocardium. Creatine kinase (CK-MB) is specific to myocardial injury and infarction, but it does not increase until 4 to 6 hours after the infarction occurs. LDL cholesterol and C-reactive protein are useful in assessing cardiovascular risk but are not helpful in determining whether a patient is having an acute myocardial infarction.

Question 16

A patient with syncope is scheduled for Holter monitoring. When teaching the patient about the purpose of the procedure, the nurse will explain that Holder monitoring provides information about the

Accepted Answer

Holter monitoring is used to assess for possible changes in HR or rhythm over a 24- to 48-hour period. The patient is usually instructed to continue with usual daily activities rather than changing exercise or activity level. Because Holter monitoring is useful only for detecting rhythm changes, it is not useful in determining ejection fraction or cardiac output.

Question 17

When reviewing the 12-lead ECG for a healthy 86-year-old patient who is having an annual physical examination, which of these observations will be of most concern to the nurse?

Accepted Answer

The resting HR does not change with aging, so the decrease in HR requires further investigation. Bundle-branch block and slight increases in PR interval or QRS duration are common in older individuals because of increases in conduction time through the AV node, the bundle of His, and the bundle branches.

Question 18

To auscultate for S₃ or S₄ gallops in the mitral area, the nurse listens with the

Accepted Answer

Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall. The diaphragm of the stethoscope is best to use for the higher-pitched sounds such as S₁ and S₂.

Question 19

The standard orders on the cardiac unit state, "Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg." The nurse will need to call the health care provider about

Accepted Answer

The mean arterial pressure (MAP) is calculated using the formula MAP = (systolic BP + 2 diastolic BP)/3. The MAP for the postoperative patient in answer 3 is 67. The MAP in the other three patients is higher than 70 mm Hg.

Question 20

A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which of these actions included in the standard TEE orders will the nurse need to accomplish first?

Accepted Answer

The patient will need to be NPO for 6 hours preceding the TEE, so the nurse should place the patient on NPO status as soon as the order is received. The other actions will also need to be accomplished, but not until just before or during the procedure.

Quiz 32: Nursing Assessment: Cardiovascular System