Deck 31: Assessment of Cardiovascular System

Question 1

The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. The laboratory test result most helpful in indicating myocardial damage will be

A)myoglobin.
B)troponins T and I.
C)homocysteine (Hcy)
D)creatine kinase-MB (CK-MB).

Answer 1

troponins T and I.

Question 2

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

A)The patient has an allergy to shellfish.
B)The patient has a history of atherosclerosis.
C)The patient has a permanent cardiac pacemaker.
D)The patient took the prescribed heart medications today.

Answer 2

The patient has a permanent cardiac pacemaker.

Question 3

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

A)thrill.
B)bruit.
C)murmur.
D)normal finding.

Answer 3

bruit.

Question 4

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

A)connect the recorder to a computer once daily.
B)exercise more than usual while the monitor is in place.
C)remove the electrodes when taking a shower or tub bath.
D)keep a diary of daily activities while the monitor is worn.

Question 5

A 74-yr-old patient has just arrived in the emergency department. After assessment reveals a pulse deficit of 46 beats,the nurse will anticipate that the patient may require

A)emergent cardioversion.
B)a cardiac catheterization.
C)hourly blood pressure (BP) checks.
D)electrocardiographic (ECG) monitoring.

Question 6

The standard policy on the cardiac unit states,"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 the

A)postoperative patient with a BP of 116/42 mm Hg.
B)newly admitted patient with a BP of 150/87 mm Hg.
C)patient with left ventricular failure who has a BP of 110/70 mm Hg.
D)patient with a myocardial infarction who has a BP of 140/86 mm Hg.

Question 7

The nurse hears a murmur between the S1 and S2 heart sounds at the patient's left fifth intercostal space and midclavicular line. How will the nurse record this information?

A)Systolic murmur heard at mitral area
B)Systolic murmur heard at Erb's point
C)Diastolic murmur heard at aortic area
D)Diastolic murmur heard at the point of maximal impulse

Question 8

A registered nurse (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

A)presses on the skin over the tibia for 10 seconds to check for edema.
B)palpates both carotid arteries simultaneously to compare pulse quality.
C)documents a murmur heard along the right sternal border as a pulmonic murmur.
D)places the patient in the left lateral position to check for the point of maximal impulse.

Question 9

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

A)Start an IV line.
B)Start O2 per nasal cannula.
C)Place the patient on NPO status.
D)Give lorazepam (Ativan) 1 mg IV.

Question 10

When admitting a patient for a cardiac catheterization and coronary angiogram,which information about the patient is most important for the nurse to communicate to the health care provider?

A)The patient's pedal pulses are +1.
B)The patient is allergic to shellfish.
C)The patient had a heart attack 1 year ago.
D)The patient has not eaten anything today.

Question 11

During a physical examination of an older patient,the nurse palpates the point of maximal impulse (PMI)in the sixth intercostal space lateral to the left midclavicular line. The best follow-up action for the nurse to take will be to

A)ask about risk factors for atherosclerosis.
B)determine family history of heart disease.
C)assess for symptoms of left ventricular hypertrophy.
D)auscultate carotid arteries for the presence of a bruit.

Question 12

When assessing a newly admitted patient,the nurse notes a murmur along the left sternal border. To acquire more information about the murmur,which action will the nurse take?

A)Palpate the peripheral pulses.
B)Determine the timing of the sound.
C)Find the point of maximal impulse.
D)Compare apical and radial pulse rates.

Question 13

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

A)diaphragm of the stethoscope with the patient lying flat.
B)bell of the stethoscope with the patient in the left lateral position.
C)diaphragm of the stethoscope with the patient in a supine position.
D)bell of the stethoscope with the patient sitting and leaning forward.

Question 14

The nurse is reviewing the 12-lead electrocardiograph (ECG)for a healthy 74-yr-old patient who is having an annual physical examination. What finding is of most concern to the nurse?

A)A right bundle-branch block.
B)The PR interval is 0.21 seconds.
C)The QRS duration is 0.13 seconds.
D)The heart rate (HR) is 41 beats/min.

Question 15

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

A)it will be important not to move at all during the procedure.
B)monitored anesthesia care will be provided during the procedure.
C)a flushed feeling may be noticed when the contrast dye is injected.
D)arterial pressure monitoring will be required for 24 hours after the test.

Question 16

To determine the effects of therapy for a patient who is being treated for heart failure,which laboratory test result will the nurse plan to review?

A)Troponin
B)Homocysteine (Hcy)
C)Low-density lipoprotein (LDL)
D)B-type natriuretic peptide (BNP)

Question 17

When the nurse is monitoring a patient who is undergoing exercise (stress)testing on a treadmill,which assessment finding requires the most rapid action by the nurse?

A)Patient complaint of feeling tired
B)Sinus tachycardia at a rate of 110 beats/min
C)Inversion of T waves on the electrocardiogram
D)Blood pressure (BP) increase from 134/68 to 150/80 mm Hg

Question 18

While doing the hospital admission assessment for a thin older adult,the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take next?

A)Teach the patient about aneurysms.
B)Notify the hospital rapid response team.
C)Instruct the patient to remain on bed rest.
D)Document the finding in the patient chart.

Question 19

The nurse notes that a patient who was admitted with heart failure has jugular venous distention (JVD)when lying flat in bed. Which follow-up action should the nurse take next?

A)Obtain vital signs, including oxygen saturation.
B)Have the patient perform the Valsalva maneuver.
C)Document this JVD finding in the patient's record.
D)Observe for JVD with the patient elevated 45 degrees.

Question 20

Which action will the nurse implement for a patient who arrives for a calcium-scoring CT scan?

A)Insert an IV catheter.
B)Administer oral sedative medications.
C)Teach the patient about the procedure.
D)Confirm that the patient has been fasting.

Question 21

While listening at the mitral area,the nurse notes abnormal heart sounds at the patient's fifth intercostal space,midclavicular line. After listening to the audio clip,describe how the nurse will document the assessment finding.

A)S3 gallop heard at the aortic area
B)Systolic murmur noted at mitral area
C)Diastolic murmur noted at tricuspid area
D)Pericardial friction rub heard at the apex

Question 22

When the nurse is screening patients for possible peripheral arterial disease,indicate where the posterior tibial artery will be palpated.

A)1
B)2
C)3
D)4

Question 23

The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular unit. Which laboratory result is most important to communicate as soon as possible to the health care provider?

A)High troponin I level
B)Increased triglyceride level
C)Very low homocysteine level
D)Elevated high-sensitivity C-reactive protein level

Question 24

The nurse and unlicensed assistive personnel (UAP)on the telemetry unit are caring for four patients. Which nursing action can be delegated to the UAP?

A)Teaching a patient about exercise electrocardiography
B)Attaching ECG monitoring electrodes after a patient bathes
C)Checking the catheter insertion site for a patient who is recovering from a coronary angiogram
D)Monitoring a patient who has just returned to the unit after a transesophageal echocardiogram