Deck 34: Nursing Assessment: Cardiovascular System

Question 1

The 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 does which of the following?

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) Places the patient in the left lateral position to check for the PMI
D) Uses the palm of the hand to assess extremity skin temperature

Answer 1

Palpates both carotid arteries simultaneously to compare pulse quality

Question 2

While assessing a patient who has just arrived in the emergency department,the nurse notes a pulse deficit.Which of the following does the nurse anticipate that the patient may require?

A) Hourly blood pressure (BP)checks
B) A coronary arteriogram
C) Electrocardiographic (ECG)monitoring
D) A two-dimensional echocardiogram

Answer 2

Electrocardiographic (ECG)monitoring

Question 3

The standard orders on the cardiac unit state,"Notify the physician for MAP less than 70 mm Hg." For which patient would the nurse call the physician?

A) The patient with left ventricular failure who has a BP of 110/70 mm Hg
B) The patient with a myocardial infarction who has a BP of 114/50 mm Hg
C) The postoperative patient with a BP of 116/42 mm Hg
D) The newly admitted patient with a BP of 122/60 mm Hg

Answer 3

The postoperative patient with a BP of 116/42 mm Hg

Question 4

While monitoring a patient's cardiac activity,the nurse recognizes that stimulation of which of the following is a normal physiological mechanism responsible for an increase in heart rate (HR)and force of cardiac contractions?

A) The vagus nerve
B) Baroreceptors in the aortic arch and carotid sinus
C) (?)-Adrenergic receptors in the vascular system
D) Chemoreceptors in the aortic arch and carotid body

Question 5

Upon auscultation,the nurse identifies an arterial bruit.What is a possible cause?

A) Cardiac dysrhythmias
B) Aneurysm
C) Pericarditis
D) Cardiac valve disorder

Question 6

A patient has a BP of 142/84 mm Hg.The nurse will calculate and document the patient's mean arterial pressure (MAP)as being which following amount?

A) 103 mm Hg
B) 113 mm Hg
C) 123 mm Hg
D) 131 mm Hg

Question 7

During physical examination of a 72-year-old patient,the nurse observes pulsation of the abdominal aorta in the epigastric area just below the xiphoid process.How will the nurse interpret this finding?

A) Normal assessment data in a thin person
B) Sclerosis and inelasticity of the aorta
C) A possible abdominal aortic aneurysm
D) Evidence of elevated systemic arterial pressure

Question 8

A patient is scheduled for cardiac catheterization with coronary angiography.Before the test,about which of the following should the nurse inform the patient?

A) A catheter will be inserted into a vein in the arm or leg and advanced to the heart.
B) ECG monitoring will be required for 24 hours following the test to detect any dysrhythmias.
C) A feeling of warmth and a fluttering sensation may be experienced as the catheter is advanced.
D) Complications of the test include breaking of the catheter,air or blood embolism,and puncture of the ventricles.

Question 9

When auscultating over the patient's abdominal aorta,the nurse hears a humming sound.How will the nurse document this finding?

A) Bruit
B) Thrill
C) Heave
D) Arterial obstruction

Question 10

A patient with syncope is scheduled for Holter monitoring.When teaching the patient about the purpose of the procedure,the nurse explains that Holter monitoring provides information about which of the following?

A) Ventricular ejection fraction during usual daily activities
B) Cardiovascular response to high-intensity exercise
C) Changes in cardiac output when the patient is resting
D) HR and rhythm during normal patient activities

Question 11

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

A) BP rising from 134/68 to 150/80 mm Hg
B) HR increasing from 80 to 96 beats/min
C) Patient complaining of feeling short of breath
D) ECG indicating the presence of coronary ischemia

Question 12

What should the nurse teach the patient being evaluated for rhythm disturbances with a Holter monitor to do?

A) Remove the electrodes to shower or bathe.
B) Exercise as much as possible while his monitor is in place.
C) Keep a diary of his activities as long as he wears the monitor.
D) Attach the recorder,and call the assigned number if an episode of irregular heartbeats occurs.

Question 13

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

A) "Systolic murmur heard at mitral area."
B) "Diastolic murmur heard at aortic area."
C) "Systolic murmur heard at Erb's point."
D) "Diastolic murmur heard at tricuspid area."

Question 14

What should the nurse expect as a possible etiology in a patient who exhibits a positive Homans sign?

A) Thyrotoxicosis
B) Thrombophlebitis
C) Incompetent valves
D) Intermittent claudication

Question 15

Which of the following is a normal cardiac index (CI)assessment finding?

A) 2 L/min
B) 3 L/min/m²
C) 6 L/min
D) 8 L/min/m²

Question 16

Which of the following is a normal age-related change in the heart?

A) Increased elastin
B) Decreased collagen
C) Decreased cardiac output
D) Increased stroke volume

Question 17

To auscultate for extra heart sounds in the mitral area,with what part of the stethoscope will the nurse listen?

A) The bell of the stethoscope with the patient in the left lateral position
B) The diaphragm of the stethoscope with the patient in a reclining position
C) The diaphragm of the stethoscope with the patient lying flat on the left side
D) The bell of the stethoscope with the patient sitting and leaning to the right side

Question 18

During physical examination of a 56-year-old man,the nurse palpates the point of maximal impulse (PMI)in the sixth intercostal space lateral to the midclavicular line.What is the most appropriate interpretation of this finding?

A) The PMI is in the normal location.
B) The patient may have left ventricular hypertrophy.
C) The patient has age-related downward displacement of the heart.
D) The patient should be observed for signs of left atrial enlargement.

Question 19

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?

A) Make the patient nothing by mouth (NPO)status.
B) Start a large-gauge IV line.
C) Administer O₂ per mask.
D) Give lorazepam (Ativan)1 mg IV.

Question 20

The physician orders serum troponin levels in a patient with a possible myocardial infarction.What will the nurse explain to the patient about this test?

A) It is the most specific indicator for myocardial damage available.
B) It measures the amount of myoglobin released from damaged myocardial cells.
C) It can provide evidence of myocardial damage more quickly than can enzyme tests.
D) It is diagnostic for myocardial damage only when used in combination with creatinine kinase-MB isoenzymes.

Question 21

Which one of the following central venous pressure (CVP)readings would the nurse report to the physician as being abnormal?

A) 3 mm Hg
B) 6 mm Hg
C) 9 mm Hg
D) 12 mm Hg