Question 1

How does a nurse accurately palpate carotid pulses?
A) Two fingers of each hand are placed firmly over the right and left temples at the same time.
B) One finger is placed gently in the space between the biceps and triceps muscles.
C) Two fingers are placed at the thumb side of the forearm at the wrist.
D) One finger is placed along the right and then the left medial sternocleidomastoid muscle.

Accepted Answer

One finger placed along the right and then the left medial sternocleidomastoid muscle is the correct procedure for palpating the carotid pulses, checking each side separately. Two fingers of each hand placed firmly over the right and left temples at the same time is the correct procedure for palpating the temporal pulse. One finger placed gently in the space between the biceps and triceps muscles is the correct procedure for palpating the brachial pulse. Two fingers placed at the thumb side of the forearm at the wrist is the correct procedure for palpating the radial pulse.

Question 2

A nurse expects which finding during a cardiovascular assessment of a healthy adult?
A) Visible, consistent pulsations of the jugular vein
B) Pink nail beds with a 90-degree angle at the base
C) Capillary refill of the toes greater than 5 seconds
D) Bruits heard on auscultation of the carotid arteries

Accepted Answer

Visible, consistent pulsations of the jugular vein is an expected finding. Pink nail beds with a 90-degree angle at the base is not a normal finding; the angle at the base should be 160 degrees. Capillary refill of the toes greater than 5 seconds is not a normal finding. Capillary refills should be 2 seconds or less. Bruits heard on auscultation of the carotid arteries is not a normal finding. Bruits indicate occlusion of a blood vessel.

Question 3

To document the palpation of a pulse, the nurse is correct in making which notation about the rhythm?
A) "Rhythm 100 beats/min"
B) "Irregular rhythm"
C) "Rhythm noted at +2"
D) "Bounding rhythm"

Accepted Answer

The rhythm should be an equal pattern or spacing between beats. Irregular rhythms without any pattern should be noted. The notation "rhythm 100 beats/min" refers to the rate rather than the rhythm. The notation "rhythm noted at +2" refers to the amplitude rather than the rhythm. The notation "Bounding rhythm" refers to the contour rather than the rhythm.

Question 4

When assessing a patient with aortic valve stenosis, the nurse should palpate for which abnormality to detect a thrill?
A) Sustained thrust of the heart against the chest wall during systole
B) Visible sinking of the tissues between and around the ribs
C) Fine, palpable vibration felt over the precordium
D) Bounding pulse noted bilaterally

Accepted Answer

A thrill is a palpable vibration over the precordium or artery. A sustained thrust of the heart against the chest wall during systole is a description of a lift. A visible sinking of the tissues between and around the ribs is a description of a retraction. A thrill feels like a palpable vibration rather than a bounding pulse.

Question 5

A nurse is completing a symptom analysis with a patient complaining of chest pain. When asked what makes the chest pain worse, the patient reports that coughing and sneezing increase the chest pain. Based on these data, what does the nurse suspect as the cause of this patient's chest pain?
A) Stable angina
B) Esophageal reflux disease
C) Mitral valve prolapse
D) Costochondritis

Accepted Answer

Coughing, deep breathing, laughing, and sneezing worsen the chest pain associated with costochondritis. Physical exertion, emotional stress, and cold worsen the chest pain associated with stable angina. A spicy or acidic meal, alcohol, or lying supine may worsen the chest pain associated with esophageal reflux. Only occasional position changes worsen the chest pain associated with mitral valve prolapse.

Question 6

A nurse informs a patient that her blood pressure is 128/78. The patient asks what the number 128 means. What is the nurse's appropriate response? The 128 represents the pressure in your blood vessels when:
A) "The ventricles relax and the aortic and pulmonic valves open."
B) "The ventricles contract and the mitral and tricuspid valves close."
C) "The ventricles contract and the mitral and tricuspid valves open."
D) "The ventricles relax and the aortic and pulmonic valves close."

Accepted Answer

During systole the ventricles contract, creating a pressure that closes the atrioventricular (AV) valves (mitral and tricuspid). The aortic and pulmonic valves open during systole, but ventricles fill during diastole. During systole the ventricles contract, creating a pressure that closes the AV valves (mitral and tricuspid). The ventricles are relaxed and the aortic and pulmonic valves close during diastole, rather than systole.

Question 7

A patient reports that he has coronary artery disease with ventricular hypertrophy. Based on these data, what finding should the nurse expect during assessment?
A) S4 heart sound
B) Clubbing of fingers
C) Splitting of the S1 heart sound
D) Pericardial friction rub

Accepted Answer

An S4 heart sound signifies a noncompliant or stiff ventricle. Coronary artery disease is a major cause of a stiff ventricle. Clubbing of fingers occurs due to chronic hypoxia rather than a stiff ventricle. Splitting of the S1 heart sound indicates a valve problem rather than ventricular hypertrophy. When the mitral and tricuspid valves do not close at the same time, S1 sounds as if it were split into two sounds instead of one. Pericardial friction rubs are caused by inflammation of the layers of the pericardial sac.

Question 8

While assessing edema on a male patient's lower leg, the nurse notices that there is a slight imprint of his fingers where he palpated the patient's leg. How does the nurse document this finding?
A) No edema
B) 1+ edema
C) 2+ edema
D) 3+ edema

Accepted Answer

A barely perceptible pit is detected after palpation. No pit left after palpation indicates no edema. A deeper pit that rebounds in a few seconds after palpation is 2+ edema. A deep pit that rebounds in 10 to 20 seconds after palpation is 3+ edema.

Question 9

While taking a history, a nurse learns that a patient had rheumatic heart disease as a child. Based on this information, what abnormal data might this nurse expect to find during an examination?
A) An extra beat just before the S2 heart sound heard during auscultation
B) A raspy machine-like or blowing sound heard during auscultation
C) A prominent thrust of the heart against the chest wall felt on palpation
D) A visible indentation of pericardial tissue noted during inspection

Accepted Answer

A raspy machine-like or blowing sound heard during auscultation is a description of a murmur that can develop after rheumatic heart disease. An extra beat just before the S1 heart sound heard during auscultation is a description of the S4 heart sound that occurs when there is hypertrophy of the ventricle. A prominent thrust of the heart against the chest wall felt on palpation is a description of a heave, which may occur from left ventricular hypertrophy due to increased workload. A visible indentation of pericardial tissue noted during inspection is a description of a retraction that begins in the intercostal spaces and occurs with increased respiratory effort.

Question 10

Which pulse may be a challenge for a nurse to palpate?
A) Temporal
B) Femoral
C) Popliteal
D) Dorsalis pedis

Accepted Answer

For the popliteal pulse, palpate the popliteal artery behind the knee in the popliteal fossa to assess perfusion. This pulse may be difficult to find. The temporal pulse is palpated over the temporal bone on each side of the head. For the femoral pulse, palpate below the inguinal ligament, midway between the symphysis pubis and anterior superior iliac. For the dorsalis pedis pulse, palpate on the inner aspect of the ankle below and slightly behind the medial malleolus (ankle bone).

Question 11

While taking a history, a nurse learns that this patient experiences shortness of breath (dyspnea). If the cause of the dyspnea is a cardiovascular problem, the nurse expects which abnormal finding on examination?
A) Flat jugular neck veins
B) Red, shiny skin on the legs
C) Weak, thready peripheral pulses
D) Edema of the feet and ankles

Accepted Answer

This patient may have heart failure. Edema of the feet occurs with right ventricular heart failure. Dyspnea occurs with left ventricular heart failure. Flat jugular veins indicate a fluid deficit, which is not associated with dyspnea. Red, shiny skin on the legs is associated with peripheral arterial disease and is not associated with dyspnea. Weak, thready peripheral pulses indicate fluid deficit, which is not associated with dyspnea.

Question 12

Where does a nurse place a stethoscope to auscultate the mitral valve area? Choose the letter that corresponds to the correct stethoscope placement.
A) A
B) B
C) D
D) E

Accepted Answer

E is the location of the mitral valve area-the fifth intercostal space, midclavicular line. A is the location of the aortic valve area-second intercostal space, right sternal border. B is the location of the pulmonic valve area-fifty-second intercostal space, left sternal border. D is the location of the tricuspid valve area-fourth intercostal space, left sternal border.

Question 13

Which patient's statement helps a nurse distinguish between chest pain originating from pericarditis rather than from angina?
A) "No, I have not done anything to strain chest muscles."
B) "If I take a deep breath, the pain gets much worse."
C) "This pain feels like there's an elephant sitting on my chest."
D) "Whenever this pain happens, it goes right away if I lie down."

Accepted Answer

The chest pain from pericarditis is aggravated by deep breathing, coughing, or lying supine. Chest pain from muscle strain may be aggravated by movement of arms. "This pain feels like there's an elephant sitting on my chest" is associated with a myocardial infarction. Chest pain relieved by rest occurs with angina.

Question 14

The patient describes her chest pain as "squeezing, crushing, and 12 on a scale of 10." This pain started more than an hour ago while she was resting, and she also feels nauseous. Based on these findings, the nurse should assess for which associated symptoms?
A) Tachycardia, tachypnea, and hypertension
B) Dyspnea, diaphoresis, and palpitations
C) Hyperventilation, fatigue, anorexia, and emotional strain
D) Fever, dyspnea, orthopnea, and friction rub

Accepted Answer

Dyspnea, diaphoresis, and palpitations are symptoms associated with unstable angina. Tachycardia, tachypnea, and hypertension are symptoms associated with cocaine-induced chest pain. Hyperventilation, fatigue, anorexia, and emotional strain are symptoms associated with panic disorder. Fever, dyspnea, orthopnea, and friction rub are symptoms associated with pericarditis.

Question 15

A nurse determines that a patient has a heart rate of 42 beats/min. What might be a cause of this heart rate?
A) Sinoatrial (SA) node failure
B) Atrial bradycardia
C) A well-conditioned heart muscle
D) Left ventricular hypertrophy

Accepted Answer

If the SA node is ineffective, the atrioventricular node may initiate contraction, but at a rate of 40 to 60 beats/min. The heart rate reflects the ventricular rate rather than the atrial rate. Although well-conditioned athletes may have slower heart rates, this rate is too slow for even an athlete. Left ventricular hypertrophy alters the strength of contraction rather than the heart rate.

Question 16

A nurse is having difficulty auscultating a patient's heart sounds because the lung sounds are too loud. What does the nurse ask the patient to do to improve hearing the heart sounds?
A) Lie in a supine position.
B) Cough.
C) Hold his or her breath for a few seconds.
D) Sit up and lean forward.

Accepted Answer

Holding the breath for a few seconds eliminates the noise of breathing long enough to hear several cardiac cycles of heart sounds. The holding of the breath can be repeated if needed to hear the heart sounds again. Lying in a supine position will not reduce the noise of breathing. Coughing may clear some secretions, but when the lung sounds are so noisy that the heart sounds are difficult to hear, coughing is not sufficient to eliminate the noise from respirations. Sitting up and leaning forward brings the heart closer to the thoracic wall, but will not eliminate noise produced by the lungs.

Question 17

A patient reports having leg pain while walking that is relieved with rest. Based on these data, the nurse expects which finding on inspection and palpation of this patient?
A) 1+ edema of the feet and ankles bilaterally
B) The circumference of the right leg is larger than the left leg
C) Patchy petechiae and purpura of the lower extremities
D) Cool feet with capillary refill of toes greater than 3 seconds

Accepted Answer

The pain while walking that is relieved by rest is called intermittent claudication and is an indication of arterial insufficiency. Cool feet and prolonged capillary refill also occur due to arterial insufficiency. Edema of 1+ of the feet and ankles bilaterally is an indication of a venous problem rather than an arterial problem. When one leg is larger in circumference than the other, it could be due to lymphedema or a deep vein thrombosis. Petechiae and purpura of the lower extremities indicate a bleeding problem, such as low platelets, rather than an arterial problem.

Question 18

A nurse is assessing a patient's peripheral circulation. Which finding indicates venous insufficiency of this patient's legs?
A) Paresthesias and weak, thin peripheral pulses
B) Leg pain that can be relieved by walking
C) Edema that is worse at the end of the day
D) Leg pain that increases when the legs are lowered

Accepted Answer

Dependent edema is an indication of venous insufficiency. Paresthesias and weak, thin peripheral pulses are characteristics of arterial insufficiencies rather than venous. Pain caused by arterial insufficiency gets worse by walking, because walking requires additional arterial blood. Arterial pain is relieved by lowering the leg and aggravated by elevating the legs.

Question 19

When auscultating the heart of a patient with pericarditis, the nurse expects to hear which sound?
A) A systolic murmur
B) An S3 heart sound
C) A friction rub
D) An S4 heart sound

Accepted Answer

Two classic findings of pericarditis are pericardial friction rub and chest pain. Most systolic murmurs are caused by obstruction of the outflow of the semilunar valves or by incompetent AV valves. An S3 heart sound occurs when there is heart failure. An S4 heart sound occurs when there is hypertrophy of the ventricle.

Question 20

Which valve does a nurse auscultate when the stethoscope is placed on the fourth intercostal space at the left of the sternal border?
A) Pulmonic
B) Tricuspid
C) Mitral
D) Aortic

Accepted Answer

Tricuspid valve sounds are best heard in the fourth intercostal space at the left of the sternal border. Pulmonic valve sounds are best heard in the second intercostal space at the left of the sternal border. Mitral valve sounds are best heard in the fifth intercostal space at the midclavicular line. Aortic valve sounds are best heard in the second intercostal space at the right of the sternal border.

Quiz 12: Heart and Peripheral Vascular System

How does a nurse accurately palpate carotid pulses?

A nurse expects which finding during a cardiovascular assessment of a healthy adult?

To document the palpation of a pulse, the nurse is correct in making which notation about the rhythm?

When assessing a patient with aortic valve stenosis, the nurse should palpate for which abnormality to detect a thrill?

A nurse is completing a symptom analysis with a patient complaining of chest pain. When asked what makes the chest pain worse, the patient reports that coughing and sneezing increase the chest pain. Based on these data, what does the nurse suspect as the cause of this patient's chest pain?

A nurse informs a patient that her blood pressure is 128/78. The patient asks what the number 128 means. What is the nurse's appropriate response? The 128 represents the pressure in your blood vessels when:

A patient reports that he has coronary artery disease with ventricular hypertrophy. Based on these data, what finding should the nurse expect during assessment?

While assessing edema on a male patient's lower leg, the nurse notices that there is a slight imprint of his fingers where he palpated the patient's leg. How does the nurse document this finding?

While taking a history, a nurse learns that a patient had rheumatic heart disease as a child. Based on this information, what abnormal data might this nurse expect to find during an examination?

Which pulse may be a challenge for a nurse to palpate?

While taking a history, a nurse learns that this patient experiences shortness of breath (dyspnea) . If the cause of the dyspnea is a cardiovascular problem, the nurse expects which abnormal finding on examination?

Where does a nurse place a stethoscope to auscultate the mitral valve area? Choose the letter that corresponds to the correct stethoscope placement.

Which patient's statement helps a nurse distinguish between chest pain originating from pericarditis rather than from angina?

The patient describes her chest pain as "squeezing, crushing, and 12 on a scale of 10." This pain started more than an hour ago while she was resting, and she also feels nauseous. Based on these findings, the nurse should assess for which associated symptoms?

A nurse determines that a patient has a heart rate of 42 beats/min. What might be a cause of this heart rate?

A nurse is having difficulty auscultating a patient's heart sounds because the lung sounds are too loud. What does the nurse ask the patient to do to improve hearing the heart sounds?

A patient reports having leg pain while walking that is relieved with rest. Based on these data, the nurse expects which finding on inspection and palpation of this patient?

A nurse is assessing a patient's peripheral circulation. Which finding indicates venous insufficiency of this patient's legs?

When auscultating the heart of a patient with pericarditis, the nurse expects to hear which sound?

Which valve does a nurse auscultate when the stethoscope is placed on the fourth intercostal space at the left of the sternal border?