Question 1

The nurse is caring for a client who is scheduled for a cardiac catheterization with coronary angiography. Which of the following information should the nurse provide to the client before the test?

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 client. The client may receive a sedative drug before the procedure, but monitored anaesthesia care is not used. ECG monitoring is used during the procedure to detect dysrhythmias, but there is not a risk for dysrhythmias after the procedure. The client is not immobile during cardiac catheterization and may be asked to cough or take deep breaths.

Question 2

Which of the following actions should the nurse implement for a client who arrives for a calcium-scoring CT scan?

Accepted Answer

The nurse will need to teach the client that the procedure is rapid and involves little risk. The other actions are not necessary.

Question 3

The RN is observing a student nurse who is doing a physical assessment on a client. The RN will need to intervene immediately if the student nurse implements which of the following interventions?

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 client.

Question 4

To auscultate for S3 or S4 gallops in the mitral area, which of the following should the nurse implement?

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 client 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 5

The nurse is caring for a client who is being treated for heart failure. Which of the following laboratory results should the nurse assess to determine the effects of therapy?

Accepted Answer

Increased levels of BNP are a marker for heart failure. The other laboratory results would be used to assess for myocardial infarction (myoglobin) or risk for coronary artery disease (Hcy and LDL).

Question 6

The nurse is assessing a client who was admitted with heart failure and notes that the client has jugular venous distension (JVD) when lying flat in bed. Which of the following actions should the nurse take next?

Accepted Answer

When the client 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 client is sitting at a 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 client is ata
45-degree angle or more. JVD is an expected finding when a client performs the Valsalva manoeuvre because right atrial pressure increases. The nurse will document the JVD in the record if it persists when the head is elevated.

Question 7

The nurse is assessing a newly admitted client and notes a thrill along the left sternal border. To obtain more information about the cause of the thrill, which of the following actions should 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 also is important in the cardiac assessment but will not provide information that is relevant to the thrill.

Question 8

During a physical examination of a client, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. Which of the following actions should the nurse implement next?

Accepted Answer

The PMI should be felt at the intersection of the 5th intercostal space and the left 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 9

The nurse is admitting a client for a coronary arteriogram and angiogram. Which of the following information about the client is most important for the nurse to communicate to the health care provider?

Accepted Answer

The contrast dye used for the procedure is iodine based, so clients who have an iodine allergy should be communicated to the health care provider. The other information also is communicated to the health care provider but will not require a change in the usual prearteriogram orders or medications.

Question 10

The nurse is monitoring a client who is undergoing exercise (stress) testing on a treadmill. Which of the following assessment findings requires the most rapid action by the nurse?

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 terminated immediately. Increases in BP and heart rate (HR) are normal responses to aerobic exercise. Tiredness also is normal as the intensity of exercise increases during the stress testing.

Question 11

The nurse is assessing the laboratory results for a client who developed chest pain 4 hours ago and may be having a myocardial infarction. Which of the following laboratory results is most important for the nurse to review?

Accepted Answer

Cardiac troponins start to elevate hours (average 4-6 hours) after myocardial injury and are specific to myocardium. Creatine kinase-MB (CK-MB) is specific to myocardial injury and infarction, but it does not increase until 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 client is having an acute myocardial infarction.

Question 12

The nurse is auscultating over the client's abdominal aorta and hears a humming sound. Which of the following terms should the nurse use to document this finding?

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 is reviewing the 12-lead electrocardiograph (ECG) of a healthy older-adult client who is having an annual physical examination. Which of the following findings should be of most concern to the nurse?

Accepted Answer

The resting supine HR is not markedly affected 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 14

The nurse hears a murmur between the S1 and S2 heart sounds at the client's left 5th intercostal space and midclavicular line. How should the nurse record this information?

Accepted Answer

The S1 signifies the onset of ventricular systole. S2 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 other responses describe murmurs heard at different landmarks on the chest or during the diastolic phase of the cardiac cycle.

Question 15

A transesophageal echocardiogram (TEE) is ordered for a client with possible endocarditis. Which of the following actions included in the standard TEE orders should the nurse accomplish first?

Accepted Answer

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

Question 16

The nurse is assessing an underweight older-adult client and observes pulsation of the abdominal aorta in the epigastric area. Which of the following actions should the nurse take?

Accepted Answer

Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals and the nurse should simply document the finding in the admission assessment. Unless there are other abnormal findings (such as a bruit, pain, or hyper/hypotension) associated with the pulsation, the other actions are not necessary.

Question 17

Which of the following information obtained by the nurse who is admitting the client 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 clients with implanted metallic devices such as pacemakers as the magnets can alter the function of the device. The other information also will be reported to the health care provider but does not impact whether or not the client can have an MRI.

Question 18

The nurse is providing teaching to a client being evaluated for rhythm disturbances with a Holter monitor. Which of the following information should the nurse include in the teaching plan?

Accepted Answer

The client is instructed to keep a diary describing daily activities while Holter monitoring is being accomplished to help correlate any rhythm disturbances with client activities.
Clients 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 client's rhythm until the end of the testing, when it is removed and the data are analyzed.

Question 19

The nurse is assessing a client who has just arrived in the emergency department and notes a pulse deficit. Which of the following actions should the nurse anticipate for the client?

Accepted Answer

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

Question 20

The standard policy on the cardiac unit states, "Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg." Which of the following clients should the nurse report to the health care provider?

Accepted Answer

The mean arterial pressure (MAP) is calculated using the formula MAP = (diastolic
BP + 1/3 pulse pressure). The MAP for the postoperative client with a BP of 116/42 is 67. The MAP in the other three clients is higher than 70 mm Hg.

Quiz 34: Nursing Assessment Cardiovascular System