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?

Accepted Answer

Palpating both carotid arteries simultaneously to compare pulse quality can cause a dangerous reflex called vagal stimulation, leading to a decrease in heart rate and blood pressure. The RN should intervene immediately to prevent harm to the patient. Pressing on the skin over the tibia for 10 seconds to check for edema, placing the patient in the left lateral position to check for the PMI, and using the palm of the hand to assess extremity skin temperature are appropriate physical assessment techniques.

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?

Accepted Answer

A pulse deficit is a difference between the heart rate and the pulse rate, indicating a lack of perfusion to peripheral tissues. The nurse would anticipate that the patient requires electrocardiographic (ECG) monitoring to assess for any cardiac abnormalities or irregularities. Hourly blood pressure checks may not be necessary unless the patient has other conditions that warrant frequent blood pressure monitoring. A coronary arteriogram and two-dimensional echocardiogram may be ordered later for diagnosis, but it is not the immediate priority for a pulse deficit.

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?

Accepted Answer

The Mean Arterial Pressure (MAP) is calculated as (SBP + 2*DBP)/3. For option C, the MAP is (116 + 2*42)/3 = 66.7 mm Hg, which is less than 70 mm Hg, thus requiring physician notification.

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?

Accepted Answer

The answer of While monitoring a patient's cardiac activity,the nurse...

Question 5

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

Accepted Answer

An arterial bruit may suggest the presence of an aneurysm, which is a weakened and bulging area in an artery that can cause turbulent blood flow and produce a bruit sound. Cardiac dysrhythmias, pericarditis, and cardiac valve disorders are not typically associated with arterial bruits.

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?

Accepted Answer

The mean arterial pressure (MAP) is calculated using the formula: MAP = [2(Diastolic) + Systolic] / 3. For a BP of 142/84 mm Hg, MAP = [2(84) + 142] / 3 = 310 / 3 = approximately 103 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?

Accepted Answer

In thin individuals, it is common to observe pulsations of the abdominal aorta due to less subcutaneous fat, making the aorta more palpable and visible.

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?

Accepted Answer

The nurse should inform the patient that they may experience a feeling of warmth and a fluttering sensation as the catheter is advanced during the procedure.

Question 9

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

Accepted Answer

A humming sound heard over the abdominal aorta is a sign of a bruit, which is an abnormal sound produced by turbulent blood flow through a narrowed or partially obstructed artery. The other choices (B, C, and D) do not accurately describe this finding.

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?

Accepted Answer

Holter monitoring is a continuous recording of the patient's electrocardiogram (ECG) for 24-48 hours. It provides information about the patient's heart rate and rhythm during normal daily activities, which may reveal any abnormalities that were not captured during a brief clinical assessment. It is used to diagnose arrhythmias, including those that cause syncope, and to evaluate the effectiveness of treatment for heart rhythm problems. It does not provide information about ventricular ejection fraction, cardiovascular response to exercise or changes in cardiac output.

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?

Accepted Answer

The presence of coronary ischemia on the ECG during exercise testing indicates reduced blood flow to the cardiac muscle, which can lead to a heart attack or other serious cardiac events. This finding requires immediate attention and may require cessation of the testing or administration of medications to reduce the risk of complications. While the other options (increased BP, increased HR, shortness of breath) may also be important considerations in the patient's care, the presence of ischemia on the ECG is the most critical finding.

Question 12

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

Accepted Answer

Keeping a diary of activities and symptoms while wearing a Holter monitor is essential for correlating any changes in heart rhythm with physical activity or symptoms experienced by the patient. This information helps healthcare providers make accurate diagnoses and treatment plans.

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?

Accepted Answer

The location described (left fifth intercostal space and midclavicular line) corresponds to the mitral area. Additionally, the description of the murmur being heard between the two heart sounds (S₁ and S₂) indicates that it is a systolic murmur.

Question 14

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

Accepted Answer

A positive Homans sign, which is pain in the calf upon dorsiflexion of the foot, is suggestive of thrombophlebitis, which is inflammation of a vein with formation of a blood clot. Thyrotoxicosis, incompetent valves, and intermittent claudication do not typically result in a positive Homans sign.

Question 15

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

Accepted Answer

A normal cardiac index (CI) ranges from 2.5 to 4.0 L/min/m^2. Option B, 3 L/min/m^2, falls within this range, making it a normal CI assessment finding.

Question 16

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

Accepted Answer

Decreased cardiac output is a normal age-related change in the heart. This is because the heart muscles become weaker with age, making it harder for the heart to pump blood effectively.

Question 17

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

Accepted Answer

To auscultate for extra heart sounds in the mitral area, the nurse should use the bell of the stethoscope with the patient in the left lateral position. This is because the bell is better at picking up low frequency sounds, such as S3 and S4, which are often heard best in this position.

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?

Accepted Answer

The point of maximal impulse (PMI) is normally located at the fifth intercostal space in the midclavicular line. Palpating the PMI in the sixth intercostal space suggests that the patient may have left ventricular hypertrophy, which causes displacement of the PMI to a lower location. Age-related downward displacement of the heart typically occurs in elderly patients and would not affect the location of the PMI. Left atrial enlargement would not cause a change in the location of the PMI.

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?

Accepted Answer

Making the patient NPO status is typically the first action required before a TEE to prevent aspiration during the procedure. The other actions may be necessary as well, but can typically be done after the patient is NPO.

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?

Accepted Answer

The answer of The physician orders serum troponin levels in...

Quiz 34: Nursing Assessment: Cardiovascular System

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?

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?

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?

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?

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

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?

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

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

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?

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?

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

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?

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

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

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

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

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 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?

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?

Quiz 34: Nursing Assessment: Cardiovascular System

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?

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?

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?

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?

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

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?

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

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

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?

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?

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

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?

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

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

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

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

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 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?

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?

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?