Ch. 32 MJ Flashcards
After noting a pulse deficit when assessing a patient who has just arrived in the emergency department, the nurse will anticipate that the patient may require
a. a 2-D echocardiogram.
b. a cardiac catheterization.
c. hourly blood pressure (BP) checks.
d. electrocardiographic (ECG) monitoring.
d. electrocardiographic (ECG) monitoring.
When reviewing the 12-lead electrocardiograph (ECG) for a healthy 86-year-old patient who is having an annual physical examination, which of the following will be of most concern to the nurse?
a. The heart rate (HR) is 43 beats/minute.
b. The PR interval is 0.21 seconds.
c. There is a right bundle-branch block.
d. The QRS duration is 0.13 seconds
a. The heart rate (HR) is 43 beats/minute.
During a physical examination of a patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The most appropriate action for the nurse to take next will be to
a. document that the PMI is in the normal anatomic location.
b. ask the patient about risk factors for coronary artery disease.
c. auscultate both the carotid arteries for the presence of a bruit.
d. assess the patient for symptoms of left ventricular hypertrophy.
d. assess the patient for symptoms of left ventricular hypertrophy.
To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the
a. bell of the stethoscope with the patient in the left lateral position.
b. bell of the stethoscope with the patient sitting and leaning forward.
c. diaphragm of the stethoscope with the patient in a reclining position.
d. diaphragm of the stethoscope with the patient lying flat on the left side.
a. bell of the stethoscope with the patient in the left lateral position.
To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory result will the nurse plan to review?
a. Myoglobin
b. Homocysteine (Hcy)
c. Low-density lipoprotein (LDL)
d. B-type natriuretic peptide (BNP)
d. B-type natriuretic peptide (BNP)
While doing the admission assessment for a thin 72-year-old patient, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take?
a. Notify the hospital rapid response team.
b. Instruct the patient to remain on bed rest.
c. Teach the patient about aortic aneurysms.
d. Document the finding in the patient chart.
d. Document the finding in the patient chart.
A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that
a. electrocardiographic (ECG) monitoring will be required for 24 hours after the test.
b. it will be important to lie completely still during the procedure.
c. a warm feeling may be noted when the contrast dye is injected.
d. monitored anesthesia care will be provided during the procedure.
c. a warm feeling may be noted when the contrast dye is injected.
While assessing a patient who was admitted with heart failure, the nurse notes that the patient has jugular venous distention (JVD) when lying flat in bed. Which action should the nurse take next?
a. Use a ruler to measure the level of the JVD.
b. Document this finding in the patient’s record.
c. Observe for JVD with the head at 30 degrees.
d. Have the patient perform the Valsalva maneuver.
c. Observe for JVD with the head at 30 degrees.
The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to
a. exercise more than usual while the monitor is in place.
b. remove the electrodes when taking a shower or tub bath.
c. keep a diary of daily activities while the monitor is worn.
d. connect the recorder to a telephone transmitter once daily.
c. keep a diary of daily activities while the monitor is worn.
When auscultating over the patient’s abdominal aorta, the nurse hears a humming sound. The nurse documents this finding as a
a. thrill.
b. bruit.
c. heave.
d. murmur.
b. bruit.
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 most important laboratory result to review will be
a. LDL cholesterol.
b. troponins T and I.
c. C-reactive protein.
d. creatine kinase-MB (CK-MB).
b. troponins T and I.
When assessing a newly admitted patient, the nurse notes a thrill along the left sternal border. To obtain more information about the cause of the thrill, which action will the nurse take next?
a. Auscultate for any cardiac murmurs.
b. Find the point of maximal impulse.
c. Compare the apical and radial pulse rates.
d. Palpate the quality of the peripheral pulses.
a. Auscultate for any cardiac murmurs.
The nurse hears a murmur between the S1 and S2 heart sounds at the patient’s left 5th intercostal space and midclavicular line. How will the nurse 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.”
a. “Systolic murmur heard at mitral area.”
The 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. places the patient in the left lateral position to check for the point of maximal impulse (PMI).
b. presses on the skin over the tibia for 10 seconds to check for edema.
c. palpates both carotid arteries simultaneously to compare pulse quality.
d. documents a murmur heard along the left sternal border as an aortic murmur
c. palpates both carotid arteries simultaneously to compare pulse quality.
Which action will the nurse implement for a patient who arrives for a calcium-scoring CT scan?
a. Administer oral sedative medications.
b. Teach the patient about the procedure.
c. Ask whether the patient has eaten today.
d. Insert a large gauge intravenous catheter
b. Teach the patient about the procedure.
Which information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI) will be most important to report to the health care provider before the MRI?
a. The patient has an allergy to shellfish and iodine.
b. The patient has a history of coronary artery disease.
c. The patient has a permanent ventricular pacemaker in place.
d. The patient took all the prescribed cardiac medications today.
c. The patient has a permanent ventricular pacemaker in place.
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. Pulse change from 80 to 96 beats/minute.
c. BP increase from 134/68 to 150/80 mm Hg.
d. Electrocardiographic (ECG) changes indicating coronary ischemia
d. Electrocardiographic (ECG) changes indicating coronary ischemia
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
a. the postoperative patient with a BP of 116/42.
b. the newly admitted patient with a BP of 122/60.
c. the patient with left ventricular failure who has a BP of 110/70.
d. the patient with a myocardial infarction who has a BP of 114/50.
a. the postoperative patient with a BP of 116/42.
When admitting a patient for a coronary arteriogram and 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 has not eaten anything today.
d. The patient had an arteriogram a year ago.
b. The patient is allergic to shellfish.
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. Administer O2 per mask.
b. Start a large-gauge IV line.
c. Place the patient on NPO status.
d. Give lorazepam (Ativan) 1 mg IV.
c. Place the patient on NPO status.
