CH 33: Assessment of the cardiovascular system Flashcards
. A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min
ANS: A
When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturations and perfusion. The client may not be able to compensate for long, and decreased oxygenation and cool, clammy skin will occur later.
A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find?
a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg
b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min
c. Oxygen saturation increased from 88% to 96%
d. Pulse decreased from 100 beats/min to 80 beats/min
ANS: D
Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output will drop because of decreased HR.
A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease?
a. An 86-year-old man with a history of asthma
b. A 32-year-old Asian-American man with colorectal cancer
c. A 45-year-old American Indian woman with diabetes mellitus
d. A 53-year-old postmenopausal woman who is on hormone therapy
ANS: C
The incidence of coronary artery disease and hypertension is higher in American Indians than in whites or Asian Americans. Diabetes mellitus increases the risk for hypertension and coronary artery disease in people of any race or ethnicity. Asthma, colorectal cancer, and hormone therapy do not increase risk for cardiovascular disease.
A nurse assesses an older adult client who has multiple chronic diseases. The clients heart rate is 48 beats/min. Which action should the nurse take first?
a. Document the finding in the chart.
b. Initiate external pacing.
c. Assess the clients medications.
d. Administer 1 mg of atropine.
ANS: C
Pacemaker cells in the conduction system decrease in number as a person ages, resulting in bradycardia. The nurse should check the medication reconciliation for medications that might cause such a drop in heart rate, then should inform the health care provider. Documentation is important, but it is not the priority action. The heart rate is not low enough for atropine or an external pacemaker to be needed.
An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?
a. I get short of breath when I climb stairs.
b. I see halos floating around my head.
c. I have trouble remembering things.
d. I have lost weight over the past month.
ANS: A
Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure.
A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema?
a. I wake up to go to the bathroom at night.
b. My shoes fit tighter by the end of the day.
c. I seem to be feeling more anxious lately.
d. I drink at least eight glasses of water a day.
ANS: B
Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse should note whether the client feels that his or her shoes or rings are tight, and should observe, when present, an indentation around the leg where the socks end. The other answers do not describe edema.
nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect?
a. Excruciating pain on inspiration
b. Left lateral chest wall pain
c. Disorientation and confusion
d. Numbness and tingling of the arm
ANS: C
In older adults, disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output. Pain manifestations and numbness and tingling of the arm could also be related to the myocardial infarction. However, the nurse should be more concerned about the new onset of disorientation or confusion caused by decreased perfusion.
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take?
a. Elevate the leg and apply a sandbag to the entrance site.
b. Increase the flow rate of intravenous fluids.
c. Assess the color and temperature of the left leg. d. Document the finding as left pedal pulse of +1/4.
ANS: C
Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The pulse may be faint because of edema. The left pulse should be compared with the right, and pulses should be compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider should be notified. Simply documenting the findings is inappropriate. The leg should be positioned below the level of the heart or dangling to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not address the clients problem.
nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention?
a. Urinary output less than intake
b. Bruising at the insertion site
c. Slurred speech and confusion
d. Discomfort in the left leg
ANS: C
A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in neurologic status needs to be acted on immediately. Discomfort and bruising are expected at the site. If intake decreases, a client can become dehydrated because of dye excretion. The second intervention would be to increase the clients fluid status. Neurologic changes would take priority.
A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The clients health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take?
a. Schedule an electrocardiogram just before the MRI.
b. Notify the health care provider before scheduling the MRI.
c. Call the physician and request a laboratory draw for cardiac enzymes.
d. Instruct the client to increase fluid intake the day before the MRI.
ANS: B
The magnetic fields of the MRI can deactivate the pacemaker. The nurse should call the health care provider and report that the client has a pacemaker so the provider can order other diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased fluids.
A nurse assesses a client who is recovering from a myocardial infarction. The clients pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first?
a. Compare the results with previous pulmonary artery pressure readings.
b. Increase the intravenous fluid rate because these readings are low.
c. Immediately notify the health care provider of the elevated pressures. d. Document the finding in the clients chart as the only action.
ANS: A
Normal pulmonary artery pressures range from 15 to 26 mm Hg for systolic and from 5 to 15 mm Hg for diastolic. Although this clients readings are within normal limits, the nurse needs to assess any trends that may indicate a need for medical treatment to prevent complications. There is no need to increase intravenous fluids or notify the provider.
A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery?
a. Administration of IV furosemide (Lasix)
b. Initiation of an external pacemaker
c. Assistance with endotracheal intubation d. Placement of central venous access
ANS: B
The RCA supplies the right atrium, the right ventricle, the inferior portion of the left ventricle, and the atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would go into heart block, so emergency pacing should be available for the client. Furosemide, intubation, and central venous access will not address the primary complication of RCA occlusion, which is AV node malfunction.
A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this clients teaching?
a. The best way to lose weight is a high-protein, low-carbohydrate diet.
b. You should balance weight loss with consuming necessary nutrients.
c. A nutritionist will provide you with information about your new diet. d. If you exercise more frequently, you wont need to change your diet.
ANS: B
Clients at risk for cardiovascular diseases should follow the American Heart Association guidelines to combat obesity and improve cardiac health. The nurse should encourage the client to eat vegetables, fruits, unrefined whole-grain products, and fat-free dairy products while losing weight. High-protein food items are often high in fat and calories. Although the nutritionist can assist with client education, the nurse should include nutrition education and assist the client to make healthy decisions. Exercising and eating nutrient-rich foods are both important components in reducing cardiovascular risk.
A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at night. How should the nurse respond?
a. I will consult the provider to prescribe a sleep study to determine the problem.
b. You become hypoxic while sleeping; oxygen therapy via nasal cannula will help.
c. A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night. d. Use pillows to elevate your head and chest while you are sleeping.
ANS: D
The client is experiencing orthopnea (shortness of breath while lying flat). The nurse should teach the client to elevate the head and chest with pillows or sleep in a recliner. A sleep study is not necessary to diagnose this client. Oxygen and CPAP will not help a client with orthopnea.
A nurse cares for a client who is recovering from a myocardial infarction. The client states, I will need to stop eating so much chili to keep that indigestion pain from returning. How should the nurse respond?
a. Chili is high in fat and calories; it would be a good idea to stop eating it.
b. The provider has prescribed an antacid for you to take every morning.
c. What do you understand about what happened to you? d. When did you start experiencing this indigestion?
ANS: C
Clients who experience myocardial infarction often respond with denial, which is a defense mechanism. The nurse should ask the client what he or she thinks happened, or what the illness means to him or her. The other responses do not address the clients misconception about recent pain and the cause of that pain.
A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond?
a. This is a routine surgery and the risk of death is very low.
b. Would you like to speak with a chaplain prior to surgery?
c. Tell me more about your concerns about the surgery. d. What support systems do you have to assist you?
ANS: C
The nurse should discuss the clients feelings and concerns related to the surgery. The nurse should not provide false hope or push the clients concerns off on the chaplain. The nurse should address support systems after addressing the clients current issue.
An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first?
a. A 42-year-old female who describes her pain as a dull ache with numbness in her fingers
b. A 49-year-old male who reports moderate pain that is worse on inspiration
c. A 53-year-old female who reports substernal pain that radiates to her abdomen
d. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest
ANS: D
All clients who have chest pain should be assessed more thoroughly. To determine which client should be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing, vise-like substernal pain that spreads through the clients chest, arms, jaw, back, or neck is indicative of a myocardial infarction. The nurse should plan to see this client first to prevent cardiac cell death. A dull ache with numbness in the fingers is consistent with anxiety. Pain that gets worse with inspiration is usually related to a pleuropulmonary problem. Pain that spreads to the abdomen is often associated with an esophageal-gastric problem, especially when this pain is experienced by a male client. Female clients may experience abdominal discomfort with a myocardial event. Although clients with anxiety, pleuropulmonary, and esophageal-gastric problems should be seen, they are not a higher priority than myocardial infarction.
nurse auscultated heart tones on an older adult client. Which action should the nurse take based on heart tones heard?
(Click the media button to hear the audio clip.)
a. Administer a diuretic.
b. Document the finding.
c. Decrease the IV flow rate.
d. Evaluate the clients medications.
ANS: B
The sound heard is an atrial gallop S4. An atrial gallop may be heard in older clients because of a stiffened ventricle. The nurse should document the finding, but no other intervention is needed at this time.
A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below should the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation?
a. Location A b. Location B c. Location C d. Location D
ANS: A
The aortic valve is auscultated in the second intercostal space just to the right of the sternum
A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.) a. Assess for allergies to iodine.
b. Administer intravenous fluids.
c. Assess blood urea nitrogen (BUN) and creatinine results.
d. Insert a Foley catheter.
e. Administer a prophylactic antibiotic.
f. Insert a central venous catheter.
ANS: A, B, C
If the client has kidney disease (as indicated by BUN and creatinine results), fluids and Mucomyst may be given 12 to 24 hours before the procedure for renal protection. The client should be assessed for allergies to iodine, including shellfish; the contrast medium used during the catheterization contains iodine. A Foley catheter and central venous catheter are not required for the procedure and would only increase the clients risk for infection. Prophylactic antibiotics are not administered prior to a cardiac catheterization.
