Chapter 33: Assessment of the Cardiovascular System 8th Edition

Question 1

1. 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

Answer 1

a. Heart rate of 120 beats/min

Question 2

2. 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

Answer 2

d. Pulse decreased from 100 beats/min to 80 beats/min

Question 3

3. 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

Answer 3

c. A 45-year-old American Indian woman with diabetes mellitus

Question 4

4. 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.

Answer 4

c. Assess the clients medications.

Question 5

5. 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.

Answer 5

a. I get short of breath when I climb stairs.

Question 6

6. 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.

Answer 6

b. My shoes fit tighter by the end of the day.

Question 7

7. A 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

Answer 7

c. Disorientation and confusion

Question 8

8. 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.

Answer 8

c. Assess the color and temperature of the left leg.

Question 9

9. A 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

Answer 9

c. Slurred speech and confusion

Question 10

10. A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure?
    a. Clients level of anxiety
    b. Ability to turn self in bed
    c. Cardiac rhythm and heart rate
    d. Allergies to iodine-based agents

Answer 10

d. Allergies to iodine-based agents

Question 11

11. 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.

Answer 11

b. Notify the health care provider before scheduling the MRI.

Question 12

12. 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.

Answer 12

a. Compare the results with previous pulmonary artery pressure readings.

Question 13

13. 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

Answer 13

b. Initiation of an external pacemaker

Question 14

14. 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.

Answer 14

b. You should balance weight loss with consuming necessary nutrients.

Question 15

15. 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.

Answer 15

d. Use pillows to elevate your head and chest while you are sleeping.

Question 16

16. 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?

Answer 16

c. What do you understand about what happened to you?

Question 17

17. 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?

Answer 17

c. Tell me more about your concerns about the surgery.

Question 18

18. 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

Answer 18

d. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest

Question 19

19. A 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.

Answer 19

b. Document the finding.

Question 20

20. 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

Answer 20

A, The aortic valve is auscultated in the second intercostal space just to the right of the sternum.

Question 21

1. 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.

Answer 21

a. Assess for allergies to iodine.
b. Administer intravenous fluids.
c. Assess blood urea nitrogen (BUN) and creatinine results.

Question 22

2. An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.)
   a. Hypertension
   b. Fatigue despite adequate rest
   c. Indigestion
   d. Abdominal pain
   e. Shortness of breath

Answer 22

b. Fatigue despite adequate rest
c. Indigestion
e. Shortness of breath

Question 23

3. A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.)
   a. Blood pressure of 140/88 mm Hg
   b. Serum potassium of 2.9 mEq/L
   c. Warmth and redness at the site
   d. Expanding groin hematoma
   e. Rhythm changes on the cardiac monitor

Answer 23

b. Serum potassium of 2.9 mEq/L
d. Expanding groin hematoma
e. Rhythm changes on the cardiac monitor

Question 24

4. A nurse reviews a clients laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.)
   a. Total cholesterol: 280 mg/dL
   b. High-density lipoprotein cholesterol: 50 mg/dL
   c. Triglycerides: 200 mg/dL
   d. Serum albumin: 4 g/dL
   e. Low-density lipoprotein cholesterol: 160 mg/dL

Answer 24

a. Total cholesterol: 280 mg/dL
c. Triglycerides: 200 mg/dL
e. Low-density lipoprotein cholesterol: 160 mg/dL

Question 25

5. A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply.)
   a. Assist the provider to place a central venous access device.
   b. Prepare for continuous blood pressure and pulse monitoring.
   c. Administer the clients prescribed beta blocker.
   d. Give the client nothing by mouth 3 to 6 hours before the procedure.
   e. Explain to the client that dobutamine will simulate exercise for this examination.

Answer 25

b. Prepare for continuous blood pressure and pulse monitoring.
d. Give the client nothing by mouth 3 to 6 hours before the procedure.
e. Explain to the client that dobutamine will simulate exercise for this examination.

Question 26

6. A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.)
   a. Thrombophlebitis
   b. Stroke
   c. Pulmonary embolism
   d. Myocardial infarction
   e. Cardiac tamponade

Answer 26

a. Thrombophlebitis
c. Pulmonary embolism
e. Cardiac tamponade