Exam 1 Flashcards
Assessment
The nurse is caring for a client with elevated blood pressure and no previous history of hypertension. At 0900, the blood pressure was 158/90 mm Hg. At 0930, the blood pressure is 142/82 mm Hg. The nurse is most correct when relating the fall in blood pressure to which structure?
A. Chemoreceptors
B. Sympathetic nerve fibers
C. Baroreceptors
D. Vagus nerve
C. Baroreceptors
Baroreceptors sense pressure in nerve endings in the walls of the atria and major blood vessels. The baroreceptors respond accordingly to raise or lower the pressure. Chemoreceptors are sensitive to pH, CO2, and O2 in the blood. Sympathetic nerve fibers increase the heart rate. The vagus nerve slows the heart rate.
The nurse cares for a client with diabetes who is scheduled for a cardiac catheterization. Before the procedure, the nurse needs to ask which question?
A. “Are you allergic to shellfish?”
B. “Are you having chest pain?”
C. “When was the last time you ate or drank?”
D. “What was your morning blood sugar reading?”
A. “Are you allergic to shellfish?”
Radiopaque contrast agents are used to visualize the coronary arteries. Some contrast agents contain iodine, and the client is assessed before the procedure for previous reactions to contrast agents or allergies to iodine-containing substances (e.g., seafood). If the client has a suspected or known allergy to the substance, antihistamines or methylprednisolone may be administered before the procedure. Although the other questions are essential to ask the client, it is most important to ascertain if the client has an allergy to shellfish.
A nurse checks laboratory values on a client with crackles in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which laboratory value does the nurse expect to be abnormal?
A. Potassium
B. B-type natriuretic peptide (BNP)
C. C-reactive protein (CRP)
D. Platelet count
B. B-type natriuretic peptide (BNP)
The client’s symptoms suggest heart failure. BNP is a neurohormone released from the ventricles when the ventricles experience increased pressure and stretch, such as in heart failure. A BNP level greater than 51 pg/ml is commonly associated with mild heart failure. As the BNP level increases, the severity of heart failure increases. Potassium levels aren’t affected by heart failure. CRP is an indicator of inflammation. It’s used to help predict the risk of coronary artery disease. There is no indication that the client has an increased CRP. There is no indication that the client is experiencing bleeding abnormalities, such as those seen with an abnormal platelet count.
The nurse is assessing a client’s blood pressure. What does the nurse document as the difference between the systolic and the diastolic pressure?
A. Pulse pressure
B. Auscultatory gap
C Pulse deficit
D. Korotkoff sound
A. Pulse pressure
The nurse reviews a client’s lab results and notes a serum calcium level of 7.9 mg/dL. What condition is most appropriate for the nurse to monitor the client for?
A. Impaired myocardial contractility
B. Enhanced sensitivity to digitalis
C. Increased risk of heart block
D. Inclination to ventricular fibrillation
A. Impaired myocardial contractility
Normal serum calcium is 8.9 to 10.3 mg/dL. A reading of 7.9 is below normal. Hypocalcemia is associated with slow nodal functioning and impaired myocardial contractility, which can increase the risk of heart failure.
A client had a cardiac catheterization and is now in the recovery area. What nursing interventions should be included in the plan of care? (Select all that apply.)
A. Assessing the peripheral pulses in the affected extremity
B. Checking the insertion site for hematoma formation
C. Evaluating temperature and color in the affected extremity
D. Assisting the client to the bathroom after the procedure E. Assessing vital signs every 8 hours
A. Assessing the peripheral pulses in the affected extremity
B. Checking the insertion site for hematoma formation
C. Evaluating temperature and color in the affected extremity
The nurse should observe the catheter access site for bleeding or hematoma formation and assess peripheral pulses in the affected extremity (dorsalis pedis and posterior tibial pulses in the lower extremity, radial pulse in the upper extremity) every 15 minutes for 1 hour, every 30 minutes for 1 hour, and hourly for 4 hours or until discharge. Blood pressure and heart rate should also be assessed during these same time intervals, not every 8 hours. The nurse should evaluate the temperature, color, and capillary refill of the affected extremity during these same time intervals. The client should maintain bed rest for 2 to 6 hours after the procedure.
After a physical examination, the provider diagnosed a client with a grade 4 heart murmur. When auscultating a murmur, what does the nurse expect to hear?
A. Easily heard with no palpable thrill.
B. Quiet but readily heard.
C. Loud and may be associated with a thrill sound similar to (a purring cat).
D. Very loud; can be heard with the stethoscope halfway off the chest.
C. Loud and may be associated with a thrill sound similar to (a purring cat).
Heart murmurs are characterized by location, timing, and intensity. A grading system describes the intensity or loudness of a murmur. A grade 1 is very faint and difficult to describe, whereas a grade 6 is extremely loud. Refer to Box 12-3 in the text for a description of grades 1 to 6.
The nurse is caring for a client who has just undergone an electrophysiologic (EP) study. The client reports nervousness about “things going wrong” during the procedure. What is the nurse’s best response?
A. “This is basically a risk-free procedure.”
B. “Thousands of clients undergo EP every year.”
C. “Remember that this step will bring you closer to enjoying good health.”
D. “The whole team will closely monitor you for the entire procedure.”
D. “The whole team will closely monitor you for the entire procedure.”
The nurse caring for a client who is suspected of having cardiovascular disease has a stress test ordered. The client has a co-morbidity of multiple sclerosis, so the nurse knows the stress test will be drug-induced. What drug will be used to dilate the coronary arteries?
A. Thallium
B. Ativan
C. Diazepam
D. Dobutamine
D. Dobutamine
Drugs such as adenosine (Adenocard), dipyridamole (Persantine), or dobutamine (Dobutrex) may be administered singularly or in combination by the IV route. The drugs dilate the coronary arteries, similar to vasodilation, when a person exercises to increase the heart muscle’s blood supply. The other options would not widen the coronary arteries.
The nurse is providing discharge education for a client going home after cardiac catheterization. What information is a priority to include when providing discharge education?
A. Avoid tub baths, but shower as desired.
B. Do not ambulate until the health care provider indicates it is appropriate.
C. Expect increased bruising to appear at the site over the next several days.
D. Returning to work immediately is okay.
A. Avoid tub baths, but shower as desired
Guidelines for self-care after hospital discharge following a cardiac catheterization include showering as desired (no tub baths) and avoiding bending at the waist and lifting heavy objects. The health care provider will indicate when it is okay to return to work. The client should notify the health care provider right away if bleeding, new bruising, swelling, or pain are noted at the puncture site. The client will be able to ambulate after the puncture site has clotted
While being prepared for echocardiography, the client asks the nurse why this test is necessary. What would be the nurse’s best response?
A. “This test will find any congenital heart defects.”
B. “This test can tell us a lot about your heart.”
C. “Echocardiography is a way of determining the functioning of the left ventricle of your heart.”
D. “Echocardiography will tell your health care provider if you have cancer of the heart.”
C. “Echocardiography is a way of determining the functioning of the left ventricle of your heart.”
Echocardiography uses ultrasound waves to determine the functioning of the left ventricle and to detect cardiac tumors, congenital defects, and changes in the tissue layers of the heart. Explaining the procedure is the best answer because it addresses the client’s question without making the client anxious or minimizing the question.
The instructor is teaching a pre-nursing anatomy and physiology class. The class is studying the cardiovascular system. What does the instructor tell the class safeguards the heart from infectious microorganisms?
A. The inner layer of the endocardium
B. The outer layer or the epicardium
C. The serous epicardium
D. The parietal pericardium
D. The parietal pericardium
The nurse assesses an older adult client and auscultates an S3 heart sound. What condition does the nurse determine may correlate with this finding?
A. congenital heart disease
B. heart failure
C. aortic stenosis
D. coronary artery disease
B. heart failure
The S3 heart sound is heard immediately after the S2 sound, early in diastole, as blood flows from the atrium into a noncompliant ventricle. The S3 heart sound is typical in children and young adults, but a significant finding suggests heart failure in older adults. A client with aortic stenosis commonly may have a murmur. A client with congenital heart disease may have more than one abnormal heart sound. Clients with coronary artery disease do not have S3 heart sounds.
The nurse cares for a client in the emergency department with a B-type natriuretic peptide (BNP) level of 115 pg/mL. The nurse recognizes that this finding is most indicative of which condition?
A. heart failure
B . ventricular hypertrophy
C. pulmonary edema
D. myocardial infarction
A. heart failure
A BNP level greater than 100 pg/mL is suggestive of heart failure. Because this serum laboratory test can be quickly obtained, BNP levels are helpful for prompt diagnosis of heart failure in settings such as the emergency department. Elevations in BNP can occur from several other conditions, such as pulmonary embolus, myocardial infarction (MI), and ventricular hypertrophy. Therefore, the health care provider correlates BNP levels with abnormal physical assessment findings and other diagnostic tests before diagnosing heart failure.
Which heart chamber is measured for central venous pressure?
A. right atrium
B. left atrium
C. left ventricle
D. right ventricle
A. right atrium
The pressure in the right atrium is used to assess right ventricular function and venous blood return to the heart. The left atrium receives oxygenated blood from the pulmonary circulation. The left ventricle receives oxygenated blood from the left atrium. The right ventricle is not the central collecting chamber of venous circulation.
A nurse is assessing a client with heart failure. When assessing hepatojugular reflux, what is the appropriate action for the nurse to take?
A. elevate the client’s head to 90 degrees.
B. press the right upper abdomen.
C. press the left upper abdomen.
D. lay the client flat in bed.
B. Press the right upper abdomen.
As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. A client has positive hepatojugular reflux if the internal jugular vein becomes distended. Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree, not 90-degree, angle.
A student nurse prepares to assess a client for postural blood pressure changes. Which action indicates the student nurse needs further education?
A. letting 30 seconds elapse after each position change before measuring BP and HR
B. Position the client supine for 10 minutes before taking the initial BP and HR.
C. taking the client’s BP with the client sitting on the edge of the bed, feet dangling
D. obtaining the supine measurements before the sitting and standing measurements
A. letting 30 seconds elapse after each position change before measuring BP and HR
(1) Position the client supine for 10 minutes before taking the initial BP and HR measurements
(2) reposition the client to a sitting position with legs in the dependent position, and wait 2 minutes to reassess both BP and HR measurements
(3) if the client is symptom-free or has no significant decreases in systolic or diastolic BP, assist the client into a standing position, obtain measurements immediately, and recheck in 2 minutes
(4) continue measurements every 2 minutes for 10 minutes to rule out postural hypotension.
During discharge teaching, an older adult client diagnosed with coronary artery disease asks why they must monitor their high-density lipid (HDL) levels regularly. Which is the nurse’s best response?
A. “Keeping HDL levels low is an easy way to help restore the normal function of your heart.”
B. “During the aging process, we produce less HDL, so monitoring the level is important.”
C. “It is important to monitor low-density lipid levels as well.”
D. “HDL helps your blood carry cholesterol to the liver so it can leave the body.”
D. “HDL helps your blood carry cholesterol to the liver so it can leave the body.”
HDL has a protective action by transporting cholesterol away from the arterial wall to the liver for excretion and so has a protective property. While it is true total cholesterol levels should be monitored, this doesn’t directly address the client’s question. Aging is not directly associated with HDL levels.
The nurse assesses a client’s peripheral pulses and indicates that the pulse quality is +1 on a scale of 0-4. What does this documented finding indicate?
A. Diminished, but cannot be obliterated with pressure.
B. Full, easy to palpate, and cannot be obliterated with pressure.
C. Difficult to palpate and is obliterated with pressure.
D. Strong and bounding and may be abnormal.
C. Difficult to palpate and is obliterated with pressure.
The quality of pulses is reported using descriptors and a scale of 0 to 4. The lower the number, the weaker the pulse and the easier it is to obliterate it. A +1 pulse is weak and thready and easily obliterated with pressure.
The nurse accompanies a client to an exercise stress test. The client can achieve the target heart rate, but the electrocardiogram indicates ST-segment elevation. Which procedure will the nurse prepare the client for next?
A. cardiac catheterization
B. telemetry monitoring
C. transesophageal echocardiogram
D. pharmacologic stress test
A. cardiac catheterization
An elevated ST-segment means an evolving myocardial infarction. A cardiac catheterization would be the logical next step.
When caring for a client with dysfunction in the conduction system, at which period would the nurse note that cells resist stimulation?
A. During polarization
B. During depolarization
C. During repolarization
D. During the refractory period
D. During the refractory period
The refractory period is the time when cells are resistant to electrical stimulation. Repolarization is when the ions realign themselves to wait for an electrical signal. Depolarization occurs during muscle contraction when positive ions move inside the myocardial cell membrane and negative ions move outside. Before an impulse is generated, the cells are in a polarized state.
