Lewis Ch 31: Assessment: Cardiovascular System

Question 1

An older adult patient who has just arrived in the emergency department has a pulse deficit of 46 beats. The nurse should expect that the patient may require:

a. cardiac catheterization.
b. emergent cardioversion.
c. hourly blood pressure checks.
d. electrocardiographic monitoring.

Answer 1

ANS: D
Pulse deficit is a difference between simultaneously obtained apical and radial pulses. It indicates that there may be a cardiac dysrhythmia that would best be detected with ECG monitoring. Frequent BP monitoring, cardiac catheterization, and emergent cardioversion are used for diagnosis and/or treatment of cardiovascular disorders but would not be as helpful in determining the immediate reason for the pulse deficit.

Question 2

The nurse is reviewing the 12-lead electrocardiograph (ECG) for a healthy older adult patient who is having an annual physical examination. What finding should be of most concern to the nurse?

a. A right bundle branch block
b. The PR interval is 0.21 seconds.
c. The QRS duration is 0.13 seconds.
d. The heart rate (HR) is 41 beats/min.

Answer 2

ANS: D
The resting HR does not change with aging, so the decrease in HR needs further investigation. Bundle branch block and slight increases in PR interval or QRS duration are common in older individuals because of increases in conduction time through the AV node, bundle of His, and bundle branches.

Question 3

During a physical examination of an older patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. What would be the most focused follow-up action for the nurse to take?

a. Ask about risk factors for atherosclerosis.
b. Determine family history of heart disease.
c. Assess for symptoms of left ventricular hypertrophy.
d. Auscultate carotid arteries for the presence of a bruit.

Answer 3

ANS: C
The PMI should be felt at the intersection of the fifth intercostal space and left midclavicular line. A PMI found outside these landmarks indicates possible cardiac enlargement, such as with left ventricular hypertrophy (LVH). The other assessments are part of a general cardiac assessment but do not represent follow-up for LVH. Cardiac enlargement is not necessarily associated with atherosclerosis or carotid artery disease.

Question 4

How should the nurse listen to auscultate for S3 or S4 gallops in the mitral area?

a. Use the diaphragm of the stethoscope with the patient lying flat.
b. Use the bell of the stethoscope with the patient in the left lateral position.
c. Use the diaphragm of the stethoscope with the patient in a supine position.
d. Use the bell of the stethoscope with the patient sitting and leaning forward.

Answer 4

ANS: B
Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall. The diaphragm of the stethoscope is best to use for the higher pitched sounds such as S1 and S2.

Question 5

Which laboratory test result will the nurse review to determine the effects of therapy for a patient being treated for heart failure?

a. Troponin
b. Homocysteine (Hcy)
c. Low-density lipoprotein (LDL)
d. B-type natriuretic peptide (BNP)

Answer 5

ANS: D
Increased levels of BNP are a marker for heart failure. The other laboratory results would assess for myocardial infarction (troponin) or risk for coronary artery disease (Hcy and LDL).

Question 6

While doing the hospital admission assessment for a thin older adult, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take next?

a. Teach the patient about aneurysms.
b. Notify the hospital rapid response team.
c. Instruct the patient to remain on bed rest.
d. Document the finding in the patient chart.

Answer 6

ANS: D
Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals. The nurse should simply document the finding in the admission assessment. Unless there are other abnormal findings (such as a bruit, pain, or hyper/hypotension) associated with the pulsation, the other actions are not necessary.

Question 7

A patient is scheduled for a cardiac catheterization with coronary angiography. What information should the nurse provide before the procedure?

a. It will be important not to move at all during the procedure.
b. A flushed feeling is common when the contrast dye is injected.
c. Monitored anesthesia care will be provided during the procedure.
d. Arterial pressure monitoring will be needed for 24 hours after the test.

Answer 7

ANS: B
A sensation of warmth or flushing is common when the contrast material is injected, which can be anxiety producing unless it has been discussed with the patient. The patient may receive a sedative drug before the procedure but monitored anesthesia care is not used. Arterial pressure monitoring is not routinely used after the procedure to monitor blood pressure. The patient is not immobile during cardiac catheterization and may be asked to cough or take deep breaths.

Question 8

The nurse notes that a patient who was admitted with heart failure has jugular venous distention (JVD) when lying flat. Which follow-up action should the nurse take?

a. Encourage the patient to drink more liquids.
b. Check the apical and radial pulse for a pulse deficit.
c. Observe the neck veins with the patient elevated 45 degrees.
d. Have the patient bear down to perform the Valsalva maneuver.

Answer 8

ANS: C
When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but not a clinically significant) finding. JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure increases. More fluids will further increase any fluid overload. JVD but is not confirmed based on the data given. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant.

Question 9

A patient will be evaluated for rhythm disturbances with a Holter monitor. What should the nurse teach the patient to do?

a. Connect the recorder to a computer once daily.
b. Exercise more than usual while the monitor is in place.
c. Remove the electrodes when taking a shower or tub bath.
d. Keep a diary of daily activities while the monitor is worn.

Answer 9

ANS: D
The patient is taught to keep a diary describing daily activities while Holter monitoring is being accomplished to help correlate any rhythm disturbances with patient activities. Patients are taught that they should not take a shower or bath during Holter monitoring and that they should continue with their usual daily activities. The recorder stores the information about the patient’s rhythm until the end of the testing, when it is removed and the data are analyzed.

Question 10

How should the nurse document a loud humming sound auscultated over the patient’s abdominal aorta?

a. Thrill
b. Bruit
c. Murmur
d. Normal finding

Answer 10

ANS: B
A bruit is the sound created by turbulent blood flow in an artery. Thrills are palpable vibrations felt when there is turbulent blood flow through the heart or in a blood vessel. A murmur is the sound caused by turbulent blood flow through the heart. Auscultating a bruit in an artery is not normal and indicates pathology.

Question 11

The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. Which laboratory test result should be most helpful in indicating myocardial damage?

a. Troponins
b. Myoglobin
c. Homocysteine (Hcy)
d. Creatine kinase-MB (CK-MB)

Answer 11

ANS: A
Cardiac troponins start to elevate 4 to 6 hours after myocardial injury and are highly specific to myocardium. They are the preferred diagnostic marker for myocardial infarction. Myoglobin rises in response to myocardial injury within 30 to 60 minutes. It is rapidly cleared from the body, thus limiting its use in the diagnosis of myocardial infarction. Creatine kinase (CK-MB) is specific to myocardial injury and infarction and increases 4 to 6 hours after the infarction occurs. It is often trended with troponin levels. Homocysteine (Hcy) is an amino acid that is made during protein catabolism. Elevated levels of Hcy are linked to a higher risk of CVD, peripheral vascular disease, and stroke.

Question 12

When assessing a newly admitted patient, the nurse notes a murmur along the left sternal border. To obtain more information about the murmur, which action should the nurse take?

a. Palpate the peripheral pulses.
b. Determine the timing of the sound.
c. Find the point of maximal impulse.
d. Compare apical and radial pulse rates.

Answer 12

ANS: B
Murmurs are caused by turbulent blood flow, such as occurs when blood flows through a damaged valve. Relevant information includes the position in which the murmur is heard best (e.g., sitting and leaning forward), the timing of the murmur in relation to the cardiac cycle (e.g., systole, diastole), and where on the thorax the murmur is heard best. The other information is important in the cardiac assessment but will not provide information that is relevant to the murmur.

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. How will the nurse record this information?

a. Systolic murmur heard at mitral area.
b. Systolic murmur heard at Erb’s point.
c. Diastolic murmur heard at aortic area.
d. Diastolic murmur heard at the point of maximal impulse.

Answer 13

ANS: A
The S1 signifies the onset of ventricular systole. S2 signifies the onset of diastole. A murmur occurring between these two sounds is a systolic murmur. The mitral area is the intersection of the left fifth intercostal space and the midclavicular line. The other responses describe murmurs heard at different landmarks on the chest and/or during the diastolic phase of the cardiac cycle.

Question 14

A registered nurse (RN) is observing a student nurse who is assessing a patient. Which action observed by the RN requires immediate intervention?
a. The student nurse presses on the skin over the tibia for 10 seconds to check for
edema.
b. The student nurse palpates both carotid arteries simultaneously to compare pulse
quality.
c. The student nurse documents a murmur heard along the right sternal border as a
pulmonic murmur.
d. The student nurse places the patient in the left lateral position to check for the
point of maximal impulse.

Answer 14

ANS: B
The carotid pulses should never be palpated at the same time to avoid vagal stimulation, dysrhythmias, and decreased cerebral blood flow. The other assessment techniques also need to be corrected. However, they are not dangerous to the patient.

Question 15

Which action will the nurse implement for a patient who arrives for a calcium-scoring CT scan?

a. Insert an IV catheter.
b. Administer oral sedative medications.
c. Teach the patient about the procedure.
d. Confirm that the patient has been fasting.

Answer 15

ANS: C
The nurse will need to teach the patient that the procedure is rapid and involves little risk. None of the other actions are necessary.

Question 16

Which information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI) will be important to report to the health care provider before the MRI?

a. The patient has an allergy to shellfish.
b. The patient has a history of atherosclerosis.
c. The patient has a permanent cardiac pacemaker.
d. The patient took the prescribed heart medications today.

Answer 16

ANS: C
MRI is contraindicated for patients with implanted metallic devices such as pacemakers. The other information does not affect whether the patient can have an MRI.

Question 17

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 reports feeling tired
b. Sinus tachycardia at a rate of 110 beats/min
c. Inversion of T waves on the electrocardiogram
d. Blood pressure (BP) increase from 134/68 to 150/80 mm Hg

Answer 17

ANS: C
ECG changes associated with coronary ischemia (such as T-wave inversions and ST segment depression) indicate that the myocardium is not getting adequate O2 delivery and that the exercise test should be stopped immediately. Increases in BP and heart rate are normal responses to aerobic exercise. Feeling tired is also normal as the intensity of exercise increases during the stress testing.

Question 18

The standard policy on the cardiac unit states, “Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg.” Which patient should the nurse call the health care provider about?

a. Postoperative patient with a BP of 116/42 mm Hg.
b. Newly admitted patient with a BP of 150/87 mm Hg.
c. Patient with left ventricular failure who has a BP of 110/70 mm Hg.
d. Patient with a myocardial infarction who has a BP of 140/86 mm Hg.

Answer 18

ANS: A
The mean arterial pressure (MAP) is calculated using the formula MAP = (systolic BP + 2 diastolic BP)/3. The MAP for the postoperative patient is 67. The MAP in the other three patients is higher than 70 mm Hg.

Question 19

When admitting a patient for a cardiac catheterization and coronary angiogram, which information about the patient is important for the nurse to communicate to the health care provider before the test?

a. The patient’s pedal pulses are +1.
b. The patient is allergic to shellfish.
c. The patient had a heart attack 1 year ago.
d. The patient has not eaten anything today.

Answer 19

ANS: B
The contrast dye used for the procedure is iodine based, so patients who have shellfish allergies will require treatment with medications, such as corticosteroids and antihistamines before the angiogram. The other information may be communicated to the health care provider but will not require a change in the usual precardiac catheterization orders or medications.

Question 20

A transesophageal echocardiogram (TEE) is planned for a patient hospitalized with possible endocarditis. Which action included in the standard TEE orders will the nurse need to accomplish first?

a. Start an IV line.
b. Start O2 per nasal cannula.
c. Place the patient on NPO status.
d. Give lorazepam (Ativan) 1 mg IV

Answer 20

ANS: C
The patient will need to be NPO for 6 hours preceding the TEE, so the nurse should place the patient on NPO status as soon as the order is received. The other actions also will need to be accomplished but not until just before or during the procedure.

Question 21

The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four patients. Which nursing action can be delegated to the UAP?

a. Teaching a patient about exercise electrocardiography
b. Attaching ECG monitoring electrodes after a patient bathes
c. Monitoring a patient after a transesophageal echocardiogram
d. Checking the patient’s catheter site after a coronary angiogram

Answer 21

ANS: B
UAP can be educated in standardized lead placement for ECG monitoring. Assessment of patients who have had procedures where airway maintenance (transesophageal echocardiography) or bleeding (coronary angiogram) is a concern must be done by the registered nurse (RN). Patient teaching requires RN level education and scope of practice.

Question 22

The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular unit. Which laboratory result is most important to communicate rapidly to the health care provider?

a. High troponin I level
b. Increased triglyceride level
c. Very low homocysteine level
d. Elevated C-reactive protein level

Answer 22

ANS: A
The elevation in troponin I indicates that the patient has had an acute myocardial infarction. Further assessment and interventions are indicated. The other laboratory results are indicative of increased risk for coronary artery disease but are not associated with acute cardiac problems that need immediate intervention.

Question 23

When the nurse is screening patients for possible peripheral arterial disease, indicate where the posterior tibial artery will be palpated.

a. 1
b. 2
c. 3
d. 4

Answer 23

ANS: C
The posterior tibial site is located behind the medial malleolus of the tibia.