ASSESSING THE CARDIOVASCULAR Flashcards
(10 cards)
A nurse is assessing a client with suspected heart failure. Which assessment finding is most consistent with left-sided heart failure?
A. Jugular vein distention
B. Peripheral edema
C. Crackles in the lungs
D. Hepatomegaly
C. Crackles in the lungs
Rationale: Crackles are a sign of pulmonary congestion caused by left-sided heart failure. The other findings are more associated with right-sided heart failure.
During a cardiovascular assessment, which finding would the nurse recognize as a sign of decreased cardiac output?
A. Warm, flushed skin
B. Strong peripheral pulses
C. Capillary refill time less than 2 seconds
D. Cool, clammy extremities
D. Cool, clammy extremities
Rationale: Decreased cardiac output can lead to poor perfusion, resulting in cool and clammy skin due to vasoconstriction.
Which pulse site should the nurse use to assess for pulse deficits during a cardiovascular assessment?
A. Brachial and radial
B. Apical and radial
C. Carotid and brachial
D. Femoral and dorsalis pedis
B. Apical and radial
Rationale: Pulse deficit is assessed by comparing apical and radial pulses; a difference may indicate an irregular heartbeat or atrial fibrillation.
Which of the following blood pressure readings indicates stage 1 hypertension according to the American Heart Association?
A. 118/76 mmHg
B. 124/78 mmHg
C. 132/84 mmHg
D. 142/92 mmHg
C. 132/84 mmHg
Rationale: Stage 1 hypertension is defined as systolic 130-139 or diastolic 80-89 mmHg.
A nurse hears a swishing sound while auscultating a patient’s carotid artery. What is the correct term for this sound?
A. Murmur
B. Bruit
C. Thrill
D. Gallop
B. Bruit
Rationale: A bruit is a turbulent blood flow sound heard over arteries, often indicating atherosclerosis.
Which heart sound is typically heard at the apex of the heart with the bell of the stethoscope in a patient with left ventricular failure?
A. S1
B. S2
C. S3
D. Murmur
C. S3
Rationale: An S3 sound may be heard in patients with heart failure and is best heard at the apex with the bell.
Which symptom reported by the client is most indicative of myocardial infarction (MI)?
A. Sharp chest pain relieved by rest
B. Crushing chest pain radiating to the left arm
C. Intermittent claudication
D. Pain worsened with inspiration
B. Crushing chest pain radiating to the left arm
Rationale: Classic signs of MI include chest pain radiating to the arm or jaw, often not relieved by rest.
The nurse assesses a client with a regular heart rate of 48 bpm. The client is alert and asymptomatic. What is the most appropriate nursing action?
A. Administer oxygen
B. Notify the healthcare provider
C. Begin chest compressions
D. Document the finding as normal
B. Notify the healthcare provider
Rationale: Bradycardia (<60 bpm) should be reported, even if the patient is asymptomatic, especially if it is a new finding.
Which finding on assessment is most indicative of aortic valve stenosis?
A. Diastolic murmur
B. Loud S2 sound
C. Harsh systolic murmur at the right second intercostal space
D. Opening snap followed by a rumbling murmur
C. Harsh systolic murmur at the right second intercostal space
Rationale: Aortic stenosis typically presents with a harsh systolic murmur best heard at the right upper sternal border.
A nurse is performing a cardiac assessment on a client with pericarditis. Which sound is most likely to be heard?
A. Systolic click
B. Pericardial friction rub
C. Opening snap
D. S3 gallop
B. Pericardial friction rub
Rationale: A pericardial friction rub is a high-pitched, scratchy sound heard with pericarditis, often best auscultated at the left lower sternal border.
