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Flashcards in Chapter 35 Deck (28):

The nurse is caring for a client who has had a recent myocardial infarction involving the left ventricle. Which assessment finding is expected? a. Faint S1 and S2 sounds b. Decreased cardiac output c. Increased blood pressure d. Absent peripheral pulses

B: The myocardium is the layer responsible for the contractile force of the heart. Damage to this layer can result in decreased cardiac output. This most likely would result in decreased blood pressure and strength of peripheral pulses. Absent peripheral pulses would be caused by an arterial occlusion. S1 and S2 most likely would not be affected.


The nurse is caring for a client with coronary artery disease. What assessment finding does the nurse expect if the client’s mean arterial blood pressure decreases below 60 mm Hg? a. Increased cardiac output b. Hypertension c. Chest pain d. Decreased heart rate

C: Coronary artery blood flow occurs primarily during diastole. Mean arterial pressure (MAP) of 60 mg Hg is necessary for adequate blood flow to coronary arteries, and MAP of 60 to 70 mm Hg is necessary for adequate perfusion to major body organs. If MAP decreases to below 60 mm Hg, the client with cardiac disease may have chest pain. Cardiac output most likely would decrease, and blood pressure also would decrease. Heart rate may increase as the body initiates compensatory mechanisms.


The nurse is assessing a client following a myocardial infarction. The client is hypotensive. What additional assessment finding does 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

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 (SA) node. This results in an increase in heart rate. This tachycardia is an early response and is seen even when blood pressure is not critically low


The nurse administers a beta blocker to a client after a myocardial infarction. What assessment finding does the nurse expect? a. Blood pressure increase of 10% b. Increasing respiratory rate c. Increased cardiac output d. Pulse decrease from 100 to 80 beats/min

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 heart rate.


The nurse is assessing clients at a community health center. Which client does the nurse determine is at high risk for cardiovascular disease? a. Older adult man with a history of asthma b. Asian-American man with colorectal cancer c. American Indian woman with diabetes mellitus d. Postmenopausal woman on hormone therapy

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.


The nurse is obtaining a client’s health history. Which illness alerts the nurse to the possibility of abnormal heart valves? a. Tuberculosis b. Recurrent viral pneumonia c. Rheumatic fever d. Asthma

C: Rheumatic fever is an inflammatory disease that typically is caused by infection with group A beta-hemolytic streptococci that can affect the endocardium.


A nurse is performing an admission assessment on an older adult client with multiple chronic diseases. The nurse assesses the heart rate to be 48 beats/min. What does the nurse do first? a. Document the finding in the chart. b. Evaluate for a pulse deficit. c. Assess the client’s medications. d. Administer 1 mg of atropine.

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 to be needed.


The nurse is assessing clients at a clinic. Which activity takes priority? a. Teaching smoking cessation to a middle-aged woman who smokes b. Planning an exercise regimen with a woman with a sedentary lifestyle c. Teaching an older man who is moderately obese to keep a food diary d. Assessing a man with familial coronary artery disease for specific risk factors

A: All of these risk factors contribute to the development of cardiovascular disease, but cigarette smoking is a major risk factor for both coronary artery disease and peripheral vascular disease.


The nurse is assessing a client in the emergency department. Which client statement alerts 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.”

A: Dyspnea on exertion (DOE) 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.


The nurse is assessing a client newly admitted to the medical unit. Which statement made by the client alerts 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.”

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.


When obtaining a client’s vital signs, the nurse assesses a blood pressure of 134/88 mm Hg. What is the nurse’s best intervention? a. Call the health care provider and report the finding. b. Reassess the client’s blood pressure at the next yearly physical. c. Administer an additional antihypertensive medication to the client. d. Teach the client lifestyle modifications to decrease blood pressure.

D: Prehypertension has been designated as 120 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic. These clients are at higher risk for developing hypertension. The client needs to institute dietary and activity changes to help decrease blood pressure. The reading is not high enough for the nurse to call the health care provider. No indications for administering medications are known. Because the client has prehypertension, the nurse should intervene now to help prevent the development of frank hypertension.


The nurse is performing a focused cardiac assessment. What assessment finding should be reported to the health care provider? a. Bruit heard on the side of the neck b. Bounding peripheral pulses c. Pulse rate of 90 beats/min d. Blood pressure of 140/90 mm Hg

A: A bruit is a swishing sound that may develop in narrowed arteries. Bruits usually are associated with atherosclerotic disease. This finding may indicate atherosclerotic disease of the carotid arteries, and further evaluation is needed. Bounding pulses, a pulse rate of 90 beats/min, and a blood pressure of 140/90 mm Hg are not assessment findings that require immediate interventions.


A client consistently reports feeling dizzy and lightheaded when moving from a supine position to a sitting position. What nursing assessment takes priority at this time? a. Pulse oximetry b. Blood pressure c. Respiratory rate d. Neurologic evaluation

B: Dizziness and lightheadedness on moving from a supine to a sitting or standing position may be symptoms of postural hypotension. Orthostatic blood pressure measurements (decrease of more than 20 mm Hg systolic, decrease of more than 10 mm Hg diastolic, and 10% to 20% increase in heart rate) are used to determine the presence of postural hypotension.


The nurse is assessing an older adult client who is experiencing a myocardial infarction. What clinical manifestation does the nurse expect in this client? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Disorientation and confusion d. Numbness and tingling of the arm

C: In older adults, disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output. Pain manifestations could also be related to the myocardial infarction. However, the nurse is more concerned about the new onset of disorientation or confusion caused by decreased perfusion.


A client is newly diagnosed with a heart murmur and asks the nurse to explain what this means. What is the nurse’s best response? a. “It is a rushing sound that blood makes moving through narrow places.” b. “It’s the sound of the heart muscle stretching in an area of weakness.” c. “It’s a term doctors use to describe the efficiency of blood circulation.” d. “It is the sound the heart makes when it is has an increased workload.”

A: Murmurs reflect turbulent blood flow through normal or abnormal valves. The significance of a murmur depends on its cause. Some murmurs are associated with a healthy heart that ejects blood quickly and turbulently from the left ventricle. Other murmurs may be indicators of severe valve, vessel, or heart problems.


A client has returned from a cardiac angiography via the left femoral artery. Two hours after the procedure, the nurse notes that the left pedal pulse is weak. What is the nurse’s best action? 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.

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.


The nurse is recovering a client after a left-sided cardiac catheterization. What 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

C: A left-sided cardiac catheterization specifically increases the risk for a cerebrovascular accident (CVA). 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 client’s fluid status. Neurologic changes would take priority.


The nurse is preparing a client for a cardiac catheterization. What assessment is a priority before the procedure? a. Client’s level of anxiety b. Ability to turn self in bed c. Cardiac rhythm and heart rate d. Allergies to iodine and shellfish

D: Before the procedure, the nurse should ascertain whether the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high priority. Second, it is important for the nurse to assess anxiety, mobility, and knowledge.


The client is scheduled for a resting electrocardiography. Which statement by the client indicates a good understanding of the preprocedure teaching? a. “I cannot eat or drink before the electrocardiography.” b. “I must lie as still as possible during the procedure.” c. “I am likely to feel warmth as the dye enters the heart.” d. “I will increase my fluid intake on the day of the procedure.”

B: Resting electrocardiography is noninvasive and painless and requires the client to be connected to a portable electrocardiographic monitor. Movement can cause artifacts and can interfere with the accuracy of the recording. The client does not have to be NPO before the procedure, and no dye is used. No reason to increase the client’s fluid intake is known.


The nurse is monitoring a client undergoing an exercise electrocardiography (stress test). Which assessment finding necessitates that the test be stopped? a. Heart rate increases to 140 beats/min b. Blood pressure of 100/80 mm Hg c. Respiratory rate exceeds 36 breaths/min d. Significant ST-segment depression

D: This electrocardiographic finding is associated with myocardial ischemia and could signal a possible myocardial infarction if the physical activity is continued or increased. The other findings do not indicate emergent assessments.


A client who is scheduled for an echocardiography today asks why this test is being performed. What is the nurse’s best response? a. “This procedure is a noninvasive way to assess the structure of the heart.” b. “This procedure assesses for abnormal electrical impulses within the heart.” c. “This procedure will evaluate the oxygen saturation in your blood.” d. “This procedure assesses for blockages within the coronary arteries.”

A: Echocardiography is performed to assess the structure and function of the heart, especially the valves and wall motion. Coronary arteries are not assessed with echocardiography, and neither is the electrical conduction system.


The nurse is caring for a client who is scheduled for magnetic resonance imaging (MRI) of the heart. The client’s history includes a previous myocardial infarction and pacemaker implantation. Which action by the nurse is most appropriate? 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.

B: The magnetic fields of the magnetic resonance imager 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 cardiac enzymes, an electrocardiogram, or increased fluids.


The nurse obtains a pulmonary artery pressure reading of 25/12 mm Hg in a client recovering from a myocardial infarction. What is the nurse’s first intervention? a. Compare the results with previous readings. b. Increase the IV fluid rate because these readings are low. c. Immediately notify the physician of the elevated pressures. d. Document the finding and continue to monitor.

A: Normal pulmonary artery pressures range from 15 to 26 mm Hg for systolic and from 5 to 15 mm Hg for diastolic. Although these readings are within normal limits, the nurse needs to assess any trends that may indicate a need for medical treatment to prevent complications.


The nurse is preparing to measure a client’s pulmonary artery wedge pressure (PAWP). In what position will the nurse place the client for the most accurate results? a. Supine, with the head elevated to 45 degrees b. Supine, with the head elevated to 30 degrees c. Reverse Trendelenburg position at 15 degrees d. Supine, with the head of the bed flat

A: To measure PAWP accurately, the client should be placed in supine position, with the head elevated to 45 degrees.


The nurse is caring for a client with an 80% blockage of the right coronary artery (RCA). While waiting for bypass surgery, what is essential for the nurse to have available? a. Furosemide (Lasix) b. External pacemaker c. Lidocaine d. Central venous access

B: The right coronary artery supplies the right atrium, the right ventricle, the inferior portion of the left ventricle, and the atrioventricular (AV) node. It also supplies the sinoatrial (SA) 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.


The nurse is caring for a client with pericarditis. What assessment finding correlates with this disorder? a. Pericardial friction rub b. Systolic murmur c. Ventricular gallop d. Paradoxical splitting

A: A pericardial friction rub originates from the pericardial sac and is heard in clients with pericarditis. The other findings are not associated with pericarditis.


The nurse is auscultating heart tones on an older client and hears the following sound. What is the nurse’s best action? a. Administer a diuretic. b. Document the finding. c. Decrease the IV flow rate. d. Evaluate the medications.

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.


The nurse is auscultating cardiac tones. Where should the nurse listen to best hear a cardiac murmur related to aortic regurgitation? a. Location A b. Location B c. Location C d. Location D

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