Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures My Nursing Test Banks

Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. The nurse is reviewing the anatomy and physiology of the cardiac system with a patient scheduled for pacemaker insertion. Which chamber of the heart should the nurse instruct has the greatest workload and usually fails first as a result?
a. Left atrium
b. Right atrium
c. Left ventricle
d. Right ventricle
____ 2. The nurse is helping a patient understand why the heart beat can change in speed. When doing so, what should the nurse explain as being the pacemaker of the heart?
a. Bundle of His
b. Sinoatrial node
c. Purkinjes fibers
d. Atrioventricular node
____ 3. The nurse is using a stethoscope to listen to a patients heart sounds. The nurse recognizes that the dupp of the characteristic lubb-dupp heart sound indicates what part of the cardiac cycle?
a. The closure of the mitral valve
b. The closure of the tricuspid valve
c. The closure of the atrioventricular valves
d. The closure of the aortic and pulmonary semilunar valves
____ 4. The nurse suspects that a patients heart rate is being affected by parasympathetic influence. What should the nurse recall as the effect the parasympathetic nervous system has on the heart?
a. Decreases heart rate
b. Decreases resting phase
c. Increases cardiac output
d. Increases strength of contraction
____ 5. The nurse is caring for a patient recovering from a cardiac catheterization with a right femoral artery entry site. Which action should the nurse take?
a. Ambulate every 2 hours.
b. Position knees with 40-degree bend.
c. Avoid movement of right leg as ordered.
d. Perform passive range of motion of right leg hourly.
____ 6. The nurse is providing care for a patient whose right atrial pressure (RAP) is 12 mm Hg. Which action should the nurse take?
a. Assess skin turgor.
b. Listen to breath sounds.
c. Measure urine specific gravity.
d. Determine level of consciousness.
____ 7. A patient is diagnosed with epicarditis. What should the nurse recall regarding the purpose of the epicardium when caring for this patient?
a. Line the chambers of the heart.
b. Line the coronary blood vessels.
c. Cover the heart muscle and prevent friction.
d. Contract and pump blood from the ventricles.
____ 8. The nurse is explaining the regulation of blood pressure to a patient newly diagnosed with hypertension. What tissues within the artery wall that helps maintain diastolic blood pressure should the nurse identify for the patient?
a. Smooth muscle and elastic connective tissue
b. Smooth muscle and simple squamous epithelium
c. Elastic connective tissue and fibrous connective tissue
d. Fibrous connective tissue and simple squamous epithelium
____ 9. The nurse instructs a patient on beverages to avoid when taking the prescribed medication warfarin (Coumadin). Which beverage should the patient state that indicates teaching has been effective?
a. Beer
b. Orange juice
c. Grapefruit juice
d. Cranberry juice
____ 10. A patient has sustained damage to the sinoatrial node. Which heart rates indicate that the patients atrioventricular node has taken over as the pacemaker for the heart?
a. 10 to 20
b. 20 to 35
c. 40 to 60
d. 80 to 100
____ 11. The nurse is measuring a patients central venous pressure (CVP). Which patient factors is reflected by this pressure reading?
a. Hydration
b. Cardiac output
c. Blood pressure
d. Peripheral vascular resistance
____ 12. A patient with type 1 diabetes mellitus arrives for cardiac surgery. During the assessment, the nurse learns the patient self-administered the usual insulin dose. Which action should the nurse take?
a. Obtain vital signs.
b. State, that is good.
c. Inform the physician.
d. Give 6 ounces of cranberry juice now.
____ 13. Upon auscultating a patients heart sounds, the nurse is concerned that a pericardial friction rub is present. Which health problem should the nurse suspect is possibly occurring in this patient?
a. Pleurisy
b. Pneumonia
c. Mitral valve prolapse
d. Myocardial infarction
____ 14. The nurse reviews the cardiac catheterization procedure with a patient scheduled for the test in 2 hours. Which patient statement indicates that teaching has been effective?
a. I know the room will be very warm.
b. Most people feel drowsy during the procedure.
c. The table may move while the test is being done.
d. I should expect a cool sensation throughout my body when they inject the dye.
____ 15. The nurse is caring for a patient who had a cardiac catheterization using the left femoral site for entry. Which data is most important for the nurse to monitor?
a. Pupil reaction
b. Left pedal pulse
c. Orientation status
d. Right foot sensation
____ 16. A patient is being instructed about a Holter monitor. Which statement indicates that the patient knows what to do a symptom occurs while wearing a Holter monitor?
a. Call an ambulance.
b. Notify the physician.
c. Take an apical pulse.
d. Push the event button.
____ 17. A patient will be wearing a Holter monitor for 2 days. What should the nurse instruct the patient about bathing while wearing the monitor?
a. Take a sponge bath.
b. You may take a tub bath.
c. Take a shower with the monitor on.
d. Remove the monitor before showering.
____ 18. A patient asks the nurse to explain what high levels of low-density lipoproteins (LDLs) means. What response by the nurse would be appropriate?
a. Increased blood clotting risk.
b. Increased risk for coronary artery disease.
c. Protection against coronary artery disease.
d. Decreased risk for atherosclerosis development.
____ 19. The nurse is reinforcing teaching provided to a patient about the role high-density lipoproteins (HDLs) play in cardiac disease. Which patient statement indicates correct understanding of the teaching?
a. There is an increased blood clotting risk.
b. There is increased risk for coronary artery disease.
c. It provides protection against coronary artery disease.
d. The risk for atherosclerosis development is increased.
____ 20. The nurse is collecting data from a patient with hypertension. Which modifiable cardiovascular risk factor should the nurse identify for care planning?
a. Gender
b. Heredity
c. Ethnic origin
d. Activity level
____ 21. The nurse is reinforcing teaching provided to a patient with a high serum cholesterol level, low HDLs and high LDLs. What should the nurse include?
a. You need to see your doctor about this as soon as possible to start medications to lower your cholesterol.
b. Your cholesterol level is too high, so you should stop eating foods high in cholesterol, such as eggs and cream.
c. Your cholesterol level is okay, but you should decrease your LDLs by lowering your fat intake and getting more exercise.
d. Your cholesterol level and LDLs are too high. You need to lower your intake of saturated fats and increase your level of exercise.
____ 22. The nurse is caring for a patient recovering from a cardiac catheterization. Which action should the nurse take?
a. Force 1000 mL of fluid per hour.
b. Keep patient NPO until gag reflex is present.
c. Encourage the patient to drink plenty of liquids.
d. Hold fluid intake for 2 hours after the procedure.
____ 23. The nurse is caring for a patient recovering from a cardiac catheterization. Which actions for site care should the nurse take?
a. Keep the site uncovered.
b. Apply a Band-Aid to the site.
c. Maintain pressure dressing on the site.
d. Apply a gauze bandage to the puncture site.
____ 24. The nurse is caring for a patient whose troponin I level is elevated. Which nursing action would be appropriate?
a. Up as desired.
b. Ambulate daily.
c. Maintain bedrest.
d. Ambulate twice daily.
____ 25. The nurse is preparing a patient for an angiogram. What should be included in data collection for this patient?
a. Ask if the patient is allergic to eggs.
b. Ask if the patient is allergic to meat.
c. Ask if the patient is allergic to peanuts.
d. Ask if the patient is allergic to contrast dyes.
____ 26. During data collection, the nurse learns that a patient with chronic cardiac problems and diabetes has gained 5 pounds of weight over 3 days and is experiencing fatigue when climbing stairs. Upon inspection, the nurse notes edema of the lower extremities. What health problem do these symptoms suggest that the nurse should report to the physician?
a. Acute heart failure
b. Myocardial infarction
c. Left-sided heart failure
d. Right-sided heart failure
____ 27. The nurse determines that a patients pulmonary artery wedge pressure is normal. What range of values did the nurse use to make this decision?
a. 1 to 7 mm Hg
b. 2 to 9 mm Hg
c. 3 to 10 mm Hg
d. 4 to 12 mm Hg
____ 28. The nurse is planning to auscultate a patients apical pulse. How long should the nurse listen to the patients heart?
a. 15 seconds
b. 30 seconds
c. 60 seconds
d. 90 seconds
____ 29. The nurse is documenting information collected about a patients pulses. How should the nurse document that a peripheral pulse was normal?
a. 0
b. 1+
c. 2+
d. 3+
____ 30. A patient being treated for a severe blood loss has a blood pressure of 90/56 mm Hg and urine output of 10 mL over the last hour. Which physiological mechanism should the nurse recall is occurring in this patient?
a. Starlings law
b. Medulla-brainstem
c. Sodium-potassium pump
d. Renin-angiotensin-aldosterone
____ 31. While collecting data a patient expectorates pink frothy sputum. Which health problem should the nurse consider is occurring in this patient?
a. Gastritis
b. Pneumonia
c. Heart failure
d. Hepatic failure
____ 32. The nurse notes that a patients lower legs are brown and the feet are blue when they are in the dependent position. For which health problem should the nurse collect additional data?
a. Anemia
b. Insufficient oxygenation
c. Decreased arterial blood flow
d. Venous blood flow problems
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 33. The nurse is preparing to measure a patient for orthostatic hypotension. Which action should the nurse take to obtain this information? (Select all that apply.)
a. Use the correct size blood pressure cuff for the patient.
b. Instruct the patient not to eat or drink for 30 minutes prior to the test.
c. Have the patient refrain from smoking for at least 4 hours prior to the test.
d. Take pulse and blood pressure readings immediately upon assisting the patient to stand.
e. Assist the patient to a sitting position, wait 3 minutes, and take the pulse and blood pressure.
f. Obtain supine reading with patient lying with head of bed elevated 30 degrees for 30 minutes.
____ 34. The nurse is attempting to detect a pericardial friction rub on a patient. Which actions will help the nurse in gathering this data during auscultation? (Select all that apply.)
a. Have the patient sit up.
b. Have the patient lie flat.
c. Have the patient lean forward.
d. Listen to the posterior of the chest.
e. Instruct patient to hold breath as listening.
f. Have the patient deep breathe as listening.
____ 35. The nurse is reinforcing teaching for a patient who is to wear a Holter monitor. Which of the following should the nurse include? (Select all that apply.)
a. Avoid strenuous activity.
b. Transmit data over the phone.
c. Push the event button when symptoms occur.
d. Keep an accurate diary of symptoms and activities.
e. Avoid showers or baths while wearing the monitor.
f. Take nothing by mouth for 6 hours before applying the monitor.
____ 36. The nurse is reviewing the role of atrial natriuretic peptide (ANP) in blood pressure regulation for a patient with hypertension. What should the nurse include in this discussion? (Select all that apply.)
a. It decreases blood volume.
b. It increases cardiac output.
c. It inhibits aldosterone secretion.
d. It causes an increase in the baseline heart rate.
e. It causes vasoconstriction throughout the body.
f. It increases renal secretion of sodium ions and water.
____ 37. The nurse is caring for a patient who is having an exercise treadmill test. What interventions would be appropriate for the test? (Select all that apply.)
a. Remove all metal objects.
b. Monitor vital signs throughout the test.
c. Administer antianxiety medication as ordered.
d. Monitor electrocardiogram before, during, and after the test.
e. Ask the patient about allergies to dyes used in diagnostic procedures.
____ 38. The nurse is caring for a patient with peripheral vascular disease. Which signs or symptoms should the nurse expect to observe in this patient? (Select all that apply.)
a. Pain
b. Pruritus
c. Purpura
d. Paralysis
e. Paresthesia
f. Pulselessness
____ 39. The nurse notes that a patient being prepared for a cardiac computed tomography (CT) scan has mild renal insufficiency. What should the nurse expect to be ordered before and after the procedure for this patient? (Select all that apply.)
a. Lasix
b. Aldactone
c. Lactic acid
d. Dextrose 10% infusion
e. N-acetylcysteine (Mucomyst)
____ 40. A patient with orthostatic hypotension asks why the health problem is occurring. What should the nurse include when explaining the causes of orthostatic hypotension to the patient? (Select all that apply.)
a. Experiencing pain
b. Use of narcotic pain medication
c. Lack of sufficient rest and sleep
d. Insufficient fluid volume in the body
e. Use of medication that takes fluid out of the body
Completion
Complete each statement.

41. A patient has a stroke volume of 75 mL and a heart rate of 88. What should the nurse calculate this patients cardiac output to be?

Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures
Answer Section

MULTIPLE CHOICE

1. ANS: C
The thicker walls of the left ventricle pump with approximately five times the force of the right ventricle. This difference in force is due to the great difference between systemic and pulmonary blood pressure. A. B. D. These heart chambers do not have the same workload volume as the left ventricle.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

2. ANS: B
The sinoatrial (SA) node is a specialized mass of cardiac muscle that depolarizes rhythmically and most rapidly, about 100 times per minute, and therefore initiates each heartbeat. For this reason, the SA node is sometimes called the pacemaker of the heart. A. C. D. These structures are not considered the pacemaker of the heart.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

3. ANS: D
The dupp indicates closure of the aortic and pulmonary semilunar valves. A. B. C. The atrioventricular valves (mitral, tricuspid) are all the same type of valves, and their closure is indicated by the lubb sound.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

4. ANS: A
Parasympathetic impulsesalong the vagus nerve to the sinoatrial (SA) node, atrioventricular (AV) node, and atrial myocardiumdecrease heart rate. B. The parasympathetic nervous system does not influence the resting phase. C. D. The parasympathetic nervous system does not increase cardiac output or the strength of contractions.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

5. ANS: C
The extremity used for catheter insertion must not be moved or flexed for several hours after the procedure. A. B. D. Since the extremity should not be moved these actions are contraindicated.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

6. ANS: B
Normal RAP is 2 to 6 mm Hg. This pressure reflects fluid volume status, so an increased level indicates heart failure. The heart is not pumping effectively, so blood is backing up, raising the RAP reading and placing the patient at risk of pulmonary edema. A. C. D. These actions would not be indicated for this pressure reading.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

7. ANS: C
The epicardium covers the heart muscle and prevents friction for efficient function. A. B. D. The epicardium does not line the heart chambers or the coronary vessels and does not contract and pump blood from the ventricles.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

8. ANS: A
The middle artery layer of smooth muscle and elastic connective tissue maintains normal blood pressure (BP), especially diastolic BP, by changing the diameter of the artery. B. C. D. These tissues are not within the layers of the arterial walls.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

9. ANS: D
Warfarin is mainly metabolized by the cytochrome P450 isoenzyme CYP2C9, and cranberry juice contains flavonoids known to inhibit P450 enzymes. Bleeding problems and hemorrhage have been attributed to this interaction. A. B. C. There is no reason for the patient to avoid these beverages.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Analysis

10. ANS: C
If the sinoatrial (SA) node becomes nonfunctional, the atrioventricular (AV) node can initiate each heartbeat, but at a slower rate of 40 to 60 beats per minute. B. The Bundle of His can generate a heartbeat at the rate of 20 to 35. A. No cardiac tissue will generate this speed of heartbeat. D. This is a normal heartbeat which would be generated by the sinoatrial node.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

11. ANS: A
CVP reflects fluid volume status, so an increased CVP indicates fluid overload, and a decreased CVP indicates fluid deficit. B. C. D. CVP is not used to determine cardiac output, blood pressure, or peripheral vascular resistance.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

12. ANS: C
The patient usually takes nothing by mouth (NPO) 8 to 12 hours before surgery. Due to this, patients with diabetes have insulin and oral hypoglycemic agents reduced or withheld the morning of surgery with blood glucose monitoring. A. Vital sign measurement is not going to help determine the impact of the insulin dose on the patients preoperative and postoperative status. B. The patient should have been instructed to withhold all medications the morning of the surgery. D. The patient should be NPO for surgery.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

13. ANS: D
A pericardial friction rub may occur after a myocardial infarction or chest trauma. A. B. C. A pericardial friction rub is not associated with these health problems.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

14. ANS: C
Patients should be told that during the test they are awake, and a warm, flushing sensation may be felt when the dye is injected; the room has a lot of equipment; a movable table is used; the patients vital signs and electrocardiogram (ECG) are monitored constantly; and the length of the procedure is 2 to 3 hours. A. B. D. These statements indicate that teaching has not been effective.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

15. ANS: B
The priority assessment is to ensure that circulation is not compromised. The puncture site and most importantly the peripheral pulses which are distal to the procedure site are verified as being present. A. C. A cardiac catheterization should not affect pupil reaction or orientation status. D. The patients left femoral artery was the entry site. The patients right foot should not be affected.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

16. ANS: D
When wearing a Holter monitor, the patient is to record a diary of activities and symptoms and push the event button if symptoms occur. A. B. C. These actions do not need to be taken if a symptom occurs while wearing the monitor.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

17. ANS: A
The patient wears loose-fitting clothing and may only sponge bathe while wearing the monitor. B. C. D. The patient should not take a tub bath, shower, or remove the monitor.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Application

18. ANS: B
High levels of LDLs are linked to an increase in coronary artery disease because they circulate cholesterol in the arteries. A. C. D. These responses are not correct about low-density lipoproteins.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

19. ANS: C
HDLs play a protective role against coronary artery disease because they carry cholesterol to the liver to be metabolized. A. B. D. These statements are incorrect about the role of high-density lipoproteins.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis

20. ANS: D
Activity level is a modifiable risk factor. A. B. C. These factors are not modifiable as they cannot be changed.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

21. ANS: D
The cholesterol level and LDLs are too high. They can be lowered by reducing intake of saturated fats and increasing level of exercise. A. B. C. These responses would not be appropriate based upon the patients laboratory values.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

22. ANS: C
The nurse should encourage the patient to drink plenty of liquids to help eliminate the dye which helps to prevent damage to the kidneys. A. This volume of oral fluid intake is unrealistic for the patient to perform. B. The procedure did not affect the patients gag reflex. D. Fluids do not need to be held after the procedure.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

23. ANS: C
Pressure is maintained at the site with a pressure dressing or sandbag to prevent bleeding and hematoma development. A. B. D. These actions could promote bleeding at the site and should not be done.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

24. ANS: C
The patient is at risk for cardiac damage, so the nurse should maintain bedrest for the patient until further orders. A. B. D. These levels of activity could potentiate cardiac damage.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

25. ANS: D
The nurse should ask if the patient is allergic to contrast dyes, as dye is used during an angiogram. A. B. C. Allergies to eggs, meat, or peanuts is not important to assess in this patient.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

26. ANS: D
These are signs of right-sided heart failure because fluid is being retained (weight gain), backing up systemically. The patient is fatigued due to reduced cardiac output and oxygenation. The nurse should report these symptoms right away. A. B. C. These symptoms are not consistent with acute heart failure, myocardial infarction, or left-sided heart failure.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

27. ANS: D
Normal pulmonary artery wedge pressure is 4 to 12 mm Hg. A. B. C. These values do not reflect the range of normal pulmonary artery wedge pressure.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

28. ANS: C
The apical pulse is auscultated for 1 minute to obtain heart rhythm and rate for increased accuracy. A. B. The apical pulse should be auscultated for longer than 15 or 30 seconds. D. The apical pulse does not need to be auscultated for 90 seconds.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

29. ANS: C
The quality of the pulses is described on a four-point scale: 0 is absent; 1+ is weak, thready; 2+ is normal; and 3+ is bounding. The nurse would document that the pulse was 2+.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

30. ANS: D
The kidneys are of great importance in the regulation of blood pressure. If blood flow through the kidneys decreases, renal filtration decreases and urinary output decreases to preserve blood volume. Decreased blood pressure stimulates the kidneys to secrete renin, which initiates the renin-angiotensin-aldosterone mechanism, raising blood pressure. A. Starlings law is used to explain how the heart adjusts blood flow to the body based upon activity. B. There is no specific medulla-brainstem mechanism that affects blood loss, blood pressure, and urine output. C. The sodium-potassium pump is a mechanism to maintain electrolyte balance within the body.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

31. ANS: C
Pink, frothy sputum is an indicator of acute heart failure. A. B. D. Pink frothy sputum is not associated with gastritis, pneumonia, or hepatic failure.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

32. ANS: D
A brown discoloration and cyanosis when the extremity is dependent may be seen in the presence of venous blood flow problems. A. Pallor may indicate anemia or lack of arterial blood flow. B. Cyanosis shows an oxygen distribution deficiency. C. A reddish brown discoloration (rubor) found in the lower extremities occurs from decreased arterial blood flow.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

MULTIPLE RESPONSE

33. ANS: A, B, D, E
To detect orthostatic hypotension: Use correct size blood pressure cuff. Explain procedure to patient; determine if patient can safely stand. Have patient lie flat in bed at least 5 minutes prior to readings. Patient should not eat or smoke 30 minutes before readings; patient should not talk during readings and should sit up with legs uncrossed while sitting. Take patients lying blood pressure and heart rate. Assist patient to sitting position. Ask if dizzy or light-headed with each position change. Wait 3 minutes, and then take patients sitting blood pressure and heart rate. If patient is dizzy or light-headed, continue sitting position for 5 minutes, if tolerated. Do not attempt to bring the patient to standing. Repeat sitting blood pressure. If blood pressure has increased and patient is no longer dizzy, assist patient to stand. Assist patient to stand and take blood pressure and pulse immediately. Then take again in 3 minutes. If blood pressure drops and patient is dizzy or light-headed, do not attempt to ambulate the patient. Document all heart rate and blood pressure measurements. B. F. These actions are not a part of the procedure to assess for orthostatic hypotension.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

34. ANS: A, C
The nurse should have the patient sit up and lean forward to bring the heart closer to the chest wall. B. D. E. F These actions will not improve the nurses ability to detect a pericardial friction rub.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

35. ANS: C, D, E
Patient teaching for wearing a Holter monitor includes keeping an accurate diary, pushing the event button for symptoms, to not take showers or baths, and making a return visit. A. B. F. These actions do not need to be done by the patient while wearing a Holter monitor.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

36. ANS: A, C, F
ANP increases the excretion of sodium by the kidneys by inhibiting secretion of aldosterone by the adrenal cortex. The loss of sodium is accompanied by the loss of more water in urine, which decreases blood volume and therefore blood pressure as well. B. D. E. These are not actions of atrial natriuretic peptide.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

37. ANS: B, D
Monitor vital signs and electrocardiogram before, during, and after the test to detect symptoms. A. C. For magnetic resonance imaging, metal objects are contraindicated and antianxiety medications are used. E. No dyes are used.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

38. ANS: A, D, F
Six Ps characterize peripheral vascular disease: pain, poikilothermia, pulselessness, pallor, paralysis, and paresthesia (decreased sensation). B. C. Pruritus and purpura are not manifestations of peripheral vascular disease.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

39. ANS: C, E
If renal insufficiency is present, prophylaxis such as N-acetylcysteine (Mucomyst) or a bicarbonate infusion may be given to protect kidneys. A. Lasix could cause additional renal damage. B. Aldactone will not prevent renal damage. D. Dextrose would cause more fluid to be removed from the body which could lead to additional renal damage.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

40. ANS: A, B, D, E
Factors that may cause orthostatic hypotension include fluid volume deficit, diuretics, analgesics, and pain. C. Lack of rest and sleep are not identified as factors to cause orthostatic hypotension.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

COMPLETION

41. ANS:
6600 mL/6.6 L
Cardiac output (CO) is the amount of blood ejected from the left ventricle in 1 minute and is determined by multiplying stroke volume (SV) by heart rate (HR). Stroke volume is the amount of blood ejected by a ventricle in one contraction and averages 60 to 80 mL/beat. With an average resting heart rate of 75 beats per minute, average resting cardiac output is 5 to 6 L To calculate the stroke volume the nurse should multiply 75 mL 88 = 6600 mL or 6.6 L.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

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