Chapter 32: Nursing Assessment: Cardiovascular System My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 32: Nursing Assessment: Cardiovascular System

Test Bank

MULTIPLE CHOICE

1. After noting a pulse deficit when assessing a patient who has just arrived in the emergency department, the nurse will anticipate that the patient may require

a.

a 2-D echocardiogram.

b.

a cardiac catheterization.

c.

hourly blood pressure (BP) checks.

d.

electrocardiographic (ECG) monitoring.

ANS: D

Pulse deficit is a difference between simultaneously obtained apical and radial pulses and indicates that there may be a cardiac dysrhythmia that would be detected with ECG monitoring. Frequent BP monitoring, cardiac catheterization, and echocardiograms are used for diagnosis of other cardiovascular disorders but would not be as helpful in determining the immediate reason for the pulse deficit.

DIF: Cognitive Level: Application REF: 726 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

2. When reviewing the 12-lead electrocardiograph (ECG) for a healthy 86-year-old patient who is having an annual physical examination, which of the following will be of most concern to the nurse?

a.

The heart rate (HR) is 43 beats/minute.

b.

The PR interval is 0.21 seconds.

c.

There is a right bundle-branch block.

d.

The QRS duration is 0.13 seconds.

ANS: A

The resting HR does not change with aging, so the decrease in HR requires 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, the bundle of His, and the bundle branches.

DIF: Cognitive Level: Application REF: 719-720

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

3. During a physical examination of a patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The most appropriate action for the nurse to take next will be to

a.

document that the PMI is in the normal anatomic location.

b.

ask the patient about risk factors for coronary artery disease.

c.

auscultate both the carotid arteries for the presence of a bruit.

d.

assess the patient for symptoms of left ventricular hypertrophy.

ANS: D

The PMI should be felt at the intersection of the 5th intercostal space and the left midclavicular line. A PMI located outside these landmarks indicates possible cardiac enlargement, such as with left ventricular hypertrophy. Cardiac enlargement is not necessarily associated with coronary or carotid artery disease.

DIF: Cognitive Level: Application REF: 724 | 726

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

4. To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the

a.

bell of the stethoscope with the patient in the left lateral position.

b.

bell of the stethoscope with the patient sitting and leaning forward.

c.

diaphragm of the stethoscope with the patient in a reclining position.

d.

diaphragm of the stethoscope with the patient lying flat on the left side.

ANS: A

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.

DIF: Cognitive Level: Application REF: 726

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

5. To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory result will the nurse plan to review?

a.

Myoglobin

b.

Homocysteine (Hcy)

c.

Low-density lipoprotein (LDL)

d.

B-type natriuretic peptide (BNP)

ANS: D

Increased levels of BNP are a marker for heart failure. The other laboratory results would be used to assess for myocardial infarction (myoglobin) or risk for coronary artery disease (Hcy and LDL).

DIF: Cognitive Level: Application REF: 727 | 733 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

6. While doing the admission assessment for a thin 72-year-old patient, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take?

a.

Notify the hospital rapid response team.

b.

Instruct the patient to remain on bed rest.

c.

Teach the patient about aortic aneurysms.

d.

Document the finding in the patient chart.

ANS: D

Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals and 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.

DIF: Cognitive Level: Application REF: 724

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

7. A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that

a.

electrocardiographic (ECG) monitoring will be required for 24 hours after the test.

b.

it will be important to lie completely still during the procedure.

c.

a warm feeling may be noted when the contrast dye is injected.

d.

monitored anesthesia care will be provided during the procedure.

ANS: C

A sensation of warmth or flushing is common when the iodine-based 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. ECG monitoring is used during the procedure to detect dysrhythmias, but there is not a risk for dysrhythmias after the procedure. The patient is not immobile during cardiac catheterization and may be asked to cough or take deep breaths.

DIF: Cognitive Level: Application REF: 732 | 735-736

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

8. While assessing a patient who was admitted with heart failure, the nurse notes that the patient has jugular venous distention (JVD) when lying flat in bed. Which action should the nurse take next?

a.

Use a ruler to measure the level of the JVD.

b.

Document this finding in the patients record.

c.

Observe for JVD with the head at 30 degrees.

d.

Have the patient perform the Valsalva maneuver.

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 clinically significant) finding. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant. The nurse may use a ruler to determine the level of JVD above the heart if the JVD persists when the patient is at a 30- to 45-degree angle or more. JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure increases. The nurse will document the JVD in the record if it persists when the head is elevated.

DIF: Cognitive Level: Application REF: 723

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

9. The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to

a.

exercise more than usual while the monitor is in place.

b.

remove the electrodes when taking a shower or tub bath.

c.

keep a diary of daily activities while the monitor is worn.

d.

connect the recorder to a telephone transmitter once daily.

ANS: C

The patient is instructed 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 patients rhythm until the end of the testing, when it is removed and the data are analyzed.

DIF: Cognitive Level: Application REF: 729

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

10. When auscultating over the patients abdominal aorta, the nurse hears a humming sound. The nurse documents this finding as a

a.

thrill.

b.

bruit.

c.

heave.

d.

murmur.

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. Heaves are sustained lifts over the precordium that can be observed or palpated. A murmur is the sound caused by turbulent blood flow through the heart.

DIF: Cognitive Level: Comprehension REF: 723-724 | 725

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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. The most important laboratory result to review will be

a.

LDL cholesterol.

b.

troponins T and I.

c.

C-reactive protein.

d.

creatine kinase-MB (CK-MB).

ANS: B

Cardiac troponins start to elevate hours (average 4 to 6 hours) after myocardial injury and are specific to myocardium. Creatine kinase (CK-MB) is specific to myocardial injury and infarction, but it does not increase until 6 hours after the infarction occurs. LDL cholesterol and C-reactive protein are useful in assessing cardiovascular risk but are not helpful in determining whether a patient is having an acute myocardial infarction.

DIF: Cognitive Level: Application REF: 726-727

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

12. When assessing a newly admitted patient, the nurse notes a thrill along the left sternal border. To obtain more information about the cause of the thrill, which action will the nurse take next?

a.

Auscultate for any cardiac murmurs.

b.

Find the point of maximal impulse.

c.

Compare the apical and radial pulse rates.

d.

Palpate the quality of the peripheral pulses.

ANS: A

Both thrills and murmurs are caused by turbulent blood flow, such as occurs when blood flows through a damaged valve. Relevant information includes the quality of the murmur, where in the cardiac cycle the murmur is heard, and where on the thorax the murmur is heard best. The other information also is important in the cardiac assessment but will not provide information that is relevant to the thrill.

DIF: Cognitive Level: Application REF: 726

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

13. The nurse hears a murmur between the S1 and S2 heart sounds at the patients left 5th intercostal space and midclavicular line. How will the nurse record this information?

a.

Systolic murmur heard at mitral area.

b.

Diastolic murmur heard at aortic area.

c.

Systolic murmur heard at Erbs point.

d.

Diastolic murmur heard at tricuspid area.

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 5th 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.

DIF: Cognitive Level: Application REF: 725 | 726

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

14. The RN is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student nurse

a.

places the patient in the left lateral position to check for the point of maximal impulse (PMI).

b.

presses on the skin over the tibia for 10 seconds to check for edema.

c.

palpates both carotid arteries simultaneously to compare pulse quality.

d.

documents a murmur heard along the left sternal border as an aortic murmur.

ANS: C

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.

DIF: Cognitive Level: Application REF: 723-724

TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

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

a.

Administer oral sedative medications.

b.

Teach the patient about the procedure.

c.

Ask whether the patient has eaten today.

d.

Insert a large gauge intravenous catheter.

ANS: B

The nurse will need to teach the patient that the procedure is rapid and involves little risk. The other actions are not necessary.

DIF: Cognitive Level: Application REF: 731-732

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

a.

The patient has an allergy to shellfish and iodine.

b.

The patient has a history of coronary artery disease.

c.

The patient has a permanent ventricular pacemaker in place.

d.

The patient took all the prescribed cardiac medications today.

ANS: C

MRI is contraindicated for patients with implanted metallic devices such as pacemakers. The other information also will be reported to the health care provider but does not impact on whether or not the patient can have an MRI.

DIF: Cognitive Level: Application REF: 731-732 | 734-735

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

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 complaint of feeling tired.

b.

Pulse change from 80 to 96 beats/minute.

c.

BP increase from 134/68 to 150/80 mm Hg.

d.

Electrocardiographic (ECG) changes indicating coronary ischemia.

ANS: D

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

DIF: Cognitive Level: Application REF: 730

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

18. The standard policy on the cardiac unit states, Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg. The nurse will need to call the health care provider about

a.

the postoperative patient with a BP of 116/42.

b.

the newly admitted patient with a BP of 122/60.

c.

the patient with left ventricular failure who has a BP of 110/70.

d.

the patient with a myocardial infarction who has a BP of 114/50.

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 in answer 3 is 67. The MAP in the other three patients is higher than 70 mm Hg.

DIF: Cognitive Level: Application REF: 719

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

19. When admitting a patient for a coronary arteriogram and angiogram, which information about the patient is most important for the nurse to communicate to the health care provider?

a.

The patients pedal pulses are +1.

b.

The patient is allergic to shellfish.

c.

The patient has not eaten anything today.

d.

The patient had an arteriogram a year ago.

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 arteriogram. The other information also is communicated to the health care provider but will not require a change in the usual prearteriogram orders or medications.

DIF: Cognitive Level: Application REF: 732

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

20. A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which of these actions included in the standard TEE orders will the nurse need to accomplish first?

a.

Administer O2 per mask.

b.

Start a large-gauge IV line.

c.

Place the patient on NPO status.

d.

Give lorazepam (Ativan) 1 mg IV.

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.

DIF: Cognitive Level: Application REF: 730

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

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