Chapter 31: Assessment: Cardiovascular System
Test Bank
MULTIPLE CHOICE
1.
After noting a pulse deficit when assessing a 74-year-old patient who has just arrived in the emergency
department, the nurse will anticipate that the patient may require
a.
emergent cardioversion.
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. 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.
2. When reviewing the 12-lead electrocardiograph (ECG) for a healthy 79-year-old patient who is having an
annual physical examination, what will be of
most
concern to the nurse?
a.
The PR interval is 0.21 seconds.
b.
The QRS duration is 0.13 seconds.
c.
There is a right bundle-branch block.
d.
The heart rate (HR) is 42 beats/minute.
ANS: D
The resting HR does not change with aging, so the decrease in HR requires further investigation. Bundlebranch 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.
3. During a physical examination of a 74-year-old 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.
ask the patient about risk factors for atherosclerosis.
b.
document that the PMI is in the normal anatomic location.
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 fifth 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 atherosclerosis or carotid artery disease.
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.
diaphragm of the stethoscope with the patient in a supine position.
c.
bell of the stethoscope with the patient sitting and leaning forward.
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.
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.
Troponin
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 (troponin) or risk for coronary artery disease (Hcy and LDL).
6. While doing the admission assessment for a thin 76-year-old patient, the nurse observes pulsation of the
abdominal aorta in the epigastric area. Which action should the nurse take?
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.
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.
7. A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse
informs the patient that
a.it will be important to lie completely still during the procedure.
b.
a flushed feeling may be noted when the contrast dye is injected.
c.
monitored anesthesia care will be provided during the procedure.
d.
arterial pressure monitoring will be required for 24 hours after the test.
ANS: B
A sensation of warmth or flushing is common when the contrast material is injected, which can be anxietyproducing 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.
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.
Document this finding in the patients record.
b.
Obtain vital signs, including oxygen saturation.
c.
Have the patient perform the Valsalva maneuver.
d.
Observe for JVD with the patient upright at 45 degrees.
ANS: D
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. Obtaining vital signs and oxygen saturation is not warranted at this point.
JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure
increases. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant. The
nurse will document the JVD in the medical record if it persists when the head is elevated.
9. The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to
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.
ANS: D
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.
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.
murmur.
d.
normal finding.
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.
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.
myoglobin.
b.
low-density lipoprotein (LDL) cholesterol.
c.
troponins T and I.
d.
creatine kinase-MB (CK-MB).
ANS: C
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. LDL cholesterol is useful in assessing cardiovascular risk but is not helpful in
determining whether a patient is having an acute 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.
12. When assessing a newly admitted patient, the nurse notes a murmur along the left sternal border. To
document more information about the murmur, which action will the nurse take
next?
a.
Find the point of maximal impulse.
b.
Determine the timing of the murmur.
c.
Compare the apical and radial pulse rates.
d.
Palpate the quality of the peripheral pulses.
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 also important in the cardiac assessment but will
not
provide information that is relevant to the murmur.
13. The nurse hears a murmur between the S1 and S2 heart sounds at the patients 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 Erbs point
c.
Diastolic murmur heard at aortic area
d.
Diastolic murmur heard at the point of maximal impulse
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.
14. A registered nurse (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.
presses on the skin over the tibia for 10 seconds to check for edema.
b.
palpates both carotid arteries simultaneously to compare pulse quality.
c.
documents a murmur heard along the right sternal border as a pulmonic murmur.
d.
places the patient in the left lateral position to check for the point of maximal impulse.
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.
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.
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.
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.
b.
The patient has a history of atherosclerosis.
c.
The patient has a permanent ventricular pacemaker.
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.
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 87 to 101 beats/minute
c.
Blood pressure (BP) increase from 134/68 to 150/80 mm Hg
d.
Newly inverted T waves on the electrocardiogram
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.
Feeling
tired is also normal as the intensity of exercise increases during the stress testing.
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 the
a.
postoperative patient with a BP of 116/42.
b.
newly admitted patient with a BP of 150/87.
c.
patient with left ventricular failure who has a BP of 110/70.
d.
patient with a myocardial infarction who has a BP of 140/86.
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.
19. When admitting a patient for a cardiac catheterization and coronary 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 had a heart attack a year ago.
d.
The patient has not eaten anything today.
Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)
360
a.
Have the patient take this medication with an aspirin.
b.
Administer the medication at the patients usual bedtime.
c.
Have the patient take the colesevelam with a sip of water.
d.
Give the patients other medications 2 hours after the colesevelam.
ANS: D
The bile acid sequestrants interfere with the absorption of many other drugs, and giving other medications at
the same time should be avoided. Taking an aspirin concurrently with the colesevelam may increase the
incidence of gastrointestinal side effects such as heartburn. An increased fluid intake is encouraged for
patients
taking the bile acid sequestrants to reduce the risk for constipation. For maximum effect, colesevelam should
be administered with meals.
25. The nurse is caring for a patient who was admitted to the coronary care unit following an acute
myocardial
infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would
include
a.
when cardiac rehabilitation will begin.
b.
the typical emotional responses to AMI.
c.
information regarding discharge medications.
d.
the pathophysiology of coronary artery disease.
ANS: A
Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this
time, the patients anxiety level or denial will interfere with good understanding of complex information such
as
the pathophysiology of coronary artery disease (CAD). Teaching about discharge medications should be done
closer to discharge. The nurse should support the patient by decreasing anxiety rather than discussing the
typical emotional responses to myocardial infarction (MI).
26. A patient who has recently started taking pravastatin (Pravachol) and niacin (Nicobid) reports the
following
symptoms to the nurse. Which is
most
important to communicate to the health care provider?
a.
Generalized muscle aches and pains
b.
Dizziness when changing positions quickly
c.
Nausea when taking the drugs before eating
d.
Flushing and pruritus after taking the medications
ANS: A
Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute kidney injury
and death in some patients who have taken the statin medications. These symptoms indicate that the
pravastatin may need to be discontinued. The other symptoms are common side effects when taking niacin,
and
although the nurse should follow-up with the health care provider, they do not indicate that a change in
medication is needed.
27. A patient who is being admitted to the emergency department with intermittent chest pain gives the
following list of medications to the nurse. Which medication has the
most
immediate implications for the
patients care?
a.
Sildenafil (Viagra)
b.
Furosemide (Lasix)
c.
Captopril (Capoten)
d.
Warfarin (Coumadin)
ANS: A
The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in
patients who are using sildenafil because of the risk of severe hypotension caused by vasodilation. The other
home medications also should be documented and reported to the health care provider but do not have as
immediate an impact on decisions about the patients treatment.
28. Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting
using a right radial artery graft is
most
important to communicate to the health care provider?
a.
Complaints of incisional chest pain
b.
Pallor and weakness of the right hand
c.
Fine crackles heard at both lung bases
d.
Redness on both sides of the sternal incision
ANS: B
The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and
actions such as prescribed calcium channel blockers or surgery. The other changes are expected and/or
require
nursing interventions.
29. When caring for a patient who has just arrived on the medical-surgical unit after having cardiac
catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse
(LPN/LVN)?
a.
Give the scheduled aspirin and lipid-lowering medication.
b.
Perform the initial assessment of the catheter insertion site.
c.
Teach the patient about the usual postprocedure plan of care.
d.
Titrate the heparin infusion according to the agency protocol.
ANS: A
Administration of oral medications is within the scope of practice for LPNs/LVNs. The initial assessment of
the patient, patient teaching, and titration of IV anticoagulant medications should be done by the registered
nurse (RN).
DIF: Cognitive Level: Apply (application)
30. Which electrocardiographic (ECG) change is
most
important for the nurse to report to the health care
provider when caring for a patient with chest pain?
a.
Inverted P wave
b.
Sinus tachycardia
c.
ST-segment elevation
d.
First-degree atrioventricular block
ANS: C
The patient is likely to be experiencing an ST-segment-elevation myocardial infarction (STEMI). Immediate
therapy with percutaneous coronary intervention (PCI) or thrombolytic medication is indicated to minimize
myocardial damage. The other ECG changes may also suggest a need for therapy, but not as rapidly.
31. When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after
having angioplasty with stent placement, the nurse obtains the following assessment data. Which data
indicate
the need for
immediate
action by the nurse?
a.
Heart rate 102 beats/min
b.
Pedal pulses 1+ bilaterally
c.
Blood pressure 103/54 mm Hg
d.
Chest pain level 7 on a 0 to 10 point scale
ANS: D
The patients chest pain indicates that restenosis of the coronary artery may be occurring and requires
immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information
indicates a need for ongoing assessments by the nurse.
32. A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction
(STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 123. Based on this information,
which nursing diagnosis is a
priority
for the patient?
a.
Acute pain related to myocardial infarction
b.
Anxiety related to perceived threat of death
c.
Stress overload related to acute change in health
d.
Decreased cardiac output related to cardiogenic shock
ANS: C
All the nursing diagnoses may be appropriate for this patient, but the hypotension and tachycardia indicate
decreased cardiac output and shock from the damaged myocardium. This will result in decreased perfusion
to
all vital organs (e.g., brain, kidney, heart) and is a priority.
33. When admitting a patient with a nonST-segment-elevation myocardial infarction (NSTEMI) to the
intensive care unit, which action should the nurse perform
first
?
a.
Obtain the blood pressure.
b.
Attach the cardiac monitor.
c.
Assess the peripheral pulses.
d.
Auscultate the breath sounds.
ANS: B
Because dysrhythmias are the most common complication of myocardial infarction (MI), the first action
should be to place the patient on a cardiac monitor. The other actions also are important and should be
accomplished as quickly as possible.
34. Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial
infarction (AMI) is
most
important for the nurse to communicate to the health care provider?
a.
No change in the patients chest pain
b.
An increase in troponin levels from baseline
c.
A large bruise at the patients IV insertion site
d.
A decrease in ST-segment elevation on the electrocardiogram
ANS: A
Continued chest pain suggests that the thrombolytic therapy is not effective and that other interventions
such as
percutaneous coronary intervention (PCI) may be needed. Bruising is a possible side effect of thrombolytic
therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST-segment
elevation indicates that thrombolysis is occurring and perfusion is returning to the injured myocardium. An
increase in troponin levels is expected with reperfusion and is related to the washout of cardiac markers into
the circulation as the blocked vessel is opened.
35. The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation
myocardial infarction (STEMI) 2 days previously. Which information is
most
important to report to the health
care provider?
a.
The troponin level is elevated.
b.
The patient denies ever having a heart attack.
c.
Bilateral crackles are auscultated in the mid-lower lobes.
d.
The patient has occasional premature atrial contractions (PACs).
ANS: C
The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial
infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-
converting enzyme (ACE) inhibitors for the patient. Elevation in troponin level at this time is expected. PACs
are not life-threatening dysrhythmias. Denial is a common response in the immediate period after the MI.
36. A patient had a nonST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing
intervention included in the plan of care is
most
appropriate for the registered nurse (RN) to delegate to an
experienced licensed practical/vocational nurse (LPN/LVN)?
a.
Evaluation of the patients response to walking in the hallway
b.
Completion of the referral form for a home health nurse follow-up
c.
Education of the patient about the pathophysiology of heart disease
d.
Reinforcement of teaching about the purpose of prescribed medications
ANS: D
LPN/LVN education and scope of practice include reinforcing education that has previously been done by the
RN. Evaluating the patient response to exercise after a NSTEMI requires more education and should be done
by the RN. Teaching and discharge planning/ documentation are higher level skills that require RN education
and scope of practice.
37. A patient who has chest pain is admitted to the emergency department (ED) and all of the following are
ordered. Which one should the nurse arrange to be completed
first?
a.
Chest x-ray
b.
Troponin level
c.
Electrocardiogram (ECG)
d.
Insertion of a peripheral IV
ANS: C
The priority for the patient is to determine whether an acute myocardial infarction (AMI) is occurring so that
reperfusion therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery
occlusion, and an ECG should be obtained as soon as possible. Troponin levels will increase after about 3
hours. Data from the chest x-ray may impact the patients care but are not helpful in determining whether the
patient is experiencing a myocardial infarction (MI). Peripheral access will be needed but not before the ECG.
38. After receiving change-of-shift report about the following four patients, which patient should the nurse
assess
first
?
a.
39-year-old with pericarditis who is complaining of sharp, stabbing chest pain
b.
56-year-old with variant angina who is to receive a dose of nifedipine (Procardia)
c.
65-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned
discharge
d.
59-year-old with unstable angina who has just returned to the unit after having a percutaneous
coronary intervention (PCI)
ANS: D
This patient is at risk for bleeding from the arterial access site for the PCI, so the nurse should assess the
patients blood pressure, pulse, and the access site immediately. The other patients should also be assessed
as
quickly as possible, but assessment of this patient has the highest priority.
39. To improve the physical activity level for a mildly obese 71-year-old patient, which action should the
nurse
plan to take?
a.
Stress that weight loss is a major benefit of increased exercise.
b.
Determine what kind of physical activities the patient usually enjoys.
c.
Tell the patient that older adults should exercise for no more than 20 minutes at a time.
d.
Teach the patient to include a short warm-up period at the beginning of physical activity.
ANS: B
Because patients are more likely to continue physical activities that they already enjoy, the nurse will plan to
ask the patient about preferred activities. The goal for older adults is 30 minutes of moderate activity on
most
days. Older adults should plan for a longer warm-up period. Benefits of exercises, such as improved activity
tolerance, should be emphasized rather than aiming for significant weight loss in older mildly obese adults.
40. Which patient at the cardiovascular clinic requires the most
immediate
action by the nurse?
a.
Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL
b.
Patient with stable angina whose chest pain has recently increased in frequency
c.
Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL
d.
Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg
ANS: B
The history of more frequent chest pain suggests that the patient may have unstable angina, which is part of
the
acute coronary syndrome spectrum. This will require rapid implementation of actions such as cardiac
catheterization and possible percutaneous coronary intervention. The data about the other patients suggest
that
their conditions are stable.
41. A patient with diabetes mellitus and chronic stable angina has a new order for captopril (Capoten). The
nurse should teach the patient that the primary purpose of captopril is to
a.
lower heart rate.
b.
control blood glucose levels.
c.
prevent changes in heart muscle.
d.
reduce the frequency of chest pain.
ANS: C
The purpose for angiotensin-converting enzyme (ACE) inhibitors in patients with chronic stable angina who
are at high risk for a cardiac event is to decrease ventricular remodeling. ACE inhibitors do not directly impact
angina frequency, blood glucose, or heart rate.