Question 1

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?

Accepted Answer

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.E) C) and D)
F) B) and D)

Question 2

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?

Accepted Answer

A)   Use a ruler to measure the level of the JVD.
B)   Document this finding in the patient's record.
C)   Observe for JVD with the head at 30 degrees.
D)   Have the patient perform the Valsalva maneuver.E) A) and C)
F) A) and B)

Question 3

When auscultating over the patient's abdominal aorta, the nurse hears a humming sound. The nurse documents this finding as a

Accepted Answer

A)   thrill.
B)   bruit.
C)   heave.
D)   murmur.E) B) and D)
F) C) and D)

Question 4

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

Accepted Answer

A)   a 2-D echocardiogram.
B)   a cardiac catheterization.
C)   hourly blood pressure (BP)  checks.
D)   electrocardiographic (ECG)  monitoring.E) A) and D)
F) All of the above

Question 5

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

Accepted Answer

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.E) None of the above
F) C) and D)

Question 6

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

Accepted Answer

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.E) C) and D)
F) A) and D)

Question 7

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

Accepted Answer

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.E) B) and D)
F) B) and C)

Question 8

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?

Accepted Answer

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.E) B) and D)
F) A) and C)

Question 9

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?

Accepted Answer

A)   The patient's 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.E) None of the above
F) All of the above

Question 10

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

Accepted Answer

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.E) A) and C)
F) A) and B)

Question 11

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

Accepted Answer

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.E) None of the above
F) All of the above

Question 12

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?

Accepted Answer

A)   Myoglobin
B)   Homocysteine (Hcy) 
C)   Low-density lipoprotein (LDL) 
D)   B-type natriuretic peptide (BNP) E) B) and C)
F) None of the above

Question 13

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

Accepted Answer

A)   "Systolic murmur heard at mitral area."
B)   "Diastolic murmur heard at aortic area."
C)   "Systolic murmur heard at Erb's point."
D)   "Diastolic murmur heard at tricuspid area."E) B) and C)
F) A) and C)

Question 14

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

Accepted Answer

A)   LDL cholesterol.
B)   troponins T and I.
C)   C-reactive protein.
D)   creatine kinase-MB ( CK-MB ) .E) All of the above
F) B) and D)

Question 15

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?

Accepted Answer

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.E) All of the above
F) C) and D)

Question 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?

Accepted Answer

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.E) A) and D)
F) A) and C) C

Question 17

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

Accepted Answer

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.E) None of the above
F) B) and D) A

Question 18

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?

Accepted Answer

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.E) B) and D)
F) B) and C) D

Question 19

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

Accepted Answer

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.E) B) and C)
F) A) and D)

Question 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?

Accepted Answer

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.E) A) and B)
F) A) and D)

Exam 32: Nursing Assessment: Cardiovascular System

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?

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedShow Answer

When auscultating over the patient's abdominal aorta, the nurse hears a humming sound. The nurse documents this finding as a

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedC

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

Correct AnswerverifiedA

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?

Correct AnswerverifiedD

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

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedShow Answer

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