Nursing Management: Chapter 17, The Cardiovascular System

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Question 1 of 9

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At which area would the nurse place the stethoscope to auscultate the “lub” heart sound?

    • Sternal areaThe sternum is a solid structure, and sounds are not readily transmitted over bony areas.
    • Mediastinal areaThe heart and other structures, such as the trachea, esophagus, and large vessels, are located within the mediastinal area, which is in the middle of the chest.
  • Correct
    • Mitral and tricuspid areaThe first heart sound (S1), which is referred to as “lub,” occurs when the ventricles contract during systole and when the mitral and tricuspid valves close.
    • Aortic and pulmonic areaThe second heart sound (S2), called “dub,” occurs during ventricular relaxation or diastole; it is caused by the closing of the aortic and pulmonic valves.

Question 2 of 9

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Which question would the nurse ask to further assess a patient’s report of chest pain? Select all that apply. One, some, or all responses may be correct.

  • Correct
    • “What seemed to cause the chest pain?”Asking the patient what seemed to cause the chest pain is part of the PQRST pneumonic that includes the precipitating events. Further assessment of chest pain requires the nurse to determine potential precipitating events.
    • “Does anyone in your family experience similar pain?”The nurse would ask questions that are part of the PQRST pneumonic to determine precipitating events, quality of pain, radiation of pain, severity of pain, and timing of pain. This assessment does not address family history. Family history is not pertinent at the time the patient reports chest pain.
  • Correct
    • “Have you had this type of pain previously?”The nurse would ask questions that are part of the PQRST pneumonic to determine precipitating events, quality of pain, radiation of pain, severity of pain, and timing of pain. Asking the patient if they have experienced this type of pain previously addresses the timing of pain in the PQRST pneumonic.
  • Correct
    • “Does the pain spread to other areas in your body?”The nurse would ask questions that are part of the PQRST pneumonic to determine precipitating events, quality of pain, radiation of pain, severity of pain, and timing of pain. Asking if the pain spreads to other areas of the body addresses radiation of pain.
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    • “What does the chest pain feel like?”The nurse would ask questions that are part of the PQRST pneumonic to determine precipitating events, quality of pain, radiation of pain, severity of pain, and timing of pain. Asking what the pain feels like addresses the quality of the patient’s pain.
  • Correct
    • “How would you rate the pain on a scale of 0 to 10?”The nurse would ask questions that are part of the PQRST pneumonic to determine precipitating events, quality of pain, radiation of pain, severity of pain, and timing of pain. Rating the pain addresses the severity of the patient’s pain.

Question 3 of 9

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Which action correctly demonstrates assessing a patient’s apical pulse?

    • The nurse palpates the radial area for 30 seconds.Palpating the radial area for 30 seconds does not assess the apical pulse. This action assesses the radial pulse. Palpating for 30 seconds requires the nurse to calculate the beats per minute. The apical pulse is assessed for one minute listening to the heart sounds over the mitral area or point of maximal impulse (PMI).
    • The nurse listens for 15 seconds over the pulmonic area.Listening to the pulmonic area for 15 seconds does not assess the apical pulse. This placement assesses the S2 sound of the heart. The apical pulse is assessed for one minute listening to the heart sounds over the mitral area or point of maximal impulse (PMI).
    • The nurse palpates the femoral area for 2 minutes.Palpating the femoral area assesses the femoral pulse rather than the apical pulse. The femoral pulse can correctly be assessed for less than 2 minutes. The apical pulse is assessed for one minute listening to the heart sounds over the mitral area or point of maximal impulse (PMI).
  • Correct
    • The nurse listens for 1 minute over the mitral area.The apical pulse is assessed for one minute listening to the heart sounds over the mitral area or point of maximal impulse (PMI).

Question 4 of 9

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During assessment the nurse determines that the patient recently consumed nicotine. Which action would the nurse take to ensure an accurate blood pressure reading?

    • Determine the patient’s blood pressure using both arms.Determining the patient’s blood pressure on both arms assists to reveal any cardiac abnormalities. It does not allow for the stimulant effects of nicotine that could cause false elevations in blood pressure. To ensure accurate blood pressure assessment, the nurse would wait until 30 minutes after the patient consumed nicotine to assess the patient’s blood pressure. Nicotine is a stimulant and vasoconstrictor, so it could alter the patient’s blood pressure reading.
  • Correct
    • Take the blood pressure 30 minutes after the patient last consumed nicotine.To ensure accurate blood pressure assessment, the nurse would wait until 30 minutes after the patient consumed nicotine to assess the patient’s blood pressure. Nicotine is a stimulant and vasoconstrictor, so it could alter the patient’s blood pressure reading.
    • Assess blood pressure readings in both sitting and standing positions.Assessing blood pressure readings in both sitting and standing positions is important to monitor for orthostatic hypotension that is associated with some antihypertensive medications such as angiotensin-converting enzyme inhibitors. Assessing the blood pressure in these two positions does not account for the potential impact nicotine could have on blood pressure readings. To ensure accurate blood pressure assessment, the nurse would wait until 30 minutes after the patient consumed nicotine to assess the patient’s blood pressure. Nicotine is a stimulant and vasoconstrictor, so it could alter the patient’s blood pressure reading.
    • Ensure that the patient’s feet are on the floor at the time of assessment.Ensuring that the patient’s feet are on the floor at the time of blood pressure assessment is the correct manner to position the patient when taking the blood pressure. This does not impact the potential effect of nicotine on the patient’s blood pressure reading. To ensure accurate blood pressure assessment, the nurse would wait until 30 minutes after the patient consumed nicotine to assess the patient’s blood pressure. Nicotine is a stimulant and vasoconstrictor, so it could alter the patient’s blood pressure reading.

Question 5 of 9

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Which nursing intervention is appropriate to implement to address the nursing diagnosis potential for injury caused by obstructed blood flow?

  • Correct
    • Administer anticoagulants according to provider prescription.Administering anticoagulants according to the provider’s prescription will prevent thrombosis from forming. Thrombosis can block blood flow leading to tissue damage that leads to tissue injury. It is essential to reduce the risk for thrombosis formation.
    • Assess the effectiveness of antihypertension therapy.Assessing the effectiveness of antihypertensive therapy is important to the nursing diagnosis of altered tissue perfusion and does not address the obstructed blood flow. Administering anticoagulants according to the provider’s prescription will prevent thrombosis from forming. Thrombosis can block blood flow leading to tissue damage that leads to tissue injury. It is essential to reduce the risk for thrombosis formation.
    • Assist the patient to remain in high Fowler’s position.Assisting the patient to remain in high Fowler’s position is essential to the nursing diagnosis of altered gas exchange rather than potential for injury caused by obstructed blood flow. The high Fowler’s position improves oxygenation. Administering anticoagulants according to the provider’s prescription will prevent thrombosis from forming. Thrombosis can block blood flow leading to tissue damage that leads to tissue injury. It is essential to reduce the risk for thrombosis formation.
    • Monitor urine output related to kidney perfusion.Monitoring urine output related to kidney perfusion addresses the nursing diagnosis of altered cardiac output. This does not address obstruction to blood flow that can cause tissue injury. Administering anticoagulants according to the provider’s prescription will prevent thrombosis from forming. Thrombosis can block blood flow leading to tissue damage that leads to tissue injury. It is essential to reduce the risk for thrombosis formation.

Question 6 of 9

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Which nursing intervention would the nurse use to prevent falls in the patient receiving cardiac medications?

    • Assess the patient’s apical pulse three times daily.Assessing the patient’s apical pulse is important before administering any medication that affects the patient’s heart rate or to monitor the patient at risk for electrolyte disturbances. Assessing the apical pulse does not prevent falls that commonly occur because of hypotension secondary to cardiac medications. The nurse would encourage the patient to sit on the edge of the bed before getting up to prevent falls related to cardiac medications.
    • Determine the patient’s ability to be compliant with treatments.Determining the patient’s ability to be compliant with treatments is an important part of reaching the expected outcomes demonstrating improvement or lack of deterioration in a patient’s cardiac condition. However, this does not prevent the patient from experiencing a fall commonly caused by hypotension from cardiac medications. The nurse would encourage the patient to sit on the edge of the bed before getting up to prevent falls related to cardiac medications.
    • Avoid administering medications that cause vasoconstriction.Avoiding administering medications that cause vasoconstriction is an important intervention to prevent recurrence of thrombosis in the patient with a history of such. Avoiding vasoconstriction does not prevent the patient from experiencing a fall commonly caused by hypotension from cardiac medications. The nurse would encourage the patient to sit on the edge of the bed before getting up to prevent falls related to cardiac medications.
  • Correct
    • Have the patient to sit on the edge of the bed for 2 minutes.The nurse would encourage the patient to sit on the edge of the bed for a couple of minutes before getting up to prevent falls related to cardiac medications that cause postural hypotension.

Question 7 of 9

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Which finding suggests that a patient with a cardiac condition is tolerating physical activity?

    • Mild, rather than severe, chest pain occurs with activity.The presence of any chest pain suggests that the patient is not tolerating physical activity. Chest pain indicates that the patient is not getting adequate perfusion to the cardiac muscle. The absence of chest pain would indicate that the patient with a cardiac condition is tolerating physical activity.
    • The patient’s blood pressure goes from 140/78 mm Hg to 125/70 mm Hg during activity.The patient whose systolic blood pressure drops with activity suggests that the patient is not tolerating activity. The patient who is tolerating physical activity will maintain blood pressure once activity starts.
  • Correct
    • The patient’s heart rates rises to 90 beats per minute (bpm) from a baseline of 82 bpm.The patient whose heart rate rises less than 20 bpm with activity suggests that the patient is tolerating physical activity.
    • Minor changes in the heart rhythm are present with activity.The patient with a cardiac condition would not be tolerating physical activity if minor changes in their heart rhythm occurs. The patient should not have an abnormal rhythm during physical activity.

Question 8 of 9

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Which finding suggests that the patient is experiencing fluid retention?

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    • The patient gains 2.3 pounds over 48 hours.The patient who gains 2 to 3 pounds over 2 to 3 days is likely experiencing fluid retention, a concern in the patient with a cardiac condition.
    • The patient demonstrates new onset of confusion.The patient with new onset confusion demonstrates a concerning finding. However, new confusion does not necessarily indicate fluid retention; instead it is likely associated with an electrolyte imbalance for example. The patient who gains 2 to 3 pounds over 2 to 3 days is likely experiencing fluid retention, a concern in the patient with a cardiac condition.
    • The patient has dyspnea and fatigue with exertion.The patient who has dyspnea and fatigue with exertion is demonstrating signs of hypoxia, a lack of oxygen to the tissues. The patient who gains 2 to 3 pounds over 2 to 3 days is likely experiencing fluid retention, a concern in the patient with a cardiac condition.
    • The patient has cool, pale skin.The patient who has cool, pale skin may be demonstrating a concerning finding, particularly if persistent and in a warm environment. Cool, pale skin is not specific to fluid retention. The patient who gains 2 to 3 pounds over 2 to 3 days is likely experiencing fluid retention, a concern in the patient with a cardiac condition.

Question 9 of 9

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Which consideration would the nurse include to provide care to the patient with peripheral vascular disease? Select all that apply. One, some, or all responses may be correct.

  • Correct
    • Avoid extreme heat such as heating pads.Heating pads provide extremes of heat, which can cause vasoconstriction. Avoiding extremes of heat promotes blood flow to the tissues.
    • Maintain cool temperatures in the patient’s room.Maintaining cool temperatures in the patient’s room does not promote vasodilation; rather, the cooler temperature could contribute to vasoconstriction. The goal of care is to maintain blood flow through vasodilation or preventing vasoconstriction.
  • Correct
    • Provide layers of clothing as able.Providing extra layers of clothing promotes warmth for the patient, promoting blood flow, and preventing vasoconstriction that would limit perfusion to the tissues.
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    • Teach the patient to avoid sources of cold temperatures.Teaching the patient to avoid sources of cold temperatures promotes blood flow and prevents vasoconstriction. The goal for the patient with peripheral vascular disease is to promote blood flow and avoid constriction of blood vessels.
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    • Use warmed blankets as needed to cover the patient.The hospital environment can be cool, contributing to constriction of blood vessels and decreased blood flow in the patient with peripheral vascular disease. Using warmed blankets as needed to promote warmth, prevent vasoconstriction, and promote blood flow assist to meet the goal of promoting blood flow for the patient.