1. A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min
When a client experiences hypoten...
1 a nurse assesses a client who had a myocardial infarction and is hypotensive which additional assessment finding should the nurse expect a heart rate of 120 beatsmin b cool
clammy skin c oxy
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AH 2 Exam 3 Study Guide
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AH 2 Exam 3 Study Guide
Chapter 33 Assessment of the Cardiovascular System
1. A nurse assesses a client who had a myocardial infarction and is hypotensive.
Which additional assessment finding should the nurse expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min
When a client experiences hypotension, baroreceptors in the aortic arch sense a
pressure decrease in the vessels. The parasympathetic system responds by lessening
the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and
respiratory rate.
2. A nurse assesses a client after administering a prescribed beta blocker.
Which assessment should the nurse expect to find?
a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg
b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min
c. Oxygen saturation increased from 88% to 96%
d. Pulse decreased from 100 beats/min to 80 beats/min
Beta blockers block the stimulation of beta1-adrenergic receptors. They block the
sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta
blocker will decrease HR and blood pressure, increasing ventricular filling time.
3. A nurse assesses clients on a medical-surgical unit. Which client should the
nurse identify as having the greatest risk for cardiovascular disease?
a. An 86-year-old man with a history of asthma
b. A 32-year-old Asian-American man with colorectal cancer
c. A 45-year-old American Indian woman with diabetes mellitus
d. A 53-year-old postmenopausal woman who is on hormone therapy
The incidence of coronary artery disease and hypertension is higher in American
Indians than in whites or Asian Americans. Diabetes mellitus increases the risk for
hypertension and coronary artery disease in people of any race or ethnicity.
4. A nurse assesses an older adult client who has multiple chronic diseases. The
client's heart rate is 48 beats/min. Which action should the nurse take first?
a. Document the finding in the chart.
b. Initiate external pacing.
c. Assess the client's medications.
d. Administer 1 mg of atropine.
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Pacemaker cells in the conduction system decrease in number as a person ages,
resulting in bradycardia. The nurse should check the medication reconciliation for
medications that might cause such a drop in heart rate, then should inform the health
care provider.
5. An emergency room nurse obtains the health history of a client. Which statement by
the client should alert the nurse to the occurrence of heart failure?
a. "I get short of breath when I climb stairs."
b. "I see halos floating around my head."
c. "I have trouble remembering things."
d. "I have lost weight over the past month."
Dyspnea on exertion is an early manifestation of heart failure and is associated with an
activity such as stair climbing.
6. A nurse obtains the health history of a client who is newly admitted to the medical
unit. Which statement by the client should alert the nurse to the presence of edema?
a. "I wake up to go to the bathroom at night."
b. "My shoes fit tighter by the end of the
day."
c. "I seem to be feeling more anxious lately."
d. "I drink at least eight glasses of water a day."
Weight gain can result from fluid accumulation in the interstitial spaces. This is known
as edema. The nurse should note whether the client feels that his or her shoes or rings
are tight, and should observe, when present, an indentation around the leg where the
socks end.
7. A nurse assesses an older adult client who is experiencing a myocardial infarction.
Which clinical manifestation should the nurse expect?
a. Excruciating pain on inspiration
b. Left lateral chest wall pain
c. Disorientation and
confusion
d. Numbness and tingling of the arm
In older adults, disorientation or confusion may be the major manifestation of
myocardial infarction caused by poor cardiac output. Pain manifestations and
numbness and tingling of the arm could also be related to the myocardial infarction.
8. A nurse assesses a client 2 hours after a cardiac angiography via the left femoral
artery. The nurse notes that the left pedal pulse is weak. Which action should the
nurse take?
a. Elevate the leg and apply a sandbag to the entrance site.
b. Increase the flow rate of intravenous fluids.
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c. Assess the color and temperature of the left leg.
d. Document the finding as "left pedal pulse of +1/4."
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