1. A nurse is describing the process by which blood is ejected into circulation as the
chambers of the heart become smaller. The instructor categorizes this as what action?
A. Systole
B. Diastole
C. Repolarization
D. Ejection fraction
ANS: A
Rationale: Systole is the action of the chambers of the heart becoming smaller and
ejecting blood. This action of the heart is not diastole (relaxation), ejection fraction
(the amount of blood expelled), or repolarization (electrical charging).
PTS: 1 REF: p. 651
NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client
Needs: Physiological Integrity: Physiological Adaptation
TOP: Chapter 21: Assessment of Cardiovascular Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice
2. During a shift assessment, the nurse is identifying the client's point of maximum
impulse (PMI). Where should the nurse best palpate the PMI?
A. Left midclavicular line of the chest at the level of the nipple
B. Left midclavicular line of the chest at the fifth intercostal space
C. Midline between the xiphoid process and the left nipple
D. Two to three centimeters to the left of the sternum
ANS: B
Rationale: The left ventricle is responsible for the apical beat or the point of maximum
impulse, which is normally palpated in the left midclavicular line of the chest wall at
,the fifth intercostal space.
PTS: 1 REF: p. 653
NAT: Client Needs: Physiological Integrity: Physiological Adaptation
TOP: Chapter 21: Assessment of Cardiovascular Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice
3. The nurse is calculating a cardiac client's pulse pressure. If the client's blood
pressure is 122/76 mm Hg, what is the client's pulse pressure?
A. 46 mm Hg
B. 99 mm Hg
C. 198 mm Hg
D. 76 mm Hg
ANS: A
Rationale: Pulse pressure is the difference between the systolic and diastolic pressure.
In this case, this value is 46 mm Hg.
PTS: 1 REF: p. 665
NAT: Client Needs: Physiological Integrity: Physiological Adaptation
TOP: Chapter 21: Assessment of Cardiovascular Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze
NOT: Multiple Choice
4. A client has been admitted to the intensive care unit (ICU) after an ischemic stroke,
and a central venous pressure (CVP) monitoring line was placed. The nurse notes a low
CVP. Which condition is the most likely reason for a low CVP?
A. Hypovolemia
B. Myocardial infarction (MI)
C. Left-sided heart failure
D. Aortic valve regurgitation
, ANS: A
Rationale: CVP is a measurement of the pressure in the vena cava or right atrium. A
low CVP indicates a reduced right ventricular preload, most often from hypovolemia.
An MI is an unlikely cause of low CVP. CVP measures the right side of the heart, so
left-sided failure is unlikely to affect CVP. Aortic valve regurgitation is a less likely
cause of low CVP.
PTS: 1 REF: p. 685
NAT: Client Needs: Physiological Integrity: Physiological Adaptation
TOP: Chapter 21: Assessment of Cardiovascular Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze
NOT: Multiple Choice
5. While auscultating a client's heart sounds, the nurse hears an extra heart sound
immediately after the second heart sound (S2). An audible S3 would be considered an
expected finding in which client?
A. A 47-year-old client
B. A 20-year-old client
C. A client who has undergone valve replacement
D. A client who takes a beta-adrenergic blocker
ANS: B
Rationale: S3 represents a normal finding in children and adults up to 35 or 40 years of
age. In these cases, it is called a physiologic S3. It is an abnormal finding in a client
with an artificial valve, an adult older than 40 years of age, or a client who takes a
beta blocker.
PTS: 1 REF: p. 669
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 21: Assessment of Cardiovascular Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
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