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 action of the heart as what? Correct Ans - systole
During a shift assessment, the nurse is identifying the clients point of
maximum impulse (PMI). Where will the nurse best palpate the PMI?
Correct Ans - Left midclavicular line of the chest at the fifth intercostal
space
The nurse is calculating a cardiac patients pulse pressure. If the patients
blood pressure is 122/76 mm Hg, what is the patients pulse pressure?
Correct Ans - 46 mm Hg
The nurse is caring for a patient admitted with unstable angina. The
laboratory result for the initial troponin I is elevated in this patient. The
nurse should recognize what implication of this assessment finding?
Correct Ans - This is an accurate indicator of myocardial injury.
The nurse is conducting patient teaching about cholesterol levels. When
discussing the patients elevated LDL and lowered HDL levels, the patient
shows an understanding of the significance of these levels by stating what?
Correct Ans - "Increased LDL and decreased HDL increase my risk of
coronary artery disease."
The physician has placed a central venous pressure (CVP) monitoring line
in an acutely ill patient so right ventricular function and venous blood
return can be closely monitored. The results show decreased CVP. What
does this indicate? Correct Ans - Possible hypovolemia
While auscultating a patients 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 what patient? Correct Ans - A
20-year-old patient
The physical therapist notifies the nurse that a patient with coronary
artery disease (CAD) experiences a much greater-than-average increase in
heart rate during physical therapy. The nurse recognizes that an increase in
, heart rate in a patient with CAD may result in what? Correct Ans -
myocardial ischemia
The nurse is caring for a patient who has a history of heart disease. What
factor should the nurse identify as possibly contributing to a decrease in
cardiac output? Correct Ans - A heart rate of 54 bpm
The nurse is caring for an 82-year-old patient. The nurse knows that
changes in cardiac structure and function occur in older adults. What is a
normal change expected in the aging heart of an older adult? Correct
Ans - Widening of the aorta
A resident of a long-term care facility has complained to the nurse of chest
pain. What aspect of the residents pain would be most suggestive of angina
as the cause? Correct Ans - The pain occurs immediately following
physical exertion.
The critical care nurse is caring for a patient with a central venous pressure
(CVP) monitoring system. The nurse notes that the patients CVP is
increasing. Of what may this indicate? Correct Ans - hypervolemia
The critical care nurse is caring for a patient with a pulmonary artery
pressure monitoring system. The nurse is aware that pulmonary artery
pressure monitoring is used to assess left ventricular function. What is an
additional function of pulmonary artery pressure monitoring systems?
Correct Ans - To assess the patients response to fluid and drug
administration
The cardiac care nurse is reviewing the conduction system of the heart. The
nurse is aware that electrical conduction of the heart usually originates in
the SA node and then proceeds in what sequence? Correct Ans - SA
node, AV node, Bundle of His, Purkinje fibers
A patient has had a myocardial infarction and has been diagnosed as having
damage to the layer of the
heart
responsible for the pumping action. You are aware that the damage
occurred where? Correct Ans - myocardium
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