Nur 107 Chapters 21-27 Cardiovascular/ Brunner & Suddarth's Textbo
o Medical-Surgical Nursing, 15th ed.,
1. A client with a history of right-sided heart failure lives in a long-term care
facility. In the daily assessment, the nurse is required to record the level of
this client's peripheral edema. Which would be the main area for
examination?: Correct response:
Feet and ankles
Explanation:
Edema occurs when blood is not pumped efficiently or plasma protein levels are
inadequate to maintain osmotic pressure. When blood has nowhere else to go, the
extra fluid enters the tissues. Particular areas for examination are the dependent
parts of the body, such as the feet and ankles. The area over, not below, the sacrum
is another area prone to edema.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 21: Assessment of
Cardiovascular Function, Assessment of the Skin and Extremities, p. 664.
Chapter 21: Assessment of Cardiovascular Function - Page 664
2. It is important for a nurse to understand cardiac hemodynamics. For
blood to flow from the right ventricle to the pulmonary artery, the following
must occur:: Correct response:
Right ventricular pressure must be higher than pulmonary arterial pressure.
Explanation:
For the right ventricle to pump blood in need of oxygenation into the lungs via the
pulmonary artery, right ventricular pressure must be higher than pulmonary arterial
pressure. Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 21: Assessment of
Cardiovascular Function, Cardiac Hemodynamics, p. 655.
Chapter 21: Assessment of Cardiovascular Function - Page 655
3. For both outpatients and inpatients scheduled for diagnostic
procedures of the cardiovascular system, the nurse performs a thorough
initial assessment to establish accurate baseline data. Which data is
necessary to collect if the
client is experiencing chest pain?: description of the pain Explanation:
If the client is experiencing chest pain, a history of its location, frequency, and
duration is necessary. A description of the pain is also needed, including if it radiates
, Nur 107 Chapters 21-27 Cardiovascular/ Brunner & Suddarth's Textbo
o Medical-Surgical Nursing, 15th ed.,
to a particular area, what precipitates its onset, and what brings relief. The nurse
weighs the client and measures vital signs. The nurse may measure blood pressure
in both arms and compare findings. The nurse assesses apical and radial pulses,
noting rate, quality, and rhythm. The nurse also checks peripheral pulses in the
lower extremities.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 21: Assessment of
Cardiovascular Function, Assessment of the Cardiovascular System, Health
History, p. 658.
Chapter 21: Assessment of Cardiovascular Function - Page 658
4. The clinic nurse caring for a client with a cardiovascular disorder is
performing an assessment of the client's pulse. Which of the following steps
is involved in determining the pulse deficit?: Count the heart rate at the apex.
Explanation:
The nurse determines the pulse deficit by counting the heart rate through
auscultation at the apex while a second nurse simultaneously palpates and counts
the radial pulse for a full minute. The difference, if any, is the pulse deficit. The pulse
quality refers to its palpated volume. Pulse rhythm is the pattern of the pulsations
and the pauses between them.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 21: Assessment of
Cardiovascular Function, Pulse Rhythm, p. 666.
Chapter 21: Assessment of Cardiovascular Function - Page 666
5. Within the heart, several structures and several layers all play a part in
protecting the heart muscle and maintaining cardiac function. The inner
layer of the heart is composed of a thin, smooth layer of cells, the folds of
which form heart valves. What is the name of this layer of cardiac tissue?:
The inner layer, the endocardium, is composed of a thin, smooth layer of
endothelial cells. Folds of endocardium form the heart valves. The middle layer,
the myocardium, consists of muscle tissue and is the force behind the heart's
pumping action. The pericardium is a saclike structure that surrounds and
supports the heart. The outer layer, the epicardium, is composed of fibrous and
loose connective tissue.
, Nur 107 Chapters 21-27 Cardiovascular/ Brunner & Suddarth's Textbo
o Medical-Surgical Nursing, 15th ed.,
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 21: Assessment of
Cardiovascular Function, Anatomy of the Heart, p. 651.
Chapter 21: Assessment of Cardiovascular Function - Page 651
6. The nurse working in the emergency department places a client in
anaphylactic shock on a cardiac monitor and sees the cardiac rhythm
shown. Which dysrythmia should the nurse document?: ventricular
tachycardia
Explanation:
The dysrhythmia shown is ventricular tachycardia because it has more than 3
premature ventricular contractions. The ventricular rate is 100 to 200 bpm; the atrial
rate depends on the underlying rhythm (e.g., sinus rhythm). The QRS duration is
0.12 seconds or more and has an abnormal shape. .
Ventricular asystole is characterized by absent QRS complexes; this rhythm is
referred to as flatline.
Normal sinus rhythm is regular with with a ventricular and atrial rate of 60 to 100
bpm. The P-wave has a consistent shape and is always in front of the QRS. The
PR interval is a consistent interval between 0.12 and 0.20 seconds, and the P:QRS
ratio is 1:1.
A junctional rhythm not caused by a complete heart block has a ventricular rate of
40 to 60 bpm and, if P waves are discernible, an atrial rate of 40 to 60 bpm. The
ventricular and atrial rhythm are regular. If the P-wave is in front of the QRS, the PR
interval is less than 0.12 seconds. The P:QRS ratio is 1:1 or 0:1.
Atrial fibrillation is indicated by an atrial rate of 300 to 600 bpm; the ventricular rate
is usually 120 to 200 bpm if untreated. Both the ventricular and atrial rhythm are
highly irregular. P-waves will not be discernible; irregular undulating waves that vary
in amplitude and shape are referred to as fibrillatory or f waves. The PR interval
cannot be measured, and the P:QRS ratio is Many:1.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 22: Management
of Patients with Arrhythmias and Conduction Problems, Types of Arrhythmias, p.
707.
, Nur 107 Chapters 21-27 Cardiovascular/ Brunner & Suddarth's Textbo
o Medical-Surgical Nursing, 15th ed.,
7. The nursing student asks the nurse how to tell the difference between
ventricular tachycardia and ventricular fibrillation on an electrocardiogram
strip. What is the best response?: Explanation:
Ventricular fibrillation is irregular with undulating waves and no QRS complex, while
ventricular tachycardia is usually regular and fast with wide QRS complexes. The
rhythms look different on the electrocardiogram strip. The QRS is wide and bizarre
or undefined in ventricular fibrillation. The P-R interval is not present in the
ventricular dysrhythmias.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 22: Management
of Patients with Arrhythmias and Conduction Problems, Types of Arrhythmias, pp.
706-707.
Chapter 22: Management of Patients with Arrhythmias and Conduction Problems -
Page 706-707
8. The nurse is assessing a patient with a probable diagnosis of first-
degree AV block. The nurse is aware that this dysrhythmia is evident on an
ECG strip by what indication?: Delayed conduction, producing a prolonged PR
interval Explanation:
First-degree AV block may occur without an underlying pathophysiology, or it can
result from medications or conditions that increase parasympathetic tone. It occurs
when atrial conduction is delayed through the AV node, resulting in a prolonged PR
interval.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 22: Management of
Patients with Arrhythmias and Conduction Problems, Types of Arrhythmias, p. 708.
Chapter 22: Management of Patients with Arrhythmias and Conduction Problems -
Page 708
9. A client experiences a faster-than-normal heart rate when drinking more
than two cups of coffee in the morning. What does the nurse identify on the
