Which instruction by the nurse is given to a patient who is about to undergo Holter monitoring is most appropriate?
A. "You may remove the monitor only to shower or bathe."
B. "You should connect the monitor whenever you feel symptoms."
C. "You should refrain from exercising while wearing this m...
Which instruction by the nurse is given to a patient who is about to undergo
Holter monitoring is most appropriate?
A. "You may remove the monitor only to shower or bathe."
B. "You should connect the monitor whenever you feel symptoms."
C. "You should refrain from exercising while wearing this monitor."
D. "You will need to keep a diary of all your activities and symptoms." - ANSWER-
D. "You will need to keep a diary of all your activities and symptoms."
A Holter monitor is worn continuously for at least 24 hours while a patient
continues with usual activity and keeps a diary of activities and symptoms. The
patient should not take a bath or shower while wearing this monitor.
The nurse is admitting a patient who is scheduled to undergo a cardiac
catheterization. What allergy information is most important for the nurse to
assess and document before this procedure?
A. Iron
B. Iodine
C. Aspirin
D. Penicillin - ANSWER-B. Iodine
The physician will usually use an iodine-based contrast to perform this
procedure. Therefore it is imperative to know whether or not the patient is allergic
to iodine or shellfish. Knowledge of allergies to iron, aspirin, or penicillin will be
secondary.
The blood pressure of an older adult patient admitted with pneumonia is 160/70
mm Hg. What is an age-related change that contributes to this finding?
A. Stenosis of the heart valves
B. Decreased adrenergic sensitivity
,C. Increased parasympathetic activity
D. Loss of elasticity in arterial vessels - ANSWER-D. Loss of elasticity in arterial
vessels Correct
An age-related change that increases the risk of systolic hypertension is a loss of
elasticity in the arterial walls. Because of the increasing resistance to flow,
pressure is increased within the blood vessel, and hypertension results. Valvular
rigidity of aging causes murmurs, and decreased adrenergic sensitivity slows the
heart rate. Blood pressure is not raised. Increased parasympathetic activity would
slow the heart rate.
The nurse is providing care for a patient who has decreased cardiac output
related to heart failure. What should the nurse recognize about cardiac output?
A. It is calculated by multiplying the patient's stroke volume by the heart rate.
B. It is the average amount of blood ejected during one complete cardiac cycle.
C. It is determined by measuring the electrical activity of the heart and the
patient's heart rate.
D. It is the patient's average resting heart rate multiplied by the patient's mean
arterial blood pressure. - ANSWER-A. It is calculated by multiplying the patient's
stroke volume by the heart rate.
Cardiac output is determined by multiplying the patient's stroke volume by heart
rate, thus identifying how much blood is pumped by the heart over a 1-minute
period. Electrical activity of the heart and blood pressure are not direct
components of cardiac output.
The nurse is performing an assessment for a patient with fatigue and shortness
of breath. Auscultation of the heart reveals the presence of a murmur. What is
this assessment finding indicative of?
A. Increased viscosity of the patient's blood
B. Turbulent blood flow across a heart valve
C. Friction between the heart and the myocardium
D. A deficit in heart conductivity that impairs normal contractility - ANSWER-B.
Turbulent blood flow across a heart valve
Turbulent blood flow across the affected valve results in a murmur. A murmur is
not a direct result of variances in blood viscosity, conductivity, or friction
between the heart and myocardium.
,While assessing the cardiovascular status of a patient, the nurse performs
auscultation. Which intervention should the nurse implement in the assessment
during auscultation?
A. Position the patient supine.
B. Ask the patient to hold his or her breath.
C. Palpate the radial pulse while auscultating the apical pulse.
D. Use the bell of the stethoscope when auscultating S1 and S2. - ANSWER-C.
Palpate the radial pulse while auscultating the apical pulse.
To detect a pulse deficit, simultaneously palpate the radial pulse when
auscultating the apical area. The diaphragm is more appropriate than the bell
when auscultating S1 and S2. A sitting or side-lying position is most appropriate
for cardiac auscultation. It is not necessary to ask the patient to hold his or her
breath during cardiac auscultation.
A patient presents to the emergency department with reports of chest pain for 3
hours. What component of his blood work is most clearly indicative of a
myocardial infarction (MI)?
A. CK-MB
B. Troponin
C. Myoglobin
D. C-reactive protein - ANSWER-B. Troponin
Troponin is the biomarker of choice in the diagnosis of MI, with sensitivity and
specificity that exceed those of CK-MB and myoglobin. CRP levels are not used
to diagnose acute MI.
The patient informs the nurse that he does not understand how there can be a
blockage in the left anterior descending artery (LAD), but there is damage to the
right ventricle. What is the best response by the nurse?
A. "The one vessel curves around from the left side to the right ventricle."
B. "The LAD supplies blood to the left side of the heart and part of the right
ventricle."
C. "The right ventricle is supplied during systole primarily by the right coronary
artery."
D. "It is actually on your right side of the heart, but we call it the left anterior
descending vessel." - ANSWER-B. "The LAD supplies blood to the left side of the
heart and part of the right ventricle."
, The best response is explaining that the lower portion of the right ventricle
receives blood flow from the left anterior descending artery as well as the right
coronary artery during diastole.
When looking at the electrocardiogram (ECG) of the patient, the nurse knows that
the QRS complex recorded on the ECG represents which part of the heart's beat?
A. Depolarization of the atria
B. Repolarization of the ventricles
C. Depolarization from atrioventricular (AV) node throughout ventricles
D. The length of time it takes for the impulse to travel from the atria to the
ventricles - ANSWER-C. Depolarization from atrioventricular (AV) node
throughout ventricles
The QRS recorded on the ECG represents depolarization from the AV node
throughout the ventricles. The P wave represents depolarization of the atria. The
T wave represents repolarization of the ventricles. The interval between the PR
and QRS represents the length of time it takes for the impulse to travel from the
atria to the ventricles.
In palpating the patient's pedal pulses, the nurse determines the pulses are
absent. What factor could contribute to this result?
A. Atherosclerosis
B. Hyperthyroidism
C. Arteriovenous fistula
D. Cardiac dysrhythmias - ANSWER-A. Atherosclerosis
Atherosclerosis can cause an absent peripheral pulse. The feet would also be
cool and may be discolored. Hyperthyroidism causes a bounding pulse.
Arteriovenous fistula gives a thrill or vibration to the vessel, although this would
not be in the foot. Cardiac dysrhythmias cause an irregular pulse rhythm.
The nurse informs the patient that she must wear intermittent sequential
compression stockings after a surgical procedure. What is an appropriate
rationale for nurse to give to the patient for the use of the device?
A. The socks keep the legs warm while the patient is not moving much.
B. The socks maintain the blood flow to the legs while the patient is on bed rest.
C. The socks keep the blood pressure down while the patient is stressed after
surgery.
D. The socks provide compression of the veins to keep the blood moving back to
the heart. - ANSWER-D. The socks provide compression of the veins to keep the
blood moving back to the heart.
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