Last Updated 04 Dec 2017

Chapter 35

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The nurse is caring for a client who has had a recent myocardial infarction involving the left ventricle. Which assessment finding is expected?
Decreased cardiac output
The nurse is caring for a client with coronary artery disease.

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. The client is hypotensive. What additional assessment finding does the nurse expect?
Heart rate of 120 beats/min
The nurse administers a beta blocker to a client after a myocardial infarction. What assessment finding does the nurse expect?
Pulse decreases from 100 to 80 BPM
The nurse is assessing clients at a community health center. Which client does the nurse determine is at high risk for cardiovascular disease?
American Indian woman with diabetes
The nurse is obtaining a client's health history. Which illness alerts the nurse to the possibility of abnormal heart valves?
Rheumatic fever
A nurse is performing an admission assessment on an older adult client with multiple chronic diseases. The nurse assesses the heart rate to be 48 beats/min. What does the nurse do first?
Assess the client's medications
The nurse is assessing clients at a clinic. Which activity takes priority?
Teaching smoking cessation
The nurse is assessing a client in the emergency department. Which client statement alerts the nurse to the occurrence of heart failure?
I get short of breath when I climb stairs
The nurse is assessing a client newly admitted to the medical unit. Which statement made by the client alerts the nurse to the presence of edema?
My shoes fit tighter at the end of the day
When obtaining a client's vital signs, the nurse assesses a blood pressure of 134/88 mm Hg. What is the nurse's best intervention?
Teach the patient lifestyle modifications to decrease blood pressure
The nurse is performing a focused cardiac assessment. What assessment finding should be reported to the health care provider?
Bruit heard on the side of the neck
A client consistently reports feeling dizzy and lightheaded when moving from a supine position to a sitting position. What nursing assessment takes priority at this time?
Blood pressure
The nurse is assessing an older adult client who is experiencing a myocardial infarction. What clinical manifestation does the nurse expect in this client?
Disorientation and confusion
A client is newly diagnosed with a heart murmur and asks the nurse to explain what this means. What is the nurse's best response?
It is a rushing sound the blood makes moving through narrow places
A client has returned from a cardiac angiography via the left femoral artery. Two hours after the procedure, the nurse notes that the left pedal pulse is weak. What is the nurse's best action?
Assess color and temperature
The nurse is recovering a client after a left-sided cardiac catheterization. What assessment finding requires immediate intervention?
Slurred speech and confusion
The nurse is preparing a client for a cardiac catheterization. What assessment is a priority before the procedure?
Allergies to iodine and shellfish
The client is scheduled for a resting electrocardiography. Which statement by the client indicates a good understanding of the preprocedure teaching?
I must lie as still as possible
The nurse is monitoring a client undergoing an exercise electrocardiography (stress test). Which assessment finding necessitates that the test be stopped?
Significant ST-segment depression
A client who is scheduled for an echocardiography today asks why this test is being performed. What is the nurse's best response?
This procedure is a noninvasive way to assess the structure of the heart
The nurse is caring for a client who is scheduled for magnetic resonance imaging (MRI) of the heart. The client's history includes a previous myocardial infarction and pacemaker implantation. Which action by the nurse is most appropriate?
Notify the doctor before scheduling the MRI
The nurse obtains a pulmonary artery pressure reading of 25/12 mm Hg in a client recovering from a myocardial infarction. What is the nurse's first intervention?
Compare to previous readings
The nurse is preparing to measure a client's pulmonary artery wedge pressure (PAWP). In what position will the nurse place the client for the most accurate results?
Supine, with the head elevated to 45 degrees
The nurse is caring for a client with an 80% blockage of the right coronary artery (RCA). While waiting for bypass surgery, what is essential for the nurse to have available?
External pacemaker
The nurse is caring for a client with pericarditis. What assessment finding correlates with this disorder?
Pericardial friction rub
The nurse is auscultating cardiac tones

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