Question 1

A transesophageal echocardiogram (TEE) is ordered for a client with possible endocarditis. Which of the following actions included in the standard TEE orders should the nurse accomplish first?

Accepted Answer

A)  Administer O2 per mask
B)  Start a large-gauge IV line
C)  Place the client on NPO status
D)  Give lorazepam 1 mg IV C

Question 2

The nurse hears a murmur between the S1 and S2 heart sounds at the client's left 5th intercostal space and midclavicular line. How should the nurse record this information?

Accepted Answer

A)  "Systolic murmur heard at mitral area."
B)  "Diastolic murmur heard at aortic area."
C)  "Systolic murmur heard at Erb's point."
D)  "Diastolic murmur heard at tricuspid area." A

Question 3

The nurse is assessing the laboratory results for a client who developed chest pain 4 hours ago and may be having a myocardial infarction. Which of the following laboratory results is most important for the nurse to review?

Accepted Answer

A)  LDL cholesterol
B)  Troponins T and I
C)  C-reactive protein
D)  Creatine kinase-MB (CK-M
B)   B

Question 4

The nurse is assessing a client who was admitted with heart failure and notes that the client has jugular venous distension (JVD) when lying flat in bed. Which of the following actions should the nurse take next?

Accepted Answer

A)  Use a ruler to measure the level of the JVD.
B)  Document this finding in the client's record.
C)  Observe for JVD with the head at 45 degrees.
D)  Have the client perform the Valsalva manoeuvre.

Question 5

The RN is observing a student nurse who is doing a physical assessment on a client. The RN will need to intervene immediately if the student nurse implements which of the following interventions?

Accepted Answer

A)  Places the client in the left lateral position to check for the point of maximal impulse (PMI) .
B)  Presses on the skin over the tibia for 10 seconds to check for edema.
C)  Palpates both carotid arteries simultaneously to compare pulse quality.
D)  Documents a murmur heard along the left sternal border as an aortic murmur.

Question 6

The nurse is monitoring a client who is undergoing exercise (stress) testing on a treadmill. Which of the following assessment findings requires the most rapid action by the nurse?

Accepted Answer

A)  Client complaint of feeling tired
B)  Pulse change from 80 to 96 beats/minute
C)  BP increase from 134/68 to 150/80 mm Hg
D)  Electrocardiographic changes indicating coronary ischemia

Question 7

The standard policy on the cardiac unit states, "Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg." Which of the following clients should the nurse report to the health care provider?

Accepted Answer

A)  Postoperative client with a BP of 116/42
B)  Newly admitted client with a BP of 122/60
C)  Client with left ventricular failure who has a BP of 110/70
D)  Client with a myocardial infarction who has a BP of 114/50

Question 8

The nurse is assessing a newly admitted client and notes a thrill along the left sternal border. To obtain more information about the cause of the thrill, which of the following actions should the nurse take next?

Accepted Answer

A)  Auscultate for any cardiac murmurs.
B)  Find the point of maximal impulse.
C)  Compare the apical and radial pulse rates.
D)  Palpate the quality of the peripheral pulses.

Question 9

The nurse is reviewing the 12-lead electrocardiograph (ECG) of a healthy older-adult client who is having an annual physical examination. Which of the following findings should be of most concern to the nurse?

Accepted Answer

A)  The heart rate is 43 beats/minute.
B)  The PR interval is 0.21 seconds.
C)  There is a right bundle-branch block.
D)  The QRS duration is 0.13 seconds.

Question 10

The nurse is providing teaching to a client being evaluated for rhythm disturbances with a Holter monitor. Which of the following information should the nurse include in the teaching plan?

Accepted Answer

A)  Exercise more than usual while the monitor is in place.
B)  Remove the electrodes when taking a shower or tub bath.
C)  Keep a diary of daily activities while the monitor is worn.
D)  Connect the recorder to a telephone transmitter once daily.

Question 11

During a physical examination of a client, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. Which of the following actions should the nurse implement next?

Accepted Answer

A)  Document that the PMI is in the normal anatomic location.
B)  Ask the client about risk factors for coronary artery disease.
C)  Auscultate both the carotid arteries for the presence of a bruit.
D)  Assess the client for symptoms of left ventricular hypertrophy.

Question 12

The nurse is auscultating over the client's abdominal aorta and hears a humming sound. Which of the following terms should the nurse use to document this finding?

Accepted Answer

A)  Thrill
B)  Bruit
C)  Heave
D)  Murmur

Question 13

The nurse is caring for a client who is scheduled for a cardiac catheterization with coronary angiography. Which of the following information should the nurse provide to the client before the test?

Accepted Answer

A)  Electrocardiographic (ECG)  monitoring will be required for 24 hours after the test.
B)  It will be important to lie completely still during the procedure.
C)  A warm feeling may be noted when the contrast dye is injected.
D)  Monitored anaesthesia care will be provided during the procedure.

Question 14

The nurse is assessing a client who has just arrived in the emergency department and notes a pulse deficit. Which of the following actions should the nurse anticipate for the client?

Accepted Answer

A)  A 2-D echocardiogram
B)  A cardiac catheterization
C)  Hourly blood pressure checks
D)  Electrocardiographic monitoring

Question 15

The nurse is admitting a client for a coronary arteriogram and angiogram. Which of the following information about the client is most important for the nurse to communicate to the health care provider?

Accepted Answer

A)  The client's pedal pulses are +1.
B)  The client is allergic to iodine.
C)  The client has not eaten anything today.
D)  The client had an arteriogram a year ago.

Question 16

The nurse is assessing an underweight older-adult client and observes pulsation of the abdominal aorta in the epigastric area. Which of the following actions should the nurse take?

Accepted Answer

A)  Notify the hospital rapid response team.
B)  Instruct the client to remain on bed rest.
C)  Teach the client about aortic aneurysms.
D)  Document the finding in the client chart.

Question 17

To auscultate for S3 or S4 gallops in the mitral area, which of the following should the nurse implement?

Accepted Answer

A)  Use the bell of the stethoscope with the client in the left lateral position.
B)  Use the bell of the stethoscope with the client sitting and leaning forward.
C)  Use the diaphragm of the stethoscope with the client in a reclining position.
D)  Use the diaphragm of the stethoscope with the client lying flat on the left side.

Question 18

The nurse is caring for a client who is being treated for heart failure. Which of the following laboratory results should the nurse assess to determine the effects of therapy?

Accepted Answer

A)  Myoglobin
B)  Homocysteine (Hcy) 
C)  Low-density lipoprotein (LDL) 
D)  B-type natriuretic peptide (BNP)

Question 19

Which of the following information obtained by the nurse who is admitting the client for magnetic resonance imaging (MRI) will be most important to report to the health care provider before the MRI?

Accepted Answer

A)  The client has an allergy to shellfish and iodine.
B)  The client has a history of coronary artery disease.
C)  The client has a permanent ventricular pacemaker in place.
D)  The client took all the prescribed cardiac medications today.

Question 20

Which of the following actions should the nurse implement for a client who arrives for a calcium-scoring CT scan?

Accepted Answer

A)  Administer oral sedative medications.
B)  Teach the client about the procedure.
C)  Ask whether the client has eaten today.
D)  Insert a large gauge intravenous catheter.

Exam 34: Nursing Assessment Cardiovascular System