Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 353
Chapter 31: Assessment: Cardiovascular System
Test Bank
MULTIPLE CHOICE
1. After noting a pulse deficit when assessing a 74-year-old patient who has just arrived in the emergency
department, the nurse will anticipate that the patient may require
a. emergent cardioversion.
b. a cardiac catheterization.
c. hourly blood pressure (BP) checks.
d. electrocardiographic (ECG) monitoring.
ANS: D
Pulse deficit is a difference between simultaneously obtained apical and radial pulses. It indicates that there
may be a cardiac dysrhythmia that would best be detected with ECG monitoring. Frequent BP monitoring,
cardiac catheterization, and emergent cardioversion are used for diagnosis and/or treatment of cardiovascular
disorders but would not be as helpful in determining the immediate reason for the pulse deficit.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
2. When reviewing the 12-lead electrocardiograph (ECG) for a healthy 79-year-old patient who is having an
annual physical examination, what will be of most concern to the nurse?
a. The PR interval is 0.21 seconds.
b. The QRS duration is 0.13 seconds.
c. There is a right bundle-branch block.
d. The heart rate (HR) is 42 beats/minute.
ANS: D
The resting HR does not change with aging, so the decrease in HR requires further investigation. Bundle-
branch block and slight increases in PR interval or QRS duration are common in older individuals because of
increases in conduction time through the AV node, bundle of His, and bundle branches.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3. During a physical examination of a 74-year-old patient, the nurse palpates the point of maximal impulse
(PMI) in the sixth intercostal space lateral to the left midclavicular line. The most appropriate action for the
nurse to take next will be to
,Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 354
a. ask the patient about risk factors for atherosclerosis.
b. document that the PMI is in the normal anatomic location.
c. auscultate both the carotid arteries for the presence of a bruit.
d. assess the patient for symptoms of left ventricular hypertrophy.
ANS: D
The PMI should be felt at the intersection of the fifth intercostal space and the left midclavicular line. A PMI
located outside these landmarks indicates possible cardiac enlargement, such as with left ventricular
hypertrophy. Cardiac enlargement is not necessarily associated with atherosclerosis or carotid artery disease.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
4. To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the
a. bell of the stethoscope with the patient in the left lateral position.
b. diaphragm of the stethoscope with the patient in a supine position.
c. bell of the stethoscope with the patient sitting and leaning forward.
d. diaphragm of the stethoscope with the patient lying flat on the left side.
ANS: A
Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds
associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart
closer to the chest wall. The diaphragm of the stethoscope is best to use for the higher-pitched sounds such as
S1 and S2.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
5. To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory
result will the nurse plan to review?
a. Troponin
b. Homocysteine (Hcy)
c. Low-density lipoprotein (LDL)
d. B-type natriuretic peptide (BNP)
,Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 355
ANS: D
Increased levels of BNP are a marker for heart failure. The other laboratory results would be used to assess for
myocardial infarction (troponin) or risk for coronary artery disease (Hcy and LDL).
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
6. While doing the admission assessment for a thin 76-year-old patient, the nurse observes pulsation of the
abdominal aorta in the epigastric area. Which action should the nurse take?
a. Teach the patient about aneurysms.
b. Notify the hospital rapid response team.
c. Instruct the patient to remain on bed rest.
d. Document the finding in the patient chart.
ANS: D
Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals. The
nurse should simply document the finding in the admission assessment. Unless there are other abnormal
findings (such as a bruit, pain, or hyper/hypotension) associated with the pulsation, the other actions are not
necessary.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
7. A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse
informs the patient that
a. it will be important to lie completely still during the procedure.
b. a flushed feeling may be noted when the contrast dye is injected.
c. monitored anesthesia care will be provided during the procedure.
d. arterial pressure monitoring will be required for 24 hours after the test.
ANS: B
A sensation of warmth or flushing is common when the contrast material is injected, which can be anxiety-
producing unless it has been discussed with the patient. The patient may receive a sedative drug before the
procedure, but monitored anesthesia care is not used. Arterial pressure monitoring is not routinely used after
the procedure to monitor blood pressure. The patient is not immobile during cardiac catheterization and may be
asked to cough or take deep breaths.
DIF: Cognitive Level: Apply (application)
, Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 356
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
8. While assessing a patient who was admitted with heart failure, the nurse notes that the patient has jugular
venous distention (JVD) when lying flat in bed. Which action should the nurse take next?
a. Document this finding in the patients record.
b. Obtain vital signs, including oxygen saturation.
c. Have the patient perform the Valsalva maneuver.
d. Observe for JVD with the patient upright at 45 degrees.
ANS: D
When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but
not a clinically significant) finding. Obtaining vital signs and oxygen saturation is not warranted at this point.
JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure
increases. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant. The
nurse will document the JVD in the medical record if it persists when the head is elevated.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
9. The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to
a. connect the recorder to a computer once daily.
b. exercise more than usual while the monitor is in place.
c. remove the electrodes when taking a shower or tub bath.
d. keep a diary of daily activities while the monitor is worn.
ANS: D
The patient is instructed to keep a diary describing daily activities while Holter monitoring is being
accomplished to help correlate any rhythm disturbances with patient activities. Patients are taught that they
should not take a shower or bath during Holter monitoring and that they should continue with their usual daily
activities. The recorder stores the information about the patients rhythm until the end of the testing, when it is
removed and the data are analyzed.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
10. When auscultating over the patients abdominal aorta, the nurse hears a humming sound. The nurse
documents this finding as a
a. thrill.
Chapter 31: Assessment: Cardiovascular System
Test Bank
MULTIPLE CHOICE
1. After noting a pulse deficit when assessing a 74-year-old patient who has just arrived in the emergency
department, the nurse will anticipate that the patient may require
a. emergent cardioversion.
b. a cardiac catheterization.
c. hourly blood pressure (BP) checks.
d. electrocardiographic (ECG) monitoring.
ANS: D
Pulse deficit is a difference between simultaneously obtained apical and radial pulses. It indicates that there
may be a cardiac dysrhythmia that would best be detected with ECG monitoring. Frequent BP monitoring,
cardiac catheterization, and emergent cardioversion are used for diagnosis and/or treatment of cardiovascular
disorders but would not be as helpful in determining the immediate reason for the pulse deficit.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
2. When reviewing the 12-lead electrocardiograph (ECG) for a healthy 79-year-old patient who is having an
annual physical examination, what will be of most concern to the nurse?
a. The PR interval is 0.21 seconds.
b. The QRS duration is 0.13 seconds.
c. There is a right bundle-branch block.
d. The heart rate (HR) is 42 beats/minute.
ANS: D
The resting HR does not change with aging, so the decrease in HR requires further investigation. Bundle-
branch block and slight increases in PR interval or QRS duration are common in older individuals because of
increases in conduction time through the AV node, bundle of His, and bundle branches.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3. During a physical examination of a 74-year-old patient, the nurse palpates the point of maximal impulse
(PMI) in the sixth intercostal space lateral to the left midclavicular line. The most appropriate action for the
nurse to take next will be to
,Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 354
a. ask the patient about risk factors for atherosclerosis.
b. document that the PMI is in the normal anatomic location.
c. auscultate both the carotid arteries for the presence of a bruit.
d. assess the patient for symptoms of left ventricular hypertrophy.
ANS: D
The PMI should be felt at the intersection of the fifth intercostal space and the left midclavicular line. A PMI
located outside these landmarks indicates possible cardiac enlargement, such as with left ventricular
hypertrophy. Cardiac enlargement is not necessarily associated with atherosclerosis or carotid artery disease.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
4. To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the
a. bell of the stethoscope with the patient in the left lateral position.
b. diaphragm of the stethoscope with the patient in a supine position.
c. bell of the stethoscope with the patient sitting and leaning forward.
d. diaphragm of the stethoscope with the patient lying flat on the left side.
ANS: A
Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds
associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart
closer to the chest wall. The diaphragm of the stethoscope is best to use for the higher-pitched sounds such as
S1 and S2.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
5. To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory
result will the nurse plan to review?
a. Troponin
b. Homocysteine (Hcy)
c. Low-density lipoprotein (LDL)
d. B-type natriuretic peptide (BNP)
,Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 355
ANS: D
Increased levels of BNP are a marker for heart failure. The other laboratory results would be used to assess for
myocardial infarction (troponin) or risk for coronary artery disease (Hcy and LDL).
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
6. While doing the admission assessment for a thin 76-year-old patient, the nurse observes pulsation of the
abdominal aorta in the epigastric area. Which action should the nurse take?
a. Teach the patient about aneurysms.
b. Notify the hospital rapid response team.
c. Instruct the patient to remain on bed rest.
d. Document the finding in the patient chart.
ANS: D
Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals. The
nurse should simply document the finding in the admission assessment. Unless there are other abnormal
findings (such as a bruit, pain, or hyper/hypotension) associated with the pulsation, the other actions are not
necessary.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
7. A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse
informs the patient that
a. it will be important to lie completely still during the procedure.
b. a flushed feeling may be noted when the contrast dye is injected.
c. monitored anesthesia care will be provided during the procedure.
d. arterial pressure monitoring will be required for 24 hours after the test.
ANS: B
A sensation of warmth or flushing is common when the contrast material is injected, which can be anxiety-
producing unless it has been discussed with the patient. The patient may receive a sedative drug before the
procedure, but monitored anesthesia care is not used. Arterial pressure monitoring is not routinely used after
the procedure to monitor blood pressure. The patient is not immobile during cardiac catheterization and may be
asked to cough or take deep breaths.
DIF: Cognitive Level: Apply (application)
, Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 356
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
8. While assessing a patient who was admitted with heart failure, the nurse notes that the patient has jugular
venous distention (JVD) when lying flat in bed. Which action should the nurse take next?
a. Document this finding in the patients record.
b. Obtain vital signs, including oxygen saturation.
c. Have the patient perform the Valsalva maneuver.
d. Observe for JVD with the patient upright at 45 degrees.
ANS: D
When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but
not a clinically significant) finding. Obtaining vital signs and oxygen saturation is not warranted at this point.
JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure
increases. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant. The
nurse will document the JVD in the medical record if it persists when the head is elevated.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
9. The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to
a. connect the recorder to a computer once daily.
b. exercise more than usual while the monitor is in place.
c. remove the electrodes when taking a shower or tub bath.
d. keep a diary of daily activities while the monitor is worn.
ANS: D
The patient is instructed to keep a diary describing daily activities while Holter monitoring is being
accomplished to help correlate any rhythm disturbances with patient activities. Patients are taught that they
should not take a shower or bath during Holter monitoring and that they should continue with their usual daily
activities. The recorder stores the information about the patients rhythm until the end of the testing, when it is
removed and the data are analyzed.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
10. When auscultating over the patients abdominal aorta, the nurse hears a humming sound. The nurse
documents this finding as a
a. thrill.
