CHAPTER 25
Question 10 See full question
A nurse is preparing to assess a patient for postural BP changes. Which of
the following indicates the need for further education?
You Selected:
Letting 30 seconds elapse after each position change before measuring BP
and heart rate (HR)
Correct response:
Letting 30 seconds elapse after each position change before measuring BP
and heart rate (HR)
Explanation:
The following steps are recommended when assessing patients for postural
hypotension: Position the patient supine for 10 minutes before taking the
initial BP and HR measurements; reposition the patient to a sitting position
with legs in the dependent position, wait 2 minutes then reassess both BP
and HR measurements; if the patient is symptom free or has no significant
decreases in systolic or diastolic BP, assist the patient into a standing
position, obtain measurements immediately and recheck in 2 minutes;
continue measurements every 2 minutes for a total of 10 minutes to rule out
postural hypotension. Return the patient to supine position if postural
hypotension is detected or if the patient becomes symptomatic. Document
HR and BP measured in each position (e.g., supine, sitting, and standing) and
any signs or symptoms that accompany the postural changes.
Question 5 See full question
You are working on a telemetry unit. Your client was admitted with a cardiac
event and is now on a cardiac monitor. You know a cardiac monitor reveals
the heart's electrical but not its mechanical activity. How would you assess
the mechanical activity of the client's heart?
You Selected:
Palpate a peripheral pulse.
Correct response:
Palpate a peripheral pulse.
Explanation:
,A cardiac monitor reveals the heart's electrical but not its mechanical
activity. The healthcare provider must palpate a peripheral pulse or
auscultate the apical heart rate to obtain this information. You cannot obtain
information on the mechanical activity of the heart by taking the client's
blood pressure, auscultating the carotid artery, or attempting to percuss the
perimeter of the heart.
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-
Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014,
Chapter 25: Assessment of Cardiovascular Function, p. 684.
Question 6 See full question
You are evaluating the expected outcomes on a client who is recovering from
a cardiac catheterization. What is an expected outcome that you would
evaluate?
You Selected:
The client and family understands the discharge instructions.
Correct response:
The client and family understands the discharge instructions.
Explanation:
The client is relaxed and feels secure. The test is performed uneventfully or
the client is stabilized when complications are managed successfully. The
client and family have an accurate understanding of the diagnostic testing
process and discharge instructions. The scenario does not indicate that the
client has a CV diagnosis, a need for medication, or a need to restrict their
activity for 72 hours.
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-
Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014,
Chapter 25: Assessment of Cardiovascular Function, p. 685.
Question 7 See full question
The nurse is caring for a client with an elevated blood pressure and no
previous history of hypertension. At 0900, the blood pressure was 158/90
mm Hg. At 0930, the blood pressure is 142/82 mm Hg. The nurse is most
correct when relating the fall in blood pressure to which structure?
You Selected:
, Baroreceptors
Correct response:
Baroreceptors
Explanation:
Baroreceptor sense pressure in nerve endings in the walls of the atria and
major blood vessels. The baroreceptors respond accordingly to raise or lower
the pressure. Chemoreceptors are sensitive to pH, CO2, and O2 in the blood.
Sympathetic nerve fibers increase the heart rate. The vagus nerve slows the
heart rate.
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-
Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014,
Chapter 25: Assessment of Cardiovascular Function, p. 659.
Question 8 See full question
The following clients are in need of exercise electrocardiography. Which client
would the nurse indicate as most appropriate for a drug-induced stress test?
You Selected:
A 55-year-old recovering from a fall and broken femur
Correct response:
A 55-year-old recovering from a fall and broken femur
Explanation:
An exercise electrocardiography or stress test monitors the electrical activity
of the heart while the client walks on a treadmill. If a client has a sedentary
lifestyle or physical disability, cardiac medications may be administered to
stress the heart similar to activity. Even though the client is middle aged at
55 years old, the client is recovering from a broken femur thus would be
unable to have vigorous exercise. None of the other clients have a history
which precludes them from exercise electrocardiography.
Question 3 See full question
Which of the following is an early warning symptom of acute coronary
syndrome (ACS) and heart failure (HF)?
You Selected:
Fatigue
, Correct response:
Fatigue
Explanation:
Fatigue is an early warning symptom of ACS, heart failure, and valvular
disease. Other signs and symptoms of cardiovascular disease are
hypotension, change in level of consciousness, and weight gain.
Question 4 See full question
The nurse caring for a client who is suspected of having cardiovascular
disease has a stress test ordered. The client has a co-morbidity of multiple
sclerosis, so the nurse knows the stress test will be drug-induced. What drug
will be used to dilate the coronary arteries?
You Selected:
Dobutamine
Correct response:
Dobutamine
Explanation:
Drugs such as adenosine (Adenocard), dipyridamole (Persantine), or
dobutamine (Dobutrex) may be administered singularly or in combination by
the IV route. The drugs dilate the coronary arteries, similar to the
vasodilation that occurs when a person exercises to increase the heart
muscle's blood supply. Options A, B, and C would not dilate the coronary
arteries.
Question 9 See full question
The nurse practitioner inspects the patient's skin during a physical
examination. She is looking for any abnormalities, especially skin findings
associated with cardiovascular disease. The nurse notes a bluish tinge in the
buccal mucosa and the tongue. She knows this is probably due to:
You Selected:
Congenital heart disease.
Correct response:
Congenital heart disease.
Explanation:
Question 10 See full question
A nurse is preparing to assess a patient for postural BP changes. Which of
the following indicates the need for further education?
You Selected:
Letting 30 seconds elapse after each position change before measuring BP
and heart rate (HR)
Correct response:
Letting 30 seconds elapse after each position change before measuring BP
and heart rate (HR)
Explanation:
The following steps are recommended when assessing patients for postural
hypotension: Position the patient supine for 10 minutes before taking the
initial BP and HR measurements; reposition the patient to a sitting position
with legs in the dependent position, wait 2 minutes then reassess both BP
and HR measurements; if the patient is symptom free or has no significant
decreases in systolic or diastolic BP, assist the patient into a standing
position, obtain measurements immediately and recheck in 2 minutes;
continue measurements every 2 minutes for a total of 10 minutes to rule out
postural hypotension. Return the patient to supine position if postural
hypotension is detected or if the patient becomes symptomatic. Document
HR and BP measured in each position (e.g., supine, sitting, and standing) and
any signs or symptoms that accompany the postural changes.
Question 5 See full question
You are working on a telemetry unit. Your client was admitted with a cardiac
event and is now on a cardiac monitor. You know a cardiac monitor reveals
the heart's electrical but not its mechanical activity. How would you assess
the mechanical activity of the client's heart?
You Selected:
Palpate a peripheral pulse.
Correct response:
Palpate a peripheral pulse.
Explanation:
,A cardiac monitor reveals the heart's electrical but not its mechanical
activity. The healthcare provider must palpate a peripheral pulse or
auscultate the apical heart rate to obtain this information. You cannot obtain
information on the mechanical activity of the heart by taking the client's
blood pressure, auscultating the carotid artery, or attempting to percuss the
perimeter of the heart.
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-
Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014,
Chapter 25: Assessment of Cardiovascular Function, p. 684.
Question 6 See full question
You are evaluating the expected outcomes on a client who is recovering from
a cardiac catheterization. What is an expected outcome that you would
evaluate?
You Selected:
The client and family understands the discharge instructions.
Correct response:
The client and family understands the discharge instructions.
Explanation:
The client is relaxed and feels secure. The test is performed uneventfully or
the client is stabilized when complications are managed successfully. The
client and family have an accurate understanding of the diagnostic testing
process and discharge instructions. The scenario does not indicate that the
client has a CV diagnosis, a need for medication, or a need to restrict their
activity for 72 hours.
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-
Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014,
Chapter 25: Assessment of Cardiovascular Function, p. 685.
Question 7 See full question
The nurse is caring for a client with an elevated blood pressure and no
previous history of hypertension. At 0900, the blood pressure was 158/90
mm Hg. At 0930, the blood pressure is 142/82 mm Hg. The nurse is most
correct when relating the fall in blood pressure to which structure?
You Selected:
, Baroreceptors
Correct response:
Baroreceptors
Explanation:
Baroreceptor sense pressure in nerve endings in the walls of the atria and
major blood vessels. The baroreceptors respond accordingly to raise or lower
the pressure. Chemoreceptors are sensitive to pH, CO2, and O2 in the blood.
Sympathetic nerve fibers increase the heart rate. The vagus nerve slows the
heart rate.
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-
Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014,
Chapter 25: Assessment of Cardiovascular Function, p. 659.
Question 8 See full question
The following clients are in need of exercise electrocardiography. Which client
would the nurse indicate as most appropriate for a drug-induced stress test?
You Selected:
A 55-year-old recovering from a fall and broken femur
Correct response:
A 55-year-old recovering from a fall and broken femur
Explanation:
An exercise electrocardiography or stress test monitors the electrical activity
of the heart while the client walks on a treadmill. If a client has a sedentary
lifestyle or physical disability, cardiac medications may be administered to
stress the heart similar to activity. Even though the client is middle aged at
55 years old, the client is recovering from a broken femur thus would be
unable to have vigorous exercise. None of the other clients have a history
which precludes them from exercise electrocardiography.
Question 3 See full question
Which of the following is an early warning symptom of acute coronary
syndrome (ACS) and heart failure (HF)?
You Selected:
Fatigue
, Correct response:
Fatigue
Explanation:
Fatigue is an early warning symptom of ACS, heart failure, and valvular
disease. Other signs and symptoms of cardiovascular disease are
hypotension, change in level of consciousness, and weight gain.
Question 4 See full question
The nurse caring for a client who is suspected of having cardiovascular
disease has a stress test ordered. The client has a co-morbidity of multiple
sclerosis, so the nurse knows the stress test will be drug-induced. What drug
will be used to dilate the coronary arteries?
You Selected:
Dobutamine
Correct response:
Dobutamine
Explanation:
Drugs such as adenosine (Adenocard), dipyridamole (Persantine), or
dobutamine (Dobutrex) may be administered singularly or in combination by
the IV route. The drugs dilate the coronary arteries, similar to the
vasodilation that occurs when a person exercises to increase the heart
muscle's blood supply. Options A, B, and C would not dilate the coronary
arteries.
Question 9 See full question
The nurse practitioner inspects the patient's skin during a physical
examination. She is looking for any abnormalities, especially skin findings
associated with cardiovascular disease. The nurse notes a bluish tinge in the
buccal mucosa and the tongue. She knows this is probably due to:
You Selected:
Congenital heart disease.
Correct response:
Congenital heart disease.
Explanation:
