University:
American Career College
Course:
NURS-113 | Beginning Medical/Surgical Nursing
Academic year:

2022
Views:

320

Pages:

2
Author:

Carissa Thomas

Assessment of Cardiovascular Function PrepU The nurse is caring for a client on a monitored telemetry unit. During morning assessment, the nurse notes abnormal ECG waves on the telemetry monitor. Which action would the nurse do first? a. b. c. d. Assess the client. Reposition the client. Call the physician with a report. Assess for mechanical dysfunction. For both outpatients and inpatients scheduled for diagnostic procedures of the cardiovascular system, the nurse performs a thorough initial assessment to establish accurate baseline data. Which data is necessary to collect if the client is experiencing chest pain? a. b. c. d. pulse rate in upper extremities sound of the apical pulses description of the pain blood pressure in the left arm What is considered the pacemaker of the heart? a. b. c. d. The AV node The bundle of HIS The Purkinje fibers The SA node For a client who has undergone peripheral arteriography, how should the nurse assess the adequacy of peripheral circulation? a. b. c. d. observing the client for bleeding hemodynamic monitoring checking peripheral pulses checking for cardiac dysrhythmias The nurse is educating a patient at risk for atherosclerosis. What nonmodifiable risk factor does the nurse identify for the patient? a. b. c. d. Stress Positive family history Hyperlipidemia Obesity A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). The client's blood pressure is 104/68 mm Hg. The client's pulse rate is 76 beats/minute. The nurse detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take? a. Document findings and check the client again in 1 hour. b. Encourage the client to perform isometric leg exercise to improve circulation in the legs. c. Slow the I.V. fluid to prevent any more swelling at the puncture site. d. Contact the health care provider and report the findings. The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include? a. b. c. d. “Contact your primary care provider if you develop a temperature above 102°F.” “You can take a tub bath or a shower when you get home.” “Do not bend at the waist, strain, or lift heavy objects for the next 24 hours.” “If any discharge occurs at the puncture site, call 911 immediately.” The nurse auscultates the apex beat at which anatomical location? a. b. c. d. fifth intercostal space, midclavicular line 5 cm to the left of the lower end of the sternum midsternum 2.5 cm to the left of the xiphoid process The nurse is caring for an elderly client with left-sided heart failure. When auscultating lung sounds, which adventitious sound is expected? a. b. c. d. Whistling Crackles Coarseness Rhonchi After a physical examination, the provider diagnosed a patient with a grade 4 heart murmur. During assessment, the nurse expects to hear a murmur that is: a. b. c. d. Easily heard with no palpable thrill. Quiet but readily heard. Loud and may be associated with a thrill sound similar to (a purring cat). Very loud; can be heard with the stethoscope half-way off the chest.