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Chapter 28

Terms in this set (25)

A patient is prescribed to have capillary blood glucose readings every four hours. What should the nurse include when explaining capillaries to the patient?
the real work of the vascular system occurs at the capillary level
While auscultating a patient's heart rate the nurse hears scratching sounds. What is most likely causing this sound?
low level of fluid in the pericardial cavity
The nurse is reviewing the anatomy of the heart with a patient scheduled for cardiac surgery. Which patient
statement indicates ADDITIONAL TEACHING IS REQUIRED?
blood leaves the right ventricle and travels through the pulmonary ARTERY to the lungs
The nurse is preparing teaching about the coronary arteries for a group of patients scheduled for heart surgery.
Which information should the nurse include in this teaching?
the coronary arteries originate in the cusps of the aortic valve
The nurse notes that a patient has a low serum potassium level. Which phase of the cardiac action potential
will be most affected by this blood level?
Phase 3
A patient's QRS complex is becoming increasingly wider. What is occurring within the heart muscle that is
reflected on this tracing?
Ventricular depolarization is prolonged
A patient with a blood pressure of 88/50 mm Hg has a heart rate of 112 beats per minute. Which mechanism
should the nurse realize is occurring in this patient?
Positive chronotropic effect
The nurse suspects that a patient is experiencing a release of norepinephrine from the adrenal medulla. Which
assessment finding did the nurse use to make this clinical decision?
Heart rate 120 beats per minute
The nurse is preparing to determine a patient's cardiac output. Which measurement should be used for
preload?
Central venous pressure
A patient's blood pressure is 174/98 mm Hg. Which aspect of cardiac output is most affected by this elevated
reading?
Afterload
The nurse notes that a patient has bilateral lower extremity edema. For which health problem should the nurse
assess further?
Venous insufficiency
After palpating a patient's radial pulses, the nurse proceeds to palpate the brachial, carotid, femoral, popliteal,
and posterior tibial pulses. What condition caused the nurse to make this more thorough physical assessment?
Various skin temperatures
The nurse is preparing to auscultate the heart sounds of a patient with mitral valve regurgitation. Which sound
should the nurse expect to hear?
Murmur
A patient is being assessed for heart disease. For which laboratory test should the nurse instruct to avoid
eating and drinking fluids for 12 hours?
Lipid panel
The nurse notes that a patient is scheduled for a brain natriuretic peptide level to be drawn. What patient
teaching should the nurse prepare for this patient?
Signs of heart failure
A patient is scheduled for a transesophageal echocardiogram (TEE). What information should the nurse
expect to be provided from this test?
Presence of clots in the atria
A patient is recovering from a cardiac catheterization. For which finding should the nurse notify the healthcare
provider?
Hematoma formation at puncture site
An older patient is being evaluated for a cardiac click audible upon auscultation. Which age-related change
should the nurse realize might be causing this heart sound?
Valve stenosis
The nurse notes that an older patient's point of maximum impulse is displaced to the left. What age-related
change should the nurse suspect as causing this assessment finding?
Left ventricular atrophy
The nurse is reviewing data collected during the assessment of an older patient. Which finding should the
nurse consider as being an age-related change of the cardiovascular system?
Blood pressure 168/96 mm Hg
The nurse is preparing a teaching tool about the cardiac electrical conduction system. In which order should
the nurse explain the route of the action potential? (Enter the number of each step in the proper sequence; do
not use punctuation or spaces. Example: 1234)
1) Impulse travels to the bundle of His
2) Sinoatrial node fires in the right atrium
3) Impulse extends through Purkinje fibers
4) Impulse travels through bundle branches
5) Impulse travels to the atrioventricular node
6) Impulse spreads through atrial myocardium
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The clinical trainer is reviewing the renin-angiotensin-aldosterone system with graduate nurses during
orientation to the telemetry unit. In which order should the trainer discuss this system? (Enter the number of
each step in the proper sequence; do not use punctuation or spaces. Example: 1234)
1) Sodium and water reabsorbed in the kidneys
2) Renin reacts with angiotensin to create angiotensin 1
3) Angiotensin I is converted to angiotensin II in the lungs
4) Kidneys release renin in response to a drop in blood pressure
5) Angiotensin II influences adrenal glands to release aldosterone
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A patient is prescribed a 12-lead electrocardiogram. In which order should the nurse apply the V leads? (Enter
the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234)
1) Midaxillary line
2) Between V2 and V4
3) Midclavicular line 5th intercostal space
4) 4th intercostal space left of the sternum
5) 4th intercostal space right of the sternum
6) Between V4 and V6 anterior axillary line
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The nurse is preparing content for a community health fair on risk factors for heart disease. What should the
nurse include as nonmodifiable risk factors? Select all that apply.
1) Age
2) Weight
3) Alcohol intake
4) Ethnic background
5) Parents' health history
1, 4, 5
Which information should the nurse include when documenting the findings of a patient's heart sounds?
Select all that apply.
1) Pitch
2) Clicks
3) Quality
4) Intensity
5) Location
1, 3, 4, 5
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