CARDIAC - Nursing Assessment: Cardiovascular System ED 9

cardiac-nursing-assessment-cardiovascular-system-ed-9

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題 1 of 1

剩下的時間

136317

120

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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

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說明

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 car

136318

120

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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?

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說明

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

136319

120

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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

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說明

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

136321

120

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To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the

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說明

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 di

136322

120

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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?

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說明

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).

136323

120

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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?

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說明

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/

136325

120

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A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that

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說明

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 i

136326

120

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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?

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說明

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 w

136327

120

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The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to

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說明

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 Ho

136328

120

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When auscultating over the patient’s abdominal aorta, the nurse hears a humming sound. The nurse documents this finding as a

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說明

A bruit is the sound created by turbulent blood flow in an artery. Thrills are palpable vibrations felt when there is turbulent blood flow through the heart or in a blood vessel. A murmur is the sound caused by turbulent blood flow through the heart. Ausc

136329

120

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The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. The most important laboratory result to review will be

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說明

Cardiac troponins start to elevate 4 to 6 hours after myocardial injury and are highly specific to myocardium. They are the preferred diagnostic marker for myocardial infarction. Myoglobin rises in response to myocardial injury within 30 to 60 minutes. It

136330

120

none

When assessing a newly admitted patient, the nurse notes a murmur along the left sternal border. To document more information about the murmur, which action will the nurse take next?

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說明

Murmurs are caused by turbulent blood flow, such as occurs when blood flows through a damaged valve. Relevant information includes the position in which the murmur is heard best (e.g., sitting and leaning forward), the timing of the murmur in relation to

136331

120

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The nurse hears a murmur between the S1 and S2 heart sounds at the patient’s left fifth intercostal space and midclavicular line. How will the nurse record this information?

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說明

The S1 signifies the onset of ventricular systole. S2 signifies the onset of diastole. A murmur occurring between these two sounds is a systolic murmur. The mitral area is the intersection of the left fifth intercostal space and the midclavicular line. Th

136332

120

none

A registered nurse (RN) is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student nurse

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(0/0)

說明

The carotid pulses should never be palpated at the same time to avoid vagal stimulation, dysrhythmias, and decreased cerebral blood flow. The other assessment techniques also need to be corrected. However, they are not dangerous to the patient.

136333

120

none

Which action will the nurse implement for a patient who arrives for a calcium-scoring CT scan?

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說明

The nurse will need to teach the patient that the procedure is rapid and involves little risk. None of the other actions are necessary.

CARDIAC - Nursing Assessment: Cardiovascular System ED 9

題 1 of 1

剩下的時間

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

選擇正確的答案

(0/0)

說明

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?

選擇正確的答案

(0/0)

說明

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

選擇正確的答案

(0/0)

說明

To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the

選擇正確的答案

(0/0)

說明

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?

選擇正確的答案

(0/0)

說明

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?

選擇正確的答案

(0/0)

說明

A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that

選擇正確的答案

(0/0)

說明

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?

選擇正確的答案

(0/0)

說明

The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to

選擇正確的答案

(0/0)

說明

When auscultating over the patient’s abdominal aorta, the nurse hears a humming sound. The nurse documents this finding as a

選擇正確的答案

(0/0)

說明

The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. The most important laboratory result to review will be

選擇正確的答案

(0/0)

說明

When assessing a newly admitted patient, the nurse notes a murmur along the left sternal border. To document more information about the murmur, which action will the nurse take next?

選擇正確的答案

(0/0)

說明

The nurse hears a murmur between the S1 and S2 heart sounds at the patient’s left fifth intercostal space and midclavicular line. How will the nurse record this information?

選擇正確的答案

(0/0)

說明

A registered nurse (RN) is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student nurse

選擇正確的答案

(0/0)

說明

Which action will the nurse implement for a patient who arrives for a calcium-scoring CT scan?

選擇正確的答案

(0/0)

說明

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