Cardiovascular
Vascular
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100
In caring for a client with a blockage of the coronary arteries, the nurse would give priority to the nursing diagnosis of: A. risk for ineffective airway clearance, B. anxiety related to suctioning, C. Social isolation related to altered body image, D. Decreased cardiac output
What is D. Decreased cardiac output
100
Name four vascular tests
What is allen test, ankle-brachial index, manual compression and Trendelenburg, and color change test
100
The nurse is assessing the lung capacity of a client using a peak flow meter. What is the order of the steps followed by the nurse while performing the procedure? 1 ] Record the number where the marker landed and repeat three times. 2 ] Instruct the client to take one deep breath and blow hard and fast. 3 ] Record the highest reading and measure the reading at the same time every day. 4 ] Instruct the client to stand straight and remove anything in the mouth. 5 ] Make sure that the arrow on the peak flow meter is at the bottom of the numbered scale. 6 ] Instruct the client to breathe deeply and put the device in the mouth while keeping the tongue away from the device.
What is 5,4,6,2,1,3
100
While assessing the temporal pulse of a client, the nurse finds that the client has a faint and weak pulse. What should the nurse do in such situation?
What is use a Doppler to detect blood flow. A faint and weak pulse indicates that the client has inadequate circulation to the lower extremities. Therefore, the nurse should use Doppler to detect blood flow.
100
The nurse is palpating the client's pulses and notes the radial pulse is bounding; he/she grades the pulse: A +1, B +2, C +3, D, +4
What is +4
200
What is cardiac output?
What is HR x stroke volume
200
The nurse is performing a vascular exam. Where would the nurse palpate the posterior tibialis pulse? A. On the dorsum of the foot, B. behind the knee, C. on the wrist, D. Behind the medial malleolus
What is D. behind the medial malleolus
200
The nurse is caring for a client with poor oxygenation. What would be the effect of this condition on the texture of the client’s nails?
What is soft and boggy.The client with poor oxygenation has clubbed nails that are soft and boggy.
200
As part of post-operative orthopedic care, the nurse performed neurovascular assessment of a child who is subjected to skeletal traction. What is the upper limit for capillary refill time?
What is 3 seconds
200
What is preload, afterload, and contractility?
Preload: amount of blood in the ventricles at the end of diastole (stretch of the muscle tissue at the end of filling) Afterload: resistance to flow the ventricle must overcome to open the semilunar valves and eject its content Contractility: force of the mechanical contraction (can be increased with sympathetic stimulation or calcium release)
300
The nurse is preparing to assess the apical pulse, which is found in the ____________________th intercostal space.
What is apical pulse is found in the 5th intercostal space for adult patients.
300
The nurse is performing a vascular exam. Which pulse is located behind the knee?
What is Popliteal
300
When a nurse is assisting a client with ambulation who has undergone a surgery, he or she finds that the client is struggling to breathe and is at risk of suffocation. In which position should the nurse place the client?
What is orthopenic position. In orthopenic position, the head of the bed is raised to 90 degrees and the overhead table is placed in front of the client with pillows on it. The client is made to rest on the pillows. This position is helpful for clients who suffer from shortness of breath.
300
The registered nurse is teaching a student nurse about critical aspects while measuring peripheral pulse in a client. Which statement made by the student nurse indicates a need for further teaching? 1 ] “I will count for 15 seconds if pulse is regular.” 2 ] “I will count for 30 seconds if pulse is irregular.” 3 ] “I will note the rate, rhythm, and quality of the pulse.” 4 ] “I will make sure that the client is resting while assessing the pulse.”
What is 2. Irregular pulse should be counted for 60 seconds to determine the number of beats per minute. An increase in beats per minute indicates tachycardia and decrease in number of beats per minute indicates bradycardia.
300
The nurse is preparing to conduct a cardiovascular assessment. Which piece of equipment is not required? 1) Stethoscope 2) Pen light 3) Scale 4) Otoscope
What is otoscope
400
Native Americans younger than ____________________ years have twice the mortality rate from heart disease as other groups.
What is 35
400
The nurse is performing a vascular exam and is unable to palpate the posterior tibialis pulse. Which is the most appropriate action? A. record finding, B. recheck in 1 hour, C. notify MD, D. check pulse with doppler
What is D. check pulse with doppler
400
A client reports chest pain, sweating, and shortness of breath. The primary health-care provider suspects angina pectoris. Tests reveal increased preload of the heart as the cause of angina. Which drug does the nurse anticipate to be administered to the client?
What is nitro.Nitroglycerin is a nitrate that is capable of causing systemic vasodilation by dilating the coronary arteries. Therefore, nitroglycerin can decrease the preload of the heart.
400
What should the nurse tell the client while conducting an assessment of the lungs using the posterior approach? 1 ] “Lean forward and cross your arms over your chest.” 2 ] “Lean forward and use the chair arms for support.” 3 ] “Sit up straight and breathe slowly.” 4 ] “Lean forward and bend at the neck.”
What is 1; The nurse asks the client to lean forward and cross the arms over the chest. This spreads the scapula and provides greater access to the lung surface.
400
The nurse is preparing to conduct a cardiovascular assessment. Which positions are appropriate for the patient to assume during cardiac auscultation? Select all that apply. 1) Sitting 2) Trendelenburg 3) Supine 4) Sims’ 5) Left lateral recumbent
What is sitting, supine, and left lateral recumbent
500
The nurse hears audible low-pitched sounds created by turbulent flow while auscultating the carotid artery. What are these sounds?
What is bruit. The nurse assessing the carotid artery for “flow” sounds may hear bruits, which are audible low-pitched sounds created by turbulent flow. Bruit may suggest carotid stenosis.
500
The nurse is palpating the client's lymph nodes 1 inch above the elbow. The site is best for assessing? A. Epitrochlear nodes, B. horizontal nodes, C. vertical nodes, D. cervical nodes.
What is A Epitrochlear nodes
500
While palpating the chest of a client, the nurse notes crepitus. What is the significance of this finding? 1 ] The client may be in pain. 2 ] The client may have an inflamed cartilage at the rib. 3 ] The client may have a fractured rib. 4 ] The client has air leaking into the subcutaneous tissue.
What is 4; Crepitus or subcutaneous emphysema feels crackly, like crumpling cellophane. It is caused by air leaking into the subcutaneous tissue. The nurse should check any wound sites, chest tubes, central lines, or tracheostomy tubes.
500
Which assessment findings should the nurse relate to pericarditis? Select all that apply. 1 ] Presence of fever 2 ] Presence of anxiety and dizziness 3 ] Presence of hacking cough 4 ] Presence of chest pain that intensifies with coughing 5 ] Presence of friction rub at the lower left sternal border (LLSB)
What is 1, 4 , 5; The inflammation of the pericardium causes elevation of temperature. Acute pericarditis can cause the temperature to elevate to 102.2oF. The client has chest pain which is aggravated by coughing, inspiration, or movement. This occurs due to an inflamed visceral or parietal pericardium. The inflammation of the pericardium causes pericardial friction rub at the LLSB. It is a high-pitched, systolic and diastolic sound.
500
Which location will the nurse use to assess the posterior tibialis pulse? 1) The dorsum of the foot 2) The back of the knee 3) The apex of the heart 4) The ventral portion of the neck
What is the dorsum of the foot
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