Cardiac Objective
A nurse auscultates a client's heart sounds and obtains a rate of 56 beats per minute. How should this rate be documented by the nurse?
The proper documentation of this rate is bradycardia, a rate less than 60 beats per minute. The normal adult heart rate is 60-100 beats per minute.
A nurse performs an initial health history on a client admitted for new onset of chest pain. Which data is considered subjective for the cardiovascular system?
Apical heart rate 70 beats per minute
No current medications or treatments
No edema of extremities noted
Apical impulse palpated at 5 intercostal space on left
Subjective data is data collected from the client. No current medications or treatments is information the nurse obtained from the client. Apical heart rate 70 beats per minute, no edema of extremities noted, and apical impulse palpated at 5 intercostal space on left are examples of objective data collected by the nurse upon physical examination.
The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. How would the nurse document this finding in the client’s electronic medical record?
2+
Arties move blood____
Veins move blood____
Arties move blood_away from the heart___
Veins move blood___back to the heart_
The nurse is preparing to assess a client's apical impulse. The nurse would palpate at which location?
The apical impulse is palpated at the fourth or fifth intercostal space at the left midclavicular line.
The nurse is preparing to assess a client's carotid arteries. Which nursing action would be most appropriate?
Palpate each artery individually to compare.
When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole?
S1
The posterior tibial pulse can be palpated at the
The posterior tibial pulse can be palpated behind the medial malleolus of the ankle.
What medication should we ask women about?
Birth Control
Afterload is....
the amount of pressure the heart has to work against
What does a heave or lift indicate?
Heaves or lifts are visible elevations of the chest. Indicate heart failure and are often seen along the left sternal border or PMI
List two risk factors for Cardiac disease
HTN
Smoking
Serum cholesterol
Physical activity
The nurse's inspection of a Caucasian client's lower extremities reveals a brownish coloration to the client's ankles and shins. The nurse should perform further assessments that address what health problem?
Venous insufficiency
A women with history of breast cancer: what to ask about in regard to PV
Lymph nodes!
_____ is the amount of blood ejected from the left ventricle each minute
cardiac output
What is the name and order of locations we auscultate the heart?
aortic, pulmonic, erbs, tricuspid, mitral (atrial)
Give 4 subjective cardiac questions
Taking any medications for the heart, HTN, or high cholesterol?
Do you have chest pain? Pain in the jaw or arm? Cough?
Do your feet and ankles swell?
Do you smoke? Drink? Use recreational drugs?
What is your dietary pattern? Do you exercise?
Any family history of cardiovascular disease?
The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. What would be most appropriate for the nurse to do next?
A Doppler ultrasound device is helpful when it is impossible or difficult to assess a pulse or when pulses are not palpable.
Give 4 Subjective Questions
•Leg pain or cramps
•Skin changes on arms or legs
•Swelling
•Lymph node enlargement
•Medications
•Smoking history
A client asks the nurse about the function that the lymph system plays in the body. Which of the following would be most appropriate for the nurse to include when responding to the client?
It filters harmful substances from the body.
The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of?
Bruits
The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first?
"Do you have any pain or discomfort in your chest?"
If palpable, superficial inguinal nodes are expected to be:
Nontender, mobile, and 1 cm in diameter
Which of the following is an essential topic when discussing risk factors for peripheral arterial disease with a client?
Tobacco use is one of the most significant risk factors for PAD
•Systole: the ventricles_______
•Diastole: the ventricles_____
Contract
Relax