Med Surg Nursing

Chapter 32: Nursing Assessment: Cardiovascular System
Test Bank
MULTIPLE CHOICE
1. 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
a. emergent cardioversion.
b. a cardiac catheterization.
c. hourly blood pressure (BP) checks.
d. electrocardiographic (ECG) monitoring.
ANS: D
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 cardioversion are
used for diagnosis and/or treatment of cardiovascular disorders but would not be as helpful in
determining the immediate reason for the pulse deficit.
DIF: Cognitive Level: Apply (application)
REF:
697 | 700
TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
2. 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?
a. The PR interval is 0.21 seconds.
b. The QRS duration is 0.13 seconds.
c. There is a right bundle-branch block.
d. The heart rate (HR) is 42 beats/minute.
ANS: D
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 node,
bundle of His, and bundle branches.
REF:
691
TOP: Nursing Process: Assessment
3. 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
a. ask the patient about risk factors for atherosclerosis.
b. document that the PMI is in the normal anatomic location.
c. auscultate both the carotid arteries for the presence of a bruit.
d. assess the patient for symptoms of left ventricular hypertrophy.
ANS: D
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 necessarily
associated with atherosclerosis or carotid artery disease.
REF:
697
4. To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the
a. bell of the stethoscope with the patient in the left lateral position.
b. diaphragm of the stethoscope with the patient in a supine position.
c. bell of the stethoscope with the patient sitting and leaning forward.
d. diaphragm of the stethoscope with the patient lying flat on the left side.
ANS: A
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 diaphragm of the stethoscope
is best to use for the higher-pitched sounds such as S1 and S2.
REF:
697
MSC: NCLEX: Health Promotion and Maintenance
5. 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?

a. Troponin
b. Homocysteine (Hcy)
c. Low-density lipoprotein (LDL)
d. B-type natriuretic peptide (BNP)
ANS: D
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).
REF:
698-699
TOP: Nursing Process: Evaluation
6. 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?
a. Teach the patient about aneurysms.
b. Notify the hospital rapid response team.
c. Instruct the patient to remain on bed rest.
d. Document the finding in the patient chart.
ANS: D
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/hypotension)
associated with the pulsation, the other actions are not necessary.
REF:
695 | 697
7. A patient is scheduled for a cardiac catheterization with coronary angiography. Before the
test, the nurse informs the patient that

it will be important to lie completely still during the procedure.
a flushed feeling may be noted when the contrast dye is injected.
monitored anesthesia care will be provided during the procedure.
arterial pressure monitoring will be required for 24 hours after the test.
a.
b.
c.
d.
ANS: B
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 is not used.
Arterial pressure monitoring is not routinely used after the procedure to monitor blood
pressure. The patient is not immobile during cardiac catheterization and may be asked to
cough or take deep breaths.
REF:
706
TOP: Nursing Process: Implementation
8. 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?
a. Document this finding in the patients record.
b. Obtain vital signs, including oxygen saturation.
c. Have the patient perform the Valsalva maneuver.
d. Observe for JVD with the patient upright at 45 degrees.
ANS: D
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 when a patient performs the
Valsalva maneuver because right atrial pressure increases. JVD that persists when the patient
is sitting at a 30- to 45-degree angle or greater is significant. The nurse will document the
JVD in the medical record if it persists when the head is elevated.
REF:
694 | 696
9. The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor
to
a.
b.
c.
d.
connect the recorder to a computer once daily.

exercise more than usual while the monitor is in place.
remove the electrodes when taking a shower or tub bath.
keep a diary of daily activities while the monitor is worn.
ANS: D
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 Holter monitoring and that they
should continue with their usual daily activities. The recorder stores the information about the
patients rhythm until the end of the testing, when it is removed and the data are analyzed.
REF:
700
10. When auscultating over the patients abdominal aorta, the nurse hears a humming sound. The
nurse documents this finding as a

thrill.
bruit.
murmur.
normal finding.
a.
b.
c.
d.
ANS: B
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. Auscultating a bruit in
an artery is not normal and indicates pathology.
DIF: Cognitive Level: Understand (comprehension)
REF: 695
11. 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
a. myoglobin.
b. low-density lipoprotein (LDL) cholesterol.
c. troponins T and I.
d. creatine kinase-MB (CK-MB).
ANS: C
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 is rapidly cleared
from the body, thus limiting its use in the diagnosis of myocardial infarction. LDL cholesterol
is useful in assessing cardiovascular risk but is not helpful in determining whether a patient is
having an acute myocardial infarction. Creatine kinase (CK-MB) is specific to myocardial
injury and infarction and increases 4 to 6 hours after the infarction occurs. It is often trended
with troponin levels.
REF:
698
12. 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?
a. Find the point of maximal impulse.
b. Determine the timing of the murmur.
c. Compare the apical and radial pulse rates.

d. Palpate the quality of the peripheral pulses.
ANS: B
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 the cardiac cycle
(e.g., systole, diastole), and where on the thorax the murmur is heard best. The other
information is also important in the cardiac assessment but will not provide information that is
relevant to the murmur.
REF:
697
13. The nurse hears a murmur between the S1 and S2 heart sounds at the patients left fifth
intercostal space and midclavicular line. How will the nurse record this information?
Systolic murmur heard at mitral area
Systolic murmur heard at Erbs point
Diastolic murmur heard at aortic area
Diastolic murmur heard at the point of maximal impulse
a.
b.
c.
d.
ANS: A
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. The other responses describe
murmurs heard at different landmarks on the chest and/or during the diastolic phase of the
cardiac cycle.
REF:
697
14. 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

presses on the skin over the tibia for 10 seconds to check for edema.
palpates both carotid arteries simultaneously to compare pulse quality.
documents a murmur heard along the right sternal border as a pulmonic murmur.
places the patient in the left lateral position to check for the point of maximal
impulse.
a.
b.
c.
d.
ANS: B
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.
REF:
694-695
MSC: NCLEX: Safe and Effective Care Environment
15. Which action will the nurse implement for a patient who arrives for a calcium-scoring CT
scan?
a. Insert an IV catheter.
b. Administer oral sedative medications.
c. Teach the patient about the procedure.
d. Confirm that the patient has been fasting.

ANS: C
The nurse will need to teach the patient that the procedure is rapid and involves little risk.
None of the other actions are necessary.
REF:
703
16. Which information obtained by the nurse who is admitting the patient for magnetic resonance
imaging (MRI) will be most important to report to the health care provider before the MRI?
The patient has an allergy to shellfish.
The patient has a history of atherosclerosis.
The patient has a permanent ventricular pacemaker.
The patient took all the prescribed cardiac medications today.
a.
b.
c.
d.
ANS: C
MRI is contraindicated for patients with implanted metallic devices such as pacemakers. The
other information also will be reported to the health care provider but does not impact on
whether or not the patient can have an MRI.
REF:
702
17. When the nurse is monitoring a patient who is undergoing exercise (stress) testing on a
treadmill, which assessment finding requires the most rapid action by the nurse?
Patient complaint of feeling tired
Pulse change from 87 to 101 beats/minute
Blood pressure (BP) increase from 134/68 to 150/80 mm Hg
Newly inverted T waves on the electrocardiogram
a.
b.
c.
d.
ANS: D
ECG changes associated with coronary ischemia (such as T-wave inversions and ST segment
depression) indicate that the myocardium is not getting adequate oxygen delivery and that the
exercise test should be terminated immediately. Increases in BP and heart rate (HR) are
normal responses to aerobic exercise. Feeling tired is also normal as the intensity of exercise
increases during the stress testing.
REF:
701
OBJ: Special Questions: Prioritization
18. The standard policy on the cardiac unit states, Notify the health care provider for mean
arterial pressure (MAP) less than 70 mm Hg. The nurse will need to call the health care
provider about the
a. postoperative patient with a BP of 116/42.
b. newly admitted patient with a BP of 150/87.
c. patient with left ventricular failure who has a BP of 110/70.
d. patient with a myocardial infarction who has a BP of 140/86.
ANS: A
The mean arterial pressure (MAP) is calculated using the formula MAP = (systolic BP + 2
diastolic BP)/3. The MAP for the postoperative patient in answer 3 is 67. The MAP in the
other three patients is higher than 70 mm Hg.
REF:
690-691
19. When admitting a patient for a cardiac catheterization and coronary angiogram, which
information about the patient is most important for the nurse to communicate to the health
care provider?
a. The patients pedal pulses are +1.
b. The patient is allergic to shellfish.
c. The patient had a heart attack a year ago.
d. The patient has not eaten anything today.
ANS: B
The contrast dye used for the procedure is iodine based, so patients who have shellfish
allergies will require treatment with medications such as corticosteroids and antihistamines
before the angiogram. The other information is also communicated to the health care provider
but will not require a change in the usual precardiac catheterization orders or medications.
REF:
703
20. A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis.
Which action included in the standard TEE orders will the nurse need to accomplish first?
Start an IV line.
Place the patient on NPO status.
Administer O2 per nasal cannula.
Give lorazepam (Ativan) 1 mg IV.
a.
b.
c.
d.
ANS: B
The patient will need to be NPO for 6 hours preceding the TEE, so the nurse should place the
patient on NPO status as soon as the order is received. The other actions also will need to be
accomplished but not until just before or during the procedure.
REF:
701
21. The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four
patients. Which nursing action can be delegated to the UAP?

a. Teaching a patient scheduled for exercise electrocardiography about the procedure
b. Placing electrodes in the correct position for a patient who is to receive ECG
monitoring
c. Checking the catheter insertion site for a patient who is recovering from a coronary
angiogram
d. Monitoring a patient who has just returned to the unit after a transesophageal
echocardiogram
ANS: B
UAP can be educated in standardized lead placement for ECG monitoring. Assessment of
patients who have had procedures where airway maintenance (transesophageal
echocardiography) or bleeding (coronary angiogram) is a concern must be done by the
registered nurse (RN). Patient teaching requires RN level education and scope of practice.
DIF: Cognitive Level: Analyze (analysis)
REF: 15-16
OBJ: Special Questions: Delegation
TOP: Nursing Process: Planning
22. The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular
unit. Which patient laboratory result is most important to communicate as soon as possible to
the health care provider?
a. Patient whose triglyceride level is high
b. Patient who has very low homocysteine level
c. Patient with increase in troponin T and troponin I level
d. Patient with elevated high-sensitivity C-reactive protein level
ANS: C
The elevation in troponin T and I indicates that the patient has had an acute myocardial
infarction. Further assessment and interventions are indicated. The other laboratory results are
indicative of increased risk for coronary artery disease but are not associated with acute
cardiac problems that need immediate intervention.
REF:
698
OBJ: Special Questions: Prioritization; Multiple Patients
23. When the nurse is screening patients for possible peripheral arterial disease, indicate where
the posterior tibial artery will be palpated.
a.
b.
c.
d.
1
2
3
4
ANS: C
The posterior tibial site is located behind the medial malleolus of the tibia.
DIF: Cognitive Level: Understand (comprehension)
REF: 696
OTHER
1. While listening at the mitral area, the nurse notes abnormal heart sounds at the patients fifth
intercostal space, midclavicular line. After listening to the audio clip, describe how the nurse
will document the assessment finding.
Click here to listen to the audio clip
a. S3 gallop heard at the aortic area
b. Systolic murmur noted at mitral area
c. Diastolic murmur noted at tricuspid area
d. Pericardial friction rub heard at the apex
ANS:
B
The mitral area location is at the intersection of the fifth intercostal space and the
midclavicular line. The murmur is a pansystolic murmur.
REF:
691

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What is the most important lab result for the nurse to communicate to the provider?

What finding would indicate possible cardiac enlargement?

Chapter 32: Nursing Assessment: Cardiovascular System

laboratory result will the nurse plan to review?

TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

test, the nurse informs the patient that

connect the recorder to a computer once daily.

nurse documents this finding as a

c. Compare the apical and radial pulse rates.

patient. The RN will need to intervene immediately if the student nurse

d. Confirm that the patient has been fasting.

patients. Which nursing action can be delegated to the UAP?

the posterior tibial artery will be palpated.

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