Nokea
A client needs additional information about a heart condition. The client asks the nurse 'What is considered the pacemaker of the heart?'
- A. The AV node
- B. The bundle of HIS
- C. The Purkinje fibers
- D. The SA node
Correct Answer: D
Rationale: The SA node is called the pacemaker of the heart because it initiates the electrical impulses that cause the atria and ventricles to contract. Normally, it produces between 60 and 100 impulses per minute; the average is approximately 72 impulses per minute.
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The nurse monitors a client with dark skin for signs of cyanosis. Which manifestation, documented by the nurse, indicates cyanosis for this client?
- A. Dark red lips and tongue
- B. Grayish cast to the skin
- C. Pale appearance to the skin
- D. Pale pink mucous membranes
Correct Answer: B
Rationale: A good light is necessary when monitoring skin color. Many clients with cardiac disorders exhibit changes in skin color (e.g., cyanosis, pallor). Cyanosis can be detected by carefully noting color changes in the oral mucous membranes as well as in the lips, earlobes, skin, and nail beds. In dark-skinned clients, a grayish cast to the skin indicates pallor. In clients who are light skinned, extreme pallor is easy to detect because the skin appears almost bloodless. Dark red lips and tongue are not manifestations associated with cyanosis. A pale appearance can indicate cyanosis for a client with light skin. The presence of pale pink mucous membranes is a normal or expected finding and is not associated with cyanosis.
The nurse is caring for a client with nursing diagnosis of ineffective tissue perfusion. Which area of the heart would the nurse anticipate being compromised?
- A. Right atrium
- B. Pulmonary artery
- C. Right ventricle
- D. Aorta
Correct Answer: C
Rationale: There are four chambers to the heart. The right and left ventricles are the heart's major pumping chamber. The right ventricle pumps to the lungs to oxygenate the blood. The left ventricle pumps blood to the tissues and cells. The pulmonary artery and aorta are not of the heart.
The nurse instructor is teaching a group of nursing students about adventitious heart sounds. The instructor explains that auscultation of the heart requires familiarization with normal and abnormal heart sounds. What would the instructor tell these students a ventricular gallop indicates in an adult?
- A. Heart failure
- B. Hypertensive heart disease
- C. Normal functioning
- D. Pericarditis
Correct Answer: A
Rationale: A sound that follows S1 and S2 is called an S3 heart sound or a ventricular gallop. An S3, normal in children, often is an indication of heart failure in an adult. An extra sound before S1 is an S4 heart sound, or atrial gallop. An S4 sound often is associated with hypertensive heart disease. A friction rub may cause a rough, grating, or scratchy sound that is an indication of pericarditis or inflammation of the pericardium.
The nurse is caring for an elderly client with left-sided heart failure. When auscultating lung sounds, which adventitious sound is expected?
- A. Whistling
- B. Rhonchi
- C. Crackles
- D. Coarseness
Correct Answer: C
Rationale: When the left side of the heart is pumping inefficiently, blood backs up into the pulmonary veins and lung tissue. Auscultation reveals a crackling sound. Wheezes and gurgles may also be heard.
The nurse is assessing a client who has dyspnea and considering the process of gas exchange. Which structural characteristic of capillaries best enables gas exchange at the cellular level?
- A. Capillaries are one cell-layer thick.
- B. Capillaries form a complex network
- C. Capillaries transport blood back to the heart.
- D. Capillaries are elastic structures.
Correct Answer: A
Rationale: Capillaries are one cell-layer thick and in direct contact with the cells of all tissues. This allows ease of gas exchange. Capillaries do form a complex network; however, it is the one cell structure that facilitates gas exchange. Venules and veins transport blood back to the heart. Arteries are elastic.