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The nurse has performed a cardiovascular assessment on a client, and while auscultating heart tones, the nurse auscultates a harsh blowing sound. The nurse should document this finding as a
- A. pericardial friction rub.
- B. heart murmur.
- C. normal lub-dub sounds.
- D. S3 heart sound.
Correct Answer: B
Rationale: A harsh blowing sound indicates a heart murmur, caused by turbulent blood flow, often due to valve dysfunction.
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The nurse is watching the monitor of a client wearing a continuous cardiac monitor when it begins to alarm and fails to display any QRS complexes. Which nursing intervention should the nurse do first?
- A. Press record on the electrocardiogram
- B. Check the client's lead placement
- C. Call the code team
- D. Contact the health care provider
Correct Answer: B
Rationale: Absent QRS complexes may result from loose or disconnected leads, so checking lead placement is the first step.
The nurse is caring for a client with congestive heart failure experiencing an exacerbation. Which of the following of the client's vital signs would indicate that the client is experiencing a complication?
- A. Decrease in blood pressure
- B. Increase in temperature
- C. Decrease in respiratory rate
- D. Increase in blood pressure
Correct Answer: A
Rationale: A decrease in blood pressure during a CHF exacerbation may indicate cardiogenic shock, a serious complication.
Which of the following interventions should the nurse include when teaching clients strategies for preventing cardiovascular disease? Select all that apply.
- A. Encouraging regular physical exercise
- B. Promoting a diet high in saturated fats
- C. Advising smoking cessation
- D. Recommend no more than 5 alcoholic drinks a day
- E. Educating about the importance of regular blood pressure monitoring
- F. Instructing on the importance of regular cholesterol screenings
Correct Answer: A,C,E,F
Rationale: Regular exercise reduces cardiovascular risk. B: Incorrect - High saturated fat diets increase cardiovascular risk. C: Correct - Smoking cessation lowers cardiovascular disease risk. D: Incorrect - Alcohol should be limited to 1-2 drinks per day for men, 1 for women. E: Correct - Blood pressure monitoring detects hypertension early. F: Correct - Cholesterol screenings identify hyperlipidemia for early intervention.
Which of the following lifestyle modifications are recommended for managing essential hypertension? Select all that apply.
- A. Isometric exercises
- B. Decreasing sodium intake
- C. Smoking cessation
- D. Use of herbal supplements
- E. Weight loss
Correct Answer: B,C,E
Rationale: Isometric exercises can increase blood pressure and are not recommended. Reducing sodium intake helps lower blood pressure. C: Correct - Smoking cessation reduces cardiovascular risk. D: Incorrect - Herbal supplements are not universally recommended and may interact with medications. E: Correct - Weight loss reduces blood pressure and cardiovascular strain.
The nurse is caring for a client who has developed cardiac tamponade. Which of the following prescriptions should the nurse clarify with the primary healthcare provider (PHCP)?
- A. Positive pressure ventilation
- B. Pericardiocentesis
- C. Echocardiography
- D. 0.9% saline bolus
Correct Answer: A
Rationale: Positive pressure ventilation can worsen cardiac tamponade by further compressing the heart, so it should be clarified.