Nokea
The nurse is assessing a newly admitted patient and notes a thrill along the left sternal border. To obtain more information about the cause of the thrill, which of the following actions should the nurse take next?
- A. Auscultate for any cardiac murmurs.
- B. Find the point of maximal impulse.
- C. Compare the apical and radial pulse rates.
- D. Palpate the quality of the peripheral pulses.
Correct Answer: A
Rationale: Both thrills and murmurs are caused by turbulent blood flow, such as occurs when blood flows through a damaged valve. Relevant information includes the quality of the murmur, where in the cardiac cycle the murmur is heard, and where on the thorax the murmur is heard best. The other information also is important in the cardiac assessment but will not provide information that is relevant to the thrill.
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The nurse is monitoring a patient who is undergoing exercise (stress) testing on a treadmill. Which of the following assessment findings requires the most rapid action by the nurse?
- A. Patient complaint of feeling tired
- B. Pulse change from 80 to 96 beats/minute
- C. BP increase from 134/68 to 150/80 mm Hg
- D. Electrocardiographic changes indicating coronary ischemia
Correct Answer: D
Rationale: 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. Tiredness also is normal as the intensity of exercise increases during the stress testing.
The nurse is auscultating over the patient's abdominal aorta and hears a humming sound. Which of the following terms should the nurse use to document this finding?
- A. Thrill
- B. Bruit
- C. Heave
- D. Murmur
Correct Answer: B
Rationale: 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. Heaves are sustained lifts over the precordium that can be observed or palpated. A murmur is the sound caused by turbulent blood flow through the heart.
Which of the following 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?
- A. The patient has an allergy to shellfish and iodine.
- B. The patient has a history of coronary artery disease.
- C. The patient has a permanent ventricular pacemaker in place.
- D. The patient took all the prescribed cardiac medications today.
Correct Answer: C
Rationale: MRI is contraindicated for patients with implanted metallic devices such as pacemakers as the magnets can alter the function of the device. The other information also will be reported to the health care provider but does not impact whether or not the patient can have an MRI.
The nurse hears a murmur between the S1 and S2 heart sounds at the patient's left 5th intercostal space and midclavicular line. How should the nurse record this information?
- A. Systolic murmur heard at mitral area.
- B. Diastolic murmur heard at aortic area.
- C. Systolic murmur heard at Erb's point.
- D. Diastolic murmur heard at tricuspid area.
Correct Answer: A
Rationale: 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 5th intercostal space and the midclavicular line. The other responses describe murmurs heard at different landmarks on the chest or during the diastolic phase of the cardiac cycle.
The nurse is assessing a patient who was admitted with heart failure and notes that the patient has jugular venous distension (JVD) when lying flat in bed. Which of the following actions should the nurse take next?
- A. Use a ruler to measure the level of the JVD.
- B. Document this finding in the patient's record.
- C. Observe for JVD with the head at 45 degrees.
- D. Have the patient perform the Valsalva manoeuvre.
Correct Answer: C
Rationale: When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but not clinically significant) finding. JVD that persists when the patient is sitting at a 45-degree angle or greater is significant. The nurse may use a ruler to determine the level of JVD above the heart if the JVD persists when the patient is at a 45-degree angle or more. JVD is an expected finding when a patient performs the Valsalva manoeuvre because right atrial pressure increases. The nurse will document the JVD in the record if it persists when the head is elevated.