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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.
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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.
Which of the following actions should the nurse implement for a patient who arrives for a calcium-scoring CT scan?
- A. Administer oral sedative medications.
- B. Teach the patient about the procedure.
- C. Ask whether the patient has eaten today.
- D. Insert a large gauge intravenous catheter.
Correct Answer: B
Rationale: The nurse will need to teach the patient that the procedure is rapid and involves little risk. The other actions are not necessary.
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.
During a physical examination of a patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. Which of the following actions should the nurse implement next?
- A. Document that the PMI is in the normal anatomic location.
- B. Ask the patient about risk factors for coronary artery disease.
- C. Auscultate both the carotid arteries for the presence of a bruit.
- D. Assess the patient for symptoms of left ventricular hypertrophy.
Correct Answer: D
Rationale: The PMI should be felt at the intersection of the 5th 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 coronary or carotid artery disease.
The nurse is reviewing the 12-lead electrocardiogram (ECG) of a healthy older-adult patient who is having an annual physical examination. Which of the following findings should be of most concern to the nurse?
- A. The heart rate is 43 beats/minute.
- B. The PR interval is 0.21 seconds.
- C. There is a right bundle-branch block.
- D. The QRS duration is 0.13 seconds.
Correct Answer: A
Rationale: The resting supine HR is not markedly affected 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, the bundle of His, and the bundle branches.