Nokea
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.
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The 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 implements which of the following interventions?
- A. Places the patient in the left lateral position to check for the point of maximal impulse (PMI).
- B. Presses on the skin over the tibia for 10 seconds to check for edema.
- C. Palpates both carotid arteries simultaneously to compare pulse quality.
- D. Documents a murmur heard along the left sternal border as an aortic murmur.
Correct Answer: C
Rationale: 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.
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.
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.
The nurse is assessing a patient who has just arrived in the emergency department and notes a pulse deficit. Which of the following actions should the nurse anticipate for the patient?
- A. A 2-D echocardiogram
- B. A cardiac catheterization
- C. Hourly blood pressure checks
- D. Electrocardiogram monitoring
Correct Answer: D
Rationale: Pulse deficit is a difference between simultaneously obtained apical and radial pulses and indicates that there may be a cardiac dysrhythmia that would be detected with ECG monitoring. Frequent BP monitoring, cardiac catheterization, and echocardiograms are used for diagnosis of other cardiovascular disorders but would not be as helpful in determining the immediate reason for the pulse deficit.
A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which of the following actions included in the standard TEE orders should the nurse accomplish first?
- A. Administer O2 per mask.
- B. Start a large-gauge IV line.
- C. Place the patient on NPO status.
- D. Give lorazepam 1 mg IV.
Correct Answer: C
Rationale: 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.