Nokea
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.
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The nurse is assessing an underweight older-adult patient and observes pulsation of the abdominal aorta in the epigastric area. Which of the following actions should the nurse take?
- A. Notify the hospital rapid response team.
- B. Instruct the patient to remain on bed rest.
- C. Teach the patient about aortic aneurysms.
- D. Document the finding in the patient chart.
Correct Answer: D
Rationale: Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals and the nurse should simply document the finding in the admission assessment. Unless there are other abnormal findings (such as a bruit, pain, or hyper/hypotension) associated with the pulsation, the other actions are not necessary.
To auscultate for S3 or S4 gallops in the mitral area, which of the following should the nurse implement?
- A. Use the bell of the stethoscope with the patient in the left lateral position.
- B. Use the bell of the stethoscope with the patient sitting and leaning forward.
- C. Use the diaphragm of the stethoscope with the patient in a reclining position.
- D. Use the diaphragm of the stethoscope with the patient lying flat on the left side.
Correct Answer: A
Rationale: Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall. The diaphragm of the stethoscope is best to use for the higher pitched sounds such as S1 and S2.
The standard policy on the cardiac unit states: 'Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg.' Which of the following patients should the nurse report to the health care provider?
- A. Postoperative patient with a BP of 116/42
- B. Newly admitted patient with a BP of 122/60
- C. Patient with left ventricular failure who has a BP of 110/70
- D. Patient with a myocardial infarction who has a BP of 114/50
Correct Answer: A
Rationale: The mean arterial pressure (MAP) is calculated using the formula MAP = (diastolic BP + 1/3 pulse pressure). The MAP for the postoperative patient with a BP of 116/42 is 67. The MAP in the other three patients is higher than 70 mm Hg.
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 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.