Nokea
While auscultating a patients heart sounds, the nurse hears an extra heart sound immediately after the second heart sound (S2). An audible S3 would be considered an expected finding in what patient?
- A. An older adult
- B. A 20-year-old patient
- C. A patient who has undergone valve replacement
- D. A patient who takes a beta-adrenergic blocker
Correct Answer: B
Rationale: S3 represents a normal finding in children and adults up to 35 or 40 years of age. In these cases, it is called a physiologic S3. It is an abnormal finding in a patient with an artificial valve, an older adult, or a patient who takes a beta blocker.
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The nurse is caring for a patient admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this patient. The nurse should recognize what implication of this assessment finding?
- A. This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours
- B. Because the patient has a history of unstable angina, this is a poor indicator of myocardial injury
- C. This is an accurate indicator of myocardial injury
- D. This result indicates muscle injury, but does not specify the source
Correct Answer: C
Rationale: Troponin I, which is specific to cardiac muscle, is elevated within hours after myocardial injury. Even with a diagnosis of unstable angina, this is an accurate indicator of myocardial injury.
The critical care nurse is caring for a patient with a central venous pressure (CVP) monitoring system. The nurse notes that the patients CVP is increasing. Of what may this indicate?
- A. Psychosocial stress
- B. Hypervolemia
- C. Dislodgment of the catheter
- D. Hypomagnesemia
Correct Answer: B
Rationale: CVP is a useful hemodynamic parameter to observe when managing an unstable patients fluid volume status. An increasing pressure may be caused by hypervolemia or by a condition, such as heart failure, that results in decreased myocardial contractility. Stress, dislodgement of the catheter, and low magnesium levels would not typically result in increased CVP.
When hemodynamic monitoring is ordered for a patient, a catheter is inserted into the appropriate blood vessel or heart chamber. When assessing a patient who has such a device in place, the nurse should check which of the following components? Select all that apply.
- A. A transducer
- B. A flush system
- C. A leveler
- D. A pressure bag
- E. An oscillator
Correct Answer: A,B,D
Rationale: To perform hemodynamic monitoring, a CVP, pulmonary artery, or arterial catheter is introduced into the appropriate blood vessel or heart chamber. It is connected to a pressure monitoring system that has several components. Included among these are a transducer, a flush system, and a pressure bag. A pressure monitoring system does not have a leveler or an oscillator.
A nurse is describing the process by which blood is ejected into circulation as the chambers of the heart become smaller. The instructor categorizes this action of the heart as what?
- A. Systole
- B. Diastole
- C. Repolarization
- D. Ejection fraction
Correct Answer: A
Rationale: Systole is the action of the chambers of the heart becoming smaller and ejecting blood. This action of the heart is not diastole (relaxations), ejection fraction (the amount of blood expelled), or repolarization (electrical charging).
The student nurse is preparing a teaching plan for a patient being discharged status post MI. What should the student include in the teaching plan? (Mark all that apply.)
- A. Need for careful monitoring for cardiac symptoms
- B. Need for carefully regulated exercise
- C. Need for dietary modifications
- D. Need for early resumption of prediagnosis activity
- E. Need for increased fluid intake
Correct Answer: A,B,C
Rationale: Dietary modifications, exercise, weight loss, and careful monitoring are important strategies for managing three major cardiovascular risk factors: hyperlipidemia, hypertension, and diabetes. There is no need to increase fluid intake and activity should be slowly and deliberately increased.