ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 22 : Introduction to the Cardiovascular System Questions
Question 1 of 5
The nurse instructor is teaching a group of nursing students about adventitious heart sounds. The instructor explains that auscultation of the heart requires familiarization with normal and abnormal heart sounds. What would the instructor tell these students a ventricular gallop indicates in an adult?
Correct Answer: A
Rationale: A sound that follows S1 and S2 is called an S3 heart sound or a ventricular gallop. An S3, normal in children, often is an indication of heart failure in an adult. An extra sound before S1 is an S4 heart sound, or atrial gallop. An S4 sound often is associated with hypertensive heart disease. A friction rub may cause a rough, grating, or scratchy sound that is an indication of pericarditis or inflammation of the pericardium.
Question 2 of 5
The nurse is caring for a client with a damaged tricuspid valve. The nurse knows that the tricuspid valve is held in place by which of the following?
Correct Answer: A
Rationale: Attached to the mitral and tricuspid valves are cordlike structures known as chordae tendineae, which in turn attach to papillary muscles, two major muscular projections from the ventricles. Neither atrioventricular tendons, semilunar tendineae, nor papillary tendons hold the tricuspid valve in place.
Question 3 of 5
The nurse is discharging a client after a cardiac catheterization. What would the nurse include in the discharge teaching?
Correct Answer: B
Rationale: Instructions for the client and family include: Keep the extremity straight for several hours and avoid movement; Report any warm, wet feeling that may indicate oozing blood, numbness, tingling, or sharp pain in the extremity; Drink a large volume of fluid to relieve thirst and promote the excretion of the dye. There is no need to eat only soft foods after a cardiac catheterization.
Question 4 of 5
The nurse is caring for a client with right-sided heart failure. When assessing the respiratory rate of this client, what is an indication that the client is having difficulty breathing?
Correct Answer: B
Rationale: When assessing the respiratory rate of a client with a cardiovascular disorder, the nurse observes the character of the respirations, noting whether the client's breathing is easy, labored, or dyspneic; deep or shallow; and noisy or quiet. The use of accessory muscles such as neck or abdominal muscles during respiration is an indication that the client is having difficulty breathing. Pulse volume is described as feeling full, weak, or thready, meaning barely palpable.
Question 5 of 5
One of the students asks what the consequences of uncorrected, left-sided heart failure would be. What would be the nursing instructor's best response?
Correct Answer: C
Rationale: If uncorrected, left-sided heart failure is followed by right-sided heart failure because the circulatory system is a continuous loop. With left-sided congestive heart failure, auscultation reveals a crackling sound, wheezes, and gurgles. Wet lung sounds are accompanied by dyspnea and an effort to sit up to breathe. If the right side of the heart fails to pump efficiently, blood becomes congested in the neck veins, and the nurse may inspect the distention of external jugular vein.