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 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 2 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.
Question 3 of 5
The nurse notes that the client has had a change in mental status. Why would it be important for the nurse to report extremes in the thought process of a client with cardiovascular disorder to the physician?
Correct Answer: C
Rationale: The nurse should report extremes in thought processes to the physician because such effects may interfere with the client's safety and prescribed therapy. Chest pain and impaired breathing may create anxiety. Extremes of emotions or disturbances in thought processes are not the indications of an impending heart failure. The client will not develop any anxiety disorder.
Question 4 of 5
The nurse caring for a client who is suspected of having cardiovascular disease has a stress test ordered. The client has a comorbidity of multiple sclerosis, so the nurse knows the stress test will be drug induced. What drug will be used to dilate the coronary arteries?
Correct Answer: D
Rationale: Drugs such as adenosine (Adenocard), dipyridamole (Persantine), or dobutamine (Dobutrex) may be administered singularly or in combination by the IV route. The drugs dilate the coronary arteries, similar to the vasodilation that occurs when a person exercises to increase the heart muscle's blood supply. The other drugs would not dilate the coronary arteries.
Question 5 of 5
While being prepared for echocardiography, the client asks nurse why this test is necessary. What would be the nurse's best response?
Correct Answer: C
Rationale: Echocardiography uses ultrasound waves to determine the functioning of the left ventricle and to detect cardiac tumors, congenital defects, and changes in the tissue layers of the heart. Explaining the procedure is the best answer because it addresses the client's question without making the client anxious or minimizing the question.