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 monitors a client with dark skin for signs of cyanosis. Which manifestation, documented by the nurse, indicates cyanosis for this client?
Correct Answer: B
Rationale: A good light is necessary when monitoring skin color. Many clients with cardiac disorders exhibit changes in skin color (e.g., cyanosis, pallor). Cyanosis can be detected by carefully noting color changes in the oral mucous membranes as well as in the lips, earlobes, skin, and nail beds. In dark-skinned clients, a grayish cast to the skin indicates pallor. In clients who are light skinned, extreme pallor is easy to detect because the skin appears almost bloodless. Dark red lips and tongue are not manifestations associated with cyanosis. A pale appearance can indicate cyanosis for a client with light skin. The presence of pale pink mucous membranes is a normal or expected finding and is not associated with cyanosis.
Question 2 of 5
The nurse is caring for a client with ECG changes consistent with a myocardial infarction. Which of the following diagnostic test does the nurse anticipate to confirm heart damage?
Correct Answer: B
Rationale: Nuclear cardiology uses a radionuclide to detect areas of myocardial damage. Chest radiography and fluoroscopy determine the size and position of the heart and condition of the lungs. Serum blood work notes elevations in enzymes suggesting tissue damage.
Question 3 of 5
The following clients are in need of exercise electrocardiography. Which client would the nurse indicate as most appropriate for a drug-induced stress test?
Correct Answer: D
Rationale: An exercise electrocardiography or stress test monitors the electrical activity of the heart while the client walks on a treadmill. If a client has a sedentary lifestyle or physical disability, cardiac medications may be administered to stress the heart similar to activity. Even though the client is middle aged at 55 years old, the client is recovering from a broken femur thus would be unable to have vigorous exercise. None of the other clients have a history which precludes them from exercise electrocardiography.
Question 4 of 5
The nurse provides care for a post-cardiac catheterization male client in the postprocedure room. Which is a priority nursing action for this client?
Correct Answer: D
Rationale: Following cardiac catheterization, the client has a pressure dressing placed over the catheter site to control bleeding. After the procedure, the nurse checks the dressing over the insertion site frequently for signs of bleeding. Additionally, the nurse monitors the client's blood pressure (BP) and pulse frequently to detect complications; however, it is not a priority for the nurse to monitor the client's temperature after this procedure. Although the client is encouraged to drink fluids as part of the discharge instructions to assist with flushing the dye used during the procedure, this is not a priority nursing action for this client in the postprocedure period of care. The client is taught to void while lying flat using a urinal; however, this is not the priority action based on the current data.
Question 5 of 5
The nurse is caring for an elderly client with left-sided heart failure. When auscultating lung sounds, which adventitious sound is expected?
Correct Answer: C
Rationale: When the left side of the heart is pumping inefficiently, blood backs up into the pulmonary veins and lung tissue. Auscultation reveals a crackling sound. Wheezes and gurgles may also be heard.