ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 34 Questions
Question 1 of 5
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?
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.
Question 2 of 5
The nurse is reviewing the 12-lead electrocardiogram (ECG) of a healthy older-adult patient who is having an annual physical examination. Which of the following findings should be of most concern to the nurse?
Correct Answer: A
Rationale: The resting supine HR is not markedly affected with aging, so the decrease in HR requires further investigation. Bundle-branch block and slight increases in PR interval or QRS duration are common in older individuals because of increases in conduction time through the AV node, the bundle of His, and the bundle branches.
Question 3 of 5
During a physical examination of a patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. Which of the following actions should the nurse implement next?
Correct Answer: D
Rationale: The PMI should be felt at the intersection of the 5th intercostal space and the left midclavicular line. A PMI located outside these landmarks indicates possible cardiac enlargement, such as with left ventricular hypertrophy. Cardiac enlargement is not necessarily associated with coronary or carotid artery disease.
Question 4 of 5
To auscultate for S3 or S4 gallops in the mitral area, which of the following should the nurse implement?
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.
Question 5 of 5
The nurse is caring for a patient who is being treated for heart failure. Which of the following laboratory results should the nurse assess to determine the effects of therapy?
Correct Answer: D
Rationale: Increased levels of BNP are a marker for heart failure. The other laboratory results would be used to assess for myocardial infarction (myoglobin) or risk for coronary artery disease (Hcy and LDL).