Essay about Chapter 32 Nursing Assessment Cardiovascular System

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Chapter 32: Nursing Assessment: Cardiovascular System
Test Bank
MULTIPLE CHOICE
1. After noting a pulse deficit when assessing a 74-year-old patient who has just arrived in the

emergency department, the nurse will anticipate that the patient may require
a. emergent cardioversion.
b. a cardiac catheterization.
c. hourly blood pressure (BP) checks.
d. electrocardiographic (ECG) monitoring.
ANS: D

Pulse deficit is a difference between simultaneously obtained apical and radial pulses. It indicates that there may be a cardiac dysrhythmia that would best be detected with ECG monitoring. Frequent BP monitoring, cardiac catheterization, and emergent cardioversion are used for diagnosis and/or treatment of cardiovascular disorders but would not
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The patient is not immobile during cardiac catheterization and may be asked to cough or take deep breaths.
DIF: Cognitive Level: Apply (application)
REF:
706
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
8. While assessing a patient who was admitted with heart failure, the nurse notes that the patient

has jugular venous distention (JVD) when lying flat in bed. Which action should the nurse take next?
a. Document this finding in the patient’s record.
b. Obtain vital signs, including oxygen saturation.
c. Have the patient perform the Valsalva maneuver.
d. Observe for JVD with the patient upright at 45 degrees.
ANS: D

When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but not a clinically significant) finding. Obtaining vital signs and oxygen saturation is not warranted at this point. JVD is an expected finding when a patient performs the
Valsalva maneuver because right atrial pressure increases. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant. The nurse will document the
JVD in the medical record if it persists when the head is elevated.
DIF: Cognitive Level: Apply (application)
REF:
694 | 696
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
9. The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor

to
a.
b.

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