NURS 318 Med Surg II: Chapter 32 Cardioviovascular
System Exam With Complete Solutions
A nurse is providing information to a new graduate about measuring the blood
pressure in a cardiac patient. Which information should the nurse include? -
ANSWER Take the blood pressures in both the left and the right arms
Rational: The correct method of obtaining the blood pressure is by taking blood
pressure on both arms. The blood pressure may vary in the arms. The arm with
the higher blood pressure should be used for further measurements of blood
pressure. The nurse should take the blood pressure in 3 positions—with the
patient supine, sitting, and standing. There may be slight variations in the three
readings. A variation of 20 mm Hg from supine to standing is normal. A variation
in blood pressure does not correspond to a variation in respirations.
p. 694
The nurse is admitting a patient who is scheduled to undergo a cardiac
catheterization. What allergy is most important for the nurse to assess before
this procedure? - ANSWER Iodine
Rational: The health care provider usually will use an iodine-based contrast to
perform this procedure . Therefore it is imperative to know whether or not the
patient is allergic to iodine or shellfish. Knowledge of allergies to iron, aspirin, or
penicillin will be secondary.
During a physical examination of a patient, the nurse performs a capillary refill
test. What test finding should the nurse consider as normal? - ANSWER Capillary
refill time of 2 seconds
Rational: The capillary refill test assesses the perfusion function of the body.
The fingernail is pressed and the time required for refilling of blood is noted.
This refill is appreciated by the change in color of the nail bed. Under normal
circumstances, the capillary refill time is 2 seconds or less. More than 2 seconds
indicates inadequate perfusion. Capillary refill times of 4 seconds, 6 seconds,
and 8 seconds indicate an underlying defect in circulation.
The nurse assesses a patient who is scheduled to undergo a cardiac
catheterization. Which question should the nurse ask the patient to ensure
safety? - ANSWER "Are you allergic to iodine or shellfish?"
, Rational: Cardiac catheterization is a diagnostic method used to examine the
heart and blood vessels. During this procedure, contrast media such as water-
soluble iodine is injected into the patient in order to better see the blood vessels.
Therefore, to ensure safety and prevent allergic reactions to the contrast agent,
the nurse should ask the patient whether he or she is allergic to iodine. Contrast
media does not interact with proteins, so the nurse will not ask whether the
patient is consuming a diet rich in protein. Contrast media does not contain
lactose and does not worsen the symptoms of lactose intolerance.
Contraceptive methods do not reduce the effectiveness of cardiac
catheterization.
Test-Taking Tip: Identifying content and what is being asked about that content
is critical to your choosing the correct response. Be alert for words in the stem
of the item that are the same or similar in nature to those in one or two of the
options.
Text Reference - p. 692
A nurse is assessing the vital signs of a patient admitted to a hospital. Which
artery should be used to check the blood pressure? - ANSWER Brachial
Rational: Blood pressure is recorded using a device known as a
sphygmomanometer and a stethoscope. The ideal and correct site for checking
blood pressure is the brachial artery. This artery is on the arm near the elbow.
The radial artery is on the wrist. The carotid artery is in the neck region, while
the femoral artery is around the groin. Any other site apart from the brachial
artery is not suitable for checking blood pressure with a sphygmomanometer.
Text Reference - p. 690
The blood pressure of a 71-year-old patient admitted with pneumonia is 160/70
mm Hg. What is an age-related change that contributes to this finding? -
ANSWER Loss of elasticity in arterial vessels
Rational: An age-related change that increases the risk of systolic hypertension
is a loss of elasticity in the arterial walls. Because of the increasing resistance to
flow, pressure is increased within the blood vessel and hypertension results.
Valvular rigidity of aging causes murmurs and decreased adrenergic sensitivity
slows the heart rate. Blood pressure is not raised. Increased parasympathetic
activity would slow the heart rate.
Text Reference - p. 691
A nurse examines a patient with cardiovascular problems and assesses for the
presence of pitting edema. What is the best location to assess for edema? -
ANSWER Ankle
Rational: Edema is a common and early symptom of cardiovascular conditions.
This edema is commonly seen in dependent areas, such as on the feet and the
System Exam With Complete Solutions
A nurse is providing information to a new graduate about measuring the blood
pressure in a cardiac patient. Which information should the nurse include? -
ANSWER Take the blood pressures in both the left and the right arms
Rational: The correct method of obtaining the blood pressure is by taking blood
pressure on both arms. The blood pressure may vary in the arms. The arm with
the higher blood pressure should be used for further measurements of blood
pressure. The nurse should take the blood pressure in 3 positions—with the
patient supine, sitting, and standing. There may be slight variations in the three
readings. A variation of 20 mm Hg from supine to standing is normal. A variation
in blood pressure does not correspond to a variation in respirations.
p. 694
The nurse is admitting a patient who is scheduled to undergo a cardiac
catheterization. What allergy is most important for the nurse to assess before
this procedure? - ANSWER Iodine
Rational: The health care provider usually will use an iodine-based contrast to
perform this procedure . Therefore it is imperative to know whether or not the
patient is allergic to iodine or shellfish. Knowledge of allergies to iron, aspirin, or
penicillin will be secondary.
During a physical examination of a patient, the nurse performs a capillary refill
test. What test finding should the nurse consider as normal? - ANSWER Capillary
refill time of 2 seconds
Rational: The capillary refill test assesses the perfusion function of the body.
The fingernail is pressed and the time required for refilling of blood is noted.
This refill is appreciated by the change in color of the nail bed. Under normal
circumstances, the capillary refill time is 2 seconds or less. More than 2 seconds
indicates inadequate perfusion. Capillary refill times of 4 seconds, 6 seconds,
and 8 seconds indicate an underlying defect in circulation.
The nurse assesses a patient who is scheduled to undergo a cardiac
catheterization. Which question should the nurse ask the patient to ensure
safety? - ANSWER "Are you allergic to iodine or shellfish?"
, Rational: Cardiac catheterization is a diagnostic method used to examine the
heart and blood vessels. During this procedure, contrast media such as water-
soluble iodine is injected into the patient in order to better see the blood vessels.
Therefore, to ensure safety and prevent allergic reactions to the contrast agent,
the nurse should ask the patient whether he or she is allergic to iodine. Contrast
media does not interact with proteins, so the nurse will not ask whether the
patient is consuming a diet rich in protein. Contrast media does not contain
lactose and does not worsen the symptoms of lactose intolerance.
Contraceptive methods do not reduce the effectiveness of cardiac
catheterization.
Test-Taking Tip: Identifying content and what is being asked about that content
is critical to your choosing the correct response. Be alert for words in the stem
of the item that are the same or similar in nature to those in one or two of the
options.
Text Reference - p. 692
A nurse is assessing the vital signs of a patient admitted to a hospital. Which
artery should be used to check the blood pressure? - ANSWER Brachial
Rational: Blood pressure is recorded using a device known as a
sphygmomanometer and a stethoscope. The ideal and correct site for checking
blood pressure is the brachial artery. This artery is on the arm near the elbow.
The radial artery is on the wrist. The carotid artery is in the neck region, while
the femoral artery is around the groin. Any other site apart from the brachial
artery is not suitable for checking blood pressure with a sphygmomanometer.
Text Reference - p. 690
The blood pressure of a 71-year-old patient admitted with pneumonia is 160/70
mm Hg. What is an age-related change that contributes to this finding? -
ANSWER Loss of elasticity in arterial vessels
Rational: An age-related change that increases the risk of systolic hypertension
is a loss of elasticity in the arterial walls. Because of the increasing resistance to
flow, pressure is increased within the blood vessel and hypertension results.
Valvular rigidity of aging causes murmurs and decreased adrenergic sensitivity
slows the heart rate. Blood pressure is not raised. Increased parasympathetic
activity would slow the heart rate.
Text Reference - p. 691
A nurse examines a patient with cardiovascular problems and assesses for the
presence of pitting edema. What is the best location to assess for edema? -
ANSWER Ankle
Rational: Edema is a common and early symptom of cardiovascular conditions.
This edema is commonly seen in dependent areas, such as on the feet and the
