Lewis's Medical-Surgical Nursing, 12th Edition
TOPIC 1: Structures and Functions of the Cardiovascular System
MULTIPLE CHOICE
1. A nurse is reviewing the anatomy of the heart with a nursing student. Which statement by the student
indicates correct understanding of the pericardium?
a. "The pericardium is composed of two layers: the endocardium and the epicardium."
b. "The pericardium is a thin inner lining that covers the heart valves."
c. "The pericardium consists of a visceral layer and a parietal layer with pericardial fluid between them."
d. "The pericardium is the muscular layer of the heart responsible for contraction."
ANS: C
Rationale:
The pericardium is a fibroserous sac covering the heart that consists of two layers: the inner (visceral) layer (part of
the epicardium) and the outer (parietal) layer. Approximately 10 to 15 mL of pericardial fluid lubricates the space
between these layers (pericardial space) and prevents friction. The endocardium is the thin inner lining of the heart,
and the myocardium is the muscular layer. Options A, B, and D incorrectly describe the pericardium.
DIF: Cognitive Level: Understand (comprehension)
REF: Page 768, Structure
TOP: Cardiac Anatomy
MSC: Physiological Integrity: Physiological Adaptation
2. A patient is diagnosed with left ventricular hypertrophy. The nurse understands that this condition results
from the left ventricle pumping against increased resistance, which is known as:
a. Preload
b. Afterload
c. Cardiac output
d. Stroke volume
ANS: B
Rationale:
Afterload is the peripheral resistance against which the left ventricle must pump. If arterial blood pressure is
elevated, the ventricles meet increased resistance to ejection of blood, increasing the work demand, which can
eventually result in ventricular hypertrophy. Preload is the volume of blood stretching the ventricles at the end of
diastole. Cardiac output is the amount of blood pumped by each ventricle in 1 minute. Stroke volume is the amount
of blood ejected from the ventricle with each heartbeat.
DIF: Cognitive Level: Understand (comprehension)
REF: Page 770, Factors Affecting Cardiac Output
TOP: Cardiac Physiology
MSC: Physiological Integrity: Physiological Adaptation
, 3. The nurse is assessing a patient's point of maximal impulse (PMI). In a healthy adult, where should the PMI
be located?
a. 2nd intercostal space at the right sternal border
b. 3rd intercostal space at the left sternal border
c. 4th or 5th intercostal space at the midclavicular line
d. 5th intercostal space at the anterior axillary line
ANS: C
Rationale:
The point of maximal impulse (PMI), also called the apical pulse, reflects the pulsation of the apex of the heart. In a
healthy adult, the PMI lies medial to the midclavicular line in the 4th or 5th intercostal space. The aortic area is
located at the 2nd intercostal space to the right of the sternum, and the pulmonic area is at the 2nd intercostal space
to the left of the sternum. Erb's point is located at the 3rd left intercostal space near the sternum.
DIF: Cognitive Level: Remember (knowledge)
REF: Page 778, Thorax: Inspection and Palpation
TOP: Cardiac Assessment
MSC: Health Promotion and Maintenance: Techniques of Physical Assessment
4. The nurse is auscultating heart sounds and hears a low-pitched sound immediately after S2. The nurse
documents this as which heart sound?
a. S1
b. S2
c. S3
d. S4
ANS: C
Rationale:
S3 is a low-intensity vibration of the ventricular walls heard in early diastole, closely after S2. It is known as a
ventricular gallop. S1 represents closure of the tricuspid and mitral valves at the beginning of systole. S2 represents
closure of the aortic and pulmonic valves at the beginning of diastole. S4 is a low-frequency vibration heard in late
diastole caused by atrial contraction and precedes S1.
DIF: Cognitive Level: Remember (knowledge)
REF: Page 778, Thorax: Auscultation
TOP: Cardiac Assessment
MSC: Health Promotion and Maintenance: Techniques of Physical Assessment
5. A patient's cardiac output is 4.5 L/min with a heart rate of 90 beats/min. The nurse calculates the patient's
stroke volume as:
a. 40 mL
b. 50 mL
c. 60 mL
d. 90 mL
,ANS: B
Rationale:
Cardiac output (CO) is calculated by multiplying stroke volume (SV) by heart rate (HR): CO = SV × HR. To
calculate SV, divide CO by HR: 4.5 L/min ÷ 90 beats/min = 0.05 L or 50 mL. Normal resting SV ranges from 60 to
100 mL per beat.
DIF: Cognitive Level: Apply (application)
REF: Page 770, Mechanical System
TOP: Cardiac Physiology
MSC: Physiological Integrity: Physiological Adaptation
6. A nurse is educating a patient about the conduction system of the heart. Which structure is correctly
identified as the pacemaker of the heart?
a. Atrioventricular (AV) node
b. Bundle of His
c. Purkinje fibers
d. Sinoatrial (SA) node
ANS: D
Rationale:
The sinoatrial (SA) node is the pacemaker of the heart, where the electrical impulse normally begins. The impulse
then travels through interatrial pathways to depolarize the atria. The AV node receives impulses from the atria
through internodal pathways, then the impulse moves through the bundle of His and the left and right bundle
branches, and finally through Purkinje fibers.
DIF: Cognitive Level: Remember (knowledge)
REF: Page 768, Conduction System
TOP: Cardiac Physiology
MSC: Physiological Integrity: Physiological Adaptation
7. The nurse is caring for a patient with a right coronary artery occlusion. The nurse understands that this may
lead to conduction defects because the right coronary artery supplies blood to which structure?
a. Left atrium
b. Left ventricle
c. Sinoatrial (SA) node and atrioventricular (AV) node
d. Right atrium and left ventricle
ANS: C
Rationale:
The right coronary artery branches supply the right atrium, right ventricle, and part of the posterior wall of the left
ventricle. In 90% of people, the atrioventricular (AV) node and the bundle of His receive blood supply from the right
coronary artery. Blockage of this artery often causes serious defects in cardiac conduction. The left coronary artery
supplies the left atrium, left ventricle, interventricular septum, and part of the right ventricle.
, DIF: Cognitive Level: Understand (comprehension)
REF: Page 768, Blood Supply to Myocardium
TOP: Coronary Circulation
MSC: Physiological Integrity: Physiological Adaptation
8. A patient has a heart rate of 120 beats/min at rest. The nurse understands that this tachycardia affects
cardiac output by:
a. Increasing stroke volume
b. Decreasing diastolic filling time
c. Increasing coronary artery perfusion
d. Decreasing myocardial oxygen demand
ANS: B
Rationale:
With rapid heart rates, there is less time for diastolic filling and perfusion of the coronary arteries. Tachycardia can
lead to decreased stroke volume because the ventricles do not have adequate time to fill. This ultimately decreases
cardiac output. Coronary artery perfusion occurs primarily during diastole. Increased heart rate increases myocardial
oxygen demand.
DIF: Cognitive Level: Understand (comprehension)
REF: Page 770, Factors Affecting Cardiac Output
TOP: Cardiac Physiology
MSC: Physiological Integrity: Physiological Adaptation
9. The nurse is assessing a patient who reports dizziness when standing up from a lying position. The nurse
should assess for which condition?
a. Hypertension
b. Orthostatic hypotension
c. Peripheral vascular disease
d. Aortic stenosis
ANS: B
Rationale:
Orthostatic hypotension is defined as a decrease in systolic blood pressure of at least 20 mm Hg or an increase in
heart rate of at least 20 beats/min when moving from a supine to a standing position. Symptoms include dizziness,
lightheadedness, and possible syncope. Hypertension is sustained elevated blood pressure. Peripheral vascular
disease affects circulation to the extremities. Aortic stenosis is a valvular disorder.
DIF: Cognitive Level: Understand (comprehension)
REF: Page 775, Physical Assessment: Vital Signs
TOP: Cardiovascular Assessment
MSC: Health Promotion and Maintenance: Techniques of Physical Assessment
TOPIC 1: Structures and Functions of the Cardiovascular System
MULTIPLE CHOICE
1. A nurse is reviewing the anatomy of the heart with a nursing student. Which statement by the student
indicates correct understanding of the pericardium?
a. "The pericardium is composed of two layers: the endocardium and the epicardium."
b. "The pericardium is a thin inner lining that covers the heart valves."
c. "The pericardium consists of a visceral layer and a parietal layer with pericardial fluid between them."
d. "The pericardium is the muscular layer of the heart responsible for contraction."
ANS: C
Rationale:
The pericardium is a fibroserous sac covering the heart that consists of two layers: the inner (visceral) layer (part of
the epicardium) and the outer (parietal) layer. Approximately 10 to 15 mL of pericardial fluid lubricates the space
between these layers (pericardial space) and prevents friction. The endocardium is the thin inner lining of the heart,
and the myocardium is the muscular layer. Options A, B, and D incorrectly describe the pericardium.
DIF: Cognitive Level: Understand (comprehension)
REF: Page 768, Structure
TOP: Cardiac Anatomy
MSC: Physiological Integrity: Physiological Adaptation
2. A patient is diagnosed with left ventricular hypertrophy. The nurse understands that this condition results
from the left ventricle pumping against increased resistance, which is known as:
a. Preload
b. Afterload
c. Cardiac output
d. Stroke volume
ANS: B
Rationale:
Afterload is the peripheral resistance against which the left ventricle must pump. If arterial blood pressure is
elevated, the ventricles meet increased resistance to ejection of blood, increasing the work demand, which can
eventually result in ventricular hypertrophy. Preload is the volume of blood stretching the ventricles at the end of
diastole. Cardiac output is the amount of blood pumped by each ventricle in 1 minute. Stroke volume is the amount
of blood ejected from the ventricle with each heartbeat.
DIF: Cognitive Level: Understand (comprehension)
REF: Page 770, Factors Affecting Cardiac Output
TOP: Cardiac Physiology
MSC: Physiological Integrity: Physiological Adaptation
, 3. The nurse is assessing a patient's point of maximal impulse (PMI). In a healthy adult, where should the PMI
be located?
a. 2nd intercostal space at the right sternal border
b. 3rd intercostal space at the left sternal border
c. 4th or 5th intercostal space at the midclavicular line
d. 5th intercostal space at the anterior axillary line
ANS: C
Rationale:
The point of maximal impulse (PMI), also called the apical pulse, reflects the pulsation of the apex of the heart. In a
healthy adult, the PMI lies medial to the midclavicular line in the 4th or 5th intercostal space. The aortic area is
located at the 2nd intercostal space to the right of the sternum, and the pulmonic area is at the 2nd intercostal space
to the left of the sternum. Erb's point is located at the 3rd left intercostal space near the sternum.
DIF: Cognitive Level: Remember (knowledge)
REF: Page 778, Thorax: Inspection and Palpation
TOP: Cardiac Assessment
MSC: Health Promotion and Maintenance: Techniques of Physical Assessment
4. The nurse is auscultating heart sounds and hears a low-pitched sound immediately after S2. The nurse
documents this as which heart sound?
a. S1
b. S2
c. S3
d. S4
ANS: C
Rationale:
S3 is a low-intensity vibration of the ventricular walls heard in early diastole, closely after S2. It is known as a
ventricular gallop. S1 represents closure of the tricuspid and mitral valves at the beginning of systole. S2 represents
closure of the aortic and pulmonic valves at the beginning of diastole. S4 is a low-frequency vibration heard in late
diastole caused by atrial contraction and precedes S1.
DIF: Cognitive Level: Remember (knowledge)
REF: Page 778, Thorax: Auscultation
TOP: Cardiac Assessment
MSC: Health Promotion and Maintenance: Techniques of Physical Assessment
5. A patient's cardiac output is 4.5 L/min with a heart rate of 90 beats/min. The nurse calculates the patient's
stroke volume as:
a. 40 mL
b. 50 mL
c. 60 mL
d. 90 mL
,ANS: B
Rationale:
Cardiac output (CO) is calculated by multiplying stroke volume (SV) by heart rate (HR): CO = SV × HR. To
calculate SV, divide CO by HR: 4.5 L/min ÷ 90 beats/min = 0.05 L or 50 mL. Normal resting SV ranges from 60 to
100 mL per beat.
DIF: Cognitive Level: Apply (application)
REF: Page 770, Mechanical System
TOP: Cardiac Physiology
MSC: Physiological Integrity: Physiological Adaptation
6. A nurse is educating a patient about the conduction system of the heart. Which structure is correctly
identified as the pacemaker of the heart?
a. Atrioventricular (AV) node
b. Bundle of His
c. Purkinje fibers
d. Sinoatrial (SA) node
ANS: D
Rationale:
The sinoatrial (SA) node is the pacemaker of the heart, where the electrical impulse normally begins. The impulse
then travels through interatrial pathways to depolarize the atria. The AV node receives impulses from the atria
through internodal pathways, then the impulse moves through the bundle of His and the left and right bundle
branches, and finally through Purkinje fibers.
DIF: Cognitive Level: Remember (knowledge)
REF: Page 768, Conduction System
TOP: Cardiac Physiology
MSC: Physiological Integrity: Physiological Adaptation
7. The nurse is caring for a patient with a right coronary artery occlusion. The nurse understands that this may
lead to conduction defects because the right coronary artery supplies blood to which structure?
a. Left atrium
b. Left ventricle
c. Sinoatrial (SA) node and atrioventricular (AV) node
d. Right atrium and left ventricle
ANS: C
Rationale:
The right coronary artery branches supply the right atrium, right ventricle, and part of the posterior wall of the left
ventricle. In 90% of people, the atrioventricular (AV) node and the bundle of His receive blood supply from the right
coronary artery. Blockage of this artery often causes serious defects in cardiac conduction. The left coronary artery
supplies the left atrium, left ventricle, interventricular septum, and part of the right ventricle.
, DIF: Cognitive Level: Understand (comprehension)
REF: Page 768, Blood Supply to Myocardium
TOP: Coronary Circulation
MSC: Physiological Integrity: Physiological Adaptation
8. A patient has a heart rate of 120 beats/min at rest. The nurse understands that this tachycardia affects
cardiac output by:
a. Increasing stroke volume
b. Decreasing diastolic filling time
c. Increasing coronary artery perfusion
d. Decreasing myocardial oxygen demand
ANS: B
Rationale:
With rapid heart rates, there is less time for diastolic filling and perfusion of the coronary arteries. Tachycardia can
lead to decreased stroke volume because the ventricles do not have adequate time to fill. This ultimately decreases
cardiac output. Coronary artery perfusion occurs primarily during diastole. Increased heart rate increases myocardial
oxygen demand.
DIF: Cognitive Level: Understand (comprehension)
REF: Page 770, Factors Affecting Cardiac Output
TOP: Cardiac Physiology
MSC: Physiological Integrity: Physiological Adaptation
9. The nurse is assessing a patient who reports dizziness when standing up from a lying position. The nurse
should assess for which condition?
a. Hypertension
b. Orthostatic hypotension
c. Peripheral vascular disease
d. Aortic stenosis
ANS: B
Rationale:
Orthostatic hypotension is defined as a decrease in systolic blood pressure of at least 20 mm Hg or an increase in
heart rate of at least 20 beats/min when moving from a supine to a standing position. Symptoms include dizziness,
lightheadedness, and possible syncope. Hypertension is sustained elevated blood pressure. Peripheral vascular
disease affects circulation to the extremities. Aortic stenosis is a valvular disorder.
DIF: Cognitive Level: Understand (comprehension)
REF: Page 775, Physical Assessment: Vital Signs
TOP: Cardiovascular Assessment
MSC: Health Promotion and Maintenance: Techniques of Physical Assessment
