Chapter 30: Assessment of the
Cardiovascular System
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse assesses a client who is recovering from a myocardial infarction. The client’s
blood pressure is 140/88 mm Hg. What action would the nurse take first?
a. Compare the results with previous blood pressure readings.
b. Increase the intravenous fluid rate because these readings are low.
c. Immediately notify the primary health care provider of the elevated blood
pressure.
d. Document the finding in the client’s chart as the only action.
ANS: A
The most recent range for normal blood pressure is less than 140 mm Hg systolic and
less than 90mm Hg diastolic. This client’s blood pressure is at the upper range of
acceptable, so the nurse would compare the client’s current reading with those
previously recorded before doing anything else. The reading is not low, so the nurse
would not increase IV fluids, nor would the nurse necessarily notify the primary
health care provider. Documentation is important, but the nurse first checks previous
readings.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: Blood pressure, Assessment MSC: Client
Needs Category: Safe and Effective Care Environment: Management of Care
,2. A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA)
and is scheduled for bypass surgery. Which intervention would the nurse be prepared
to implement while this client waits for surgery?
a. Administration of IV furosemide
b. Initiation of an external pacemaker
c. Assistance with endotracheal intubation
d. Placement of central venous access
ANS: B
The RCA supplies the right atrium, right ventricle, inferior portion of the left
ventricle, and atrioventricular (AV) node. It also supplies the sinoatrial node in 50%
of people. If the client totally occludes the RCA, the AV node would not function and
the client would go into heart block, so emergency pacing would be available for the
client. Furosemide, intubation, and central venous access will not address the primary
complication of RCA occlusion, which is AV node (and possibly SA node)
malfunction.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Planning
KEY: Coronary perfusion MSC: Client Needs Category:
Physiological Integrity: Reduction of Risk Potential
3. A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at
high risk for coronary artery disease. Which statement related to nutrition would the
nurse include in this client’s teaching?
a. “The best way to lose weight is a high-protein, low-carbohydrate diet.”
b. “You should balance weight loss with consuming necessary nutrients.”
c. “A nutritionist will provide you with information about your new diet.”
d. “If you exercise more frequently, you won’t need to change your diet.”
ANS: B
Clients at risk for cardiovascular diseases should follow the American Heart
Association guidelines to combat obesity and improve cardiac health. The nurse
, would encourage the client to eat vegetables, fruits, unrefined whole-grain products,
and fat-free dairy products while losing weight. High-protein food items are often
high in fat and calories. Although the nutritionist can assist with client education, the
nurse would include nutrition education and assist the client to make healthy
decisions. Exercising and eating nutrient-rich foods are both important components in
reducing cardiovascular risk.
DIF: Applying TOP: Integrated Process: Teaching/Learning
KEY: Nutrition, Health teaching MSC: Client Needs Category:
Physiological Integrity: Physiological Adaptation
4. A nurse cares for a client who has advanced cardiac disease and states, “I am having
trouble breathing while I’m sleeping at night.” What is the nurse’s best response?
a. “I will consult your primary health care provider to prescribe a sleep study.”
b. “You become hypoxic while sleeping; oxygen therapy via nasal cannula will
help.”
c. “A continuous positive airway pressure, or CPAP, breathing mask will help
you breathe at night.”
d. “Use pillows to elevate your head and chest while you are sleeping.”
ANS: D
The client is experiencing orthopnea (shortness of breath while lying flat). The nurse
would teach the client to elevate the head and chest with pillows or sleep in a recliner.
A sleep study is not necessary to diagnose this client. Oxygen and CPAP will not help
a client with orthopnea.
DIF: Understanding TOP: Integrated Process: Teaching/Learning
KEY: Heart failure, Orthopnea, Health teaching MSC:
Client Needs Category: Physiological Integrity: Basic Care and Comfort
Cardiovascular System
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse assesses a client who is recovering from a myocardial infarction. The client’s
blood pressure is 140/88 mm Hg. What action would the nurse take first?
a. Compare the results with previous blood pressure readings.
b. Increase the intravenous fluid rate because these readings are low.
c. Immediately notify the primary health care provider of the elevated blood
pressure.
d. Document the finding in the client’s chart as the only action.
ANS: A
The most recent range for normal blood pressure is less than 140 mm Hg systolic and
less than 90mm Hg diastolic. This client’s blood pressure is at the upper range of
acceptable, so the nurse would compare the client’s current reading with those
previously recorded before doing anything else. The reading is not low, so the nurse
would not increase IV fluids, nor would the nurse necessarily notify the primary
health care provider. Documentation is important, but the nurse first checks previous
readings.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: Blood pressure, Assessment MSC: Client
Needs Category: Safe and Effective Care Environment: Management of Care
,2. A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA)
and is scheduled for bypass surgery. Which intervention would the nurse be prepared
to implement while this client waits for surgery?
a. Administration of IV furosemide
b. Initiation of an external pacemaker
c. Assistance with endotracheal intubation
d. Placement of central venous access
ANS: B
The RCA supplies the right atrium, right ventricle, inferior portion of the left
ventricle, and atrioventricular (AV) node. It also supplies the sinoatrial node in 50%
of people. If the client totally occludes the RCA, the AV node would not function and
the client would go into heart block, so emergency pacing would be available for the
client. Furosemide, intubation, and central venous access will not address the primary
complication of RCA occlusion, which is AV node (and possibly SA node)
malfunction.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Planning
KEY: Coronary perfusion MSC: Client Needs Category:
Physiological Integrity: Reduction of Risk Potential
3. A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at
high risk for coronary artery disease. Which statement related to nutrition would the
nurse include in this client’s teaching?
a. “The best way to lose weight is a high-protein, low-carbohydrate diet.”
b. “You should balance weight loss with consuming necessary nutrients.”
c. “A nutritionist will provide you with information about your new diet.”
d. “If you exercise more frequently, you won’t need to change your diet.”
ANS: B
Clients at risk for cardiovascular diseases should follow the American Heart
Association guidelines to combat obesity and improve cardiac health. The nurse
, would encourage the client to eat vegetables, fruits, unrefined whole-grain products,
and fat-free dairy products while losing weight. High-protein food items are often
high in fat and calories. Although the nutritionist can assist with client education, the
nurse would include nutrition education and assist the client to make healthy
decisions. Exercising and eating nutrient-rich foods are both important components in
reducing cardiovascular risk.
DIF: Applying TOP: Integrated Process: Teaching/Learning
KEY: Nutrition, Health teaching MSC: Client Needs Category:
Physiological Integrity: Physiological Adaptation
4. A nurse cares for a client who has advanced cardiac disease and states, “I am having
trouble breathing while I’m sleeping at night.” What is the nurse’s best response?
a. “I will consult your primary health care provider to prescribe a sleep study.”
b. “You become hypoxic while sleeping; oxygen therapy via nasal cannula will
help.”
c. “A continuous positive airway pressure, or CPAP, breathing mask will help
you breathe at night.”
d. “Use pillows to elevate your head and chest while you are sleeping.”
ANS: D
The client is experiencing orthopnea (shortness of breath while lying flat). The nurse
would teach the client to elevate the head and chest with pillows or sleep in a recliner.
A sleep study is not necessary to diagnose this client. Oxygen and CPAP will not help
a client with orthopnea.
DIF: Understanding TOP: Integrated Process: Teaching/Learning
KEY: Heart failure, Orthopnea, Health teaching MSC:
Client Needs Category: Physiological Integrity: Basic Care and Comfort
