Chapter 35: Assessment of the Cardiovascular
System
MULTIPLE CHOICE
1. The nurse is caring for a client who has had a recent myocardial infarction involving the left ventricle. Which
assessment finding is expected? A. Faint S1 and S2 sounds
b. Decreased cardiac output
c. Increased blood pressure
d. Absent peripheral pulses
2. The nurse is caring for a client with coronary artery disease. What assessment finding does the nurse expect if
the client’s mean arterial blood pressure decreases below 60 mm Hg? A. Increased cardiac output
b. Hypertension
c. Chest pain
d. Decreased heart rate
3. The nurse is assessing a client following a myocardial infarction. The client is hypotensive. What
additional assessment finding does the nurse expect? A. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min
4. The nurse administers a beta blocker to a client after a myocardial infarction. What assessment finding does the
nurse expect?
a. Blood pressure increase of 10%
b. Increasing respiratory rate
c. Increased cardiac output
d. Pulse decrease from 100 to 80 beats/min
5. The nurse is assessing clients at a community health center. Which client does the nurse determine is at high
risk for cardiovascular disease?
a. Older adult man with a history of asthma
b. Asian-American man with colorectal cancer
c. American Indian woman with diabetes mellitus
d. Postmenopausal woman on hormone therapy
6. The nurse is obtaining a client’s health history. Which illness alerts the nurse to the possibility of
abnormal heart valves? A. Tuberculosis
b. Recurrent viral pneumonia
c. Rheumatic fever
d. Asthma
7. A nurse is performing an admission assessment on an older adult client with multiple chronic diseases.
The nurse assesses the heart rate to be 48 beats/min. What does the nurse do first? A.
Document the finding in the chart.
b. Evaluate for a pulse deficit.
,c. Assess the client’s medications.
d. Administer 1 mg of atropine.
8. The nurse is assessing clients at a clinic. Which activity takes priority?
a. Teaching smoking cessation to a middle-aged woman who smokes
b. Planning an exercise regimen with a woman with a sedentary lifestyle
c. Teaching an older man who is moderately obese to keep a fooddiary
d. Assessing a man with familial coronary artery disease for specific risk factors
9. The nurse is assessing a client in the emergency department. Which client statement alerts the nurse to the
occurrence of heart failure?
a. “I get short of breath when I climb stairs.”
b. “I see halos floating around my head.”
c. “I have trouble remembering things.”
d. “I have lost weight over the past month.”
10. The nurse is assessing a client newly admitted to the medical unit. Which statement made by the client
alerts the nurse to the presence of edema? A. “I wake up to go to the bathroom at night.”
b. “My shoes fit tighter by the end of the day.”
c. “I seem to be feeling more anxious lately.”
d. “I drink at least eight glasses of water a day.”
11. When obtaining a client’s vital signs, the nurse assesses a blood pressure of 134/88 mm Hg. What is the
nurse’s best intervention?
a. Call the health care provider and report the finding.
b. Reassess the client’s blood pressure at the next yearly physical.
c. Administer an additional antihypertensive medication to the client.
d. Teach the client lifestyle modifications to decrease blood pressure.
12. The nurse is performing a focused cardiac assessment. What assessment finding should be reported to the
health care provider?
a. Bruit heard on the side of the neck
b. Bounding peripheral pulses
c. Pulse rate of 90 beats/min
d. Blood pressure of 140/90 mm Hg
13. A client consistently reports feeling dizzy and lightheaded when moving from a supine position to a sitting
position. What nursing assessment takes priority at this time? A. Pulse oximetry
b. Blood pressure
c. Respiratory rate
d. Neurologic evaluation
14. The nurse is assessing an older adult client who is experiencing a myocardial infarction. What clinical
manifestation does the nurse expect in this client? A. Excruciating pain on inspiration
b. Left lateral chest wall pain
c. Disorientation and confusion
d. Numbness and tingling of the arm
15. A client is newly diagnosed with a heart murmur and asks the nurse to explain what this means. What is the
nurse’s best response?
a. “It is a rushing sound that blood makes moving through narrow places.”
b. “It’s the sound of the heart muscle stretching in an area of weakness.”
,c. “It’s a term doctors use to describe the efficiency of blood circulation.”
d. “It is the sound the heart makes when it is has an increased workload.”
16. A client has returned from a cardiac angiography via the left femoral artery. Two hours after the
procedure, the nurse notes that the left pedal pulse is weak. What is the nurse’s best action? A. Elevate the
leg and apply a sandbag to the entrance site.
b. Increase the flow rate of intravenous fluids.
c. Assess the color and temperature of the left leg.
d. Document the finding as left pedal pulse of +1/4.
17. The nurse is recovering a client after a left-sided cardiac catheterization. What assessment finding requires
immediate intervention?
a. Urinary output less than intake
b. Bruising at the insertion site
c. Slurred speech and confusion
d. Discomfort in the left leg
18. The nurse is preparing a client for a cardiac catheterization. What assessment is a priority before the
procedure?
a. Client’s level of anxiety
b. Ability to turn self in bed
c. Cardiac rhythm and heart rate
d. Allergies to iodine and shellfish
19. The client is scheduled for a resting electrocardiography. Which statement by the client indicates a good
understanding of the preprocedure teaching?
a. “I cannot eat or drink before the electrocardiography.”
b. “I must lie as still as possible during the procedure.”
c. “I am likely to feel warmth as the dye enters the heart.”
d. “I will increase my fluid intake on the day of the procedure.”
20. The nurse is monitoring a client undergoing an exercise electrocardiography (stress test). Which
assessment finding necessitates that the test be stopped? A. Heart rate increases to 140 beats/min
b. Blood pressure of 100/80 mm Hg
c. Respiratory rate exceeds 36 breaths/min
d. Significant ST-segment depression
21. A client who is scheduled for an echocardiography today asks why this test is being performed. What is the
nurse’s best response?
a. “This procedure is a noninvasive way to assess the structure of the heart.”
b. “This procedure assesses for abnormal electrical impulses within the heart.”
c. “This procedure will evaluate the oxygen saturation in your blood.”
d. “This procedure assesses for blockages within the coronary arteries.”
22. The nurse is caring for a client who is scheduled for magnetic resonance imaging (MRI) of the heart. The
client’s history includes a previous myocardial infarction and pacemaker implantation. Which action by the nurse
is most appropriate?
a. Schedule an electrocardiogram just before the MRI.
b. Notify the health care provider before scheduling the MRI.
c. Call the physician and request a laboratory draw for cardiac enzymes.
d. Instruct the client to increase fluid intake the day before the MRI.
, 23. The nurse obtains a pulmonary artery pressure reading of 25/12 mm Hg in a client recovering from a
myocardial infarction. What is the nurse’s first intervention? A. Compare the results with previous readings.
b. Increase the IV fluid rate because these readings are low.
c. Immediately notify the physician of the elevated pressures.
d. Document the finding and continue to monitor.
24. The nurse is preparing to measure a client’s pulmonary artery wedge pressure (PAWP). In what position
will the nurse place the client for the most accurate results? A. Supine, with the head elevated to 45 degrees
b. Supine, with the head elevated to 30 degrees
c. Reverse Trendelenburg position at 15 degrees
d. Supine, with the head of the bed flat
25. The nurse is caring for a client with an 80% blockage of the right coronary artery (RCA). While waiting
for bypass surgery, what is essential for the nurseto have available? A. Furosemide (Lasix)
b. External pacemaker
c. Lidocaine
d. Central venous access
26. The nurse is caring for a client with pericarditis. What assessment finding correlates with this disorder?
a. Pericardial friction rub
b. Systolic murmur
c. Ventricular gallop
d. Paradoxical splitting
27. The nurse is auscultating heart tones on an older client and hears the following sound. What is the nurse’s
best action? (Click the media button to hear the audio clip.) A. Administer a diuretic.
b. Document the finding.
c. Decrease the IV flow rate.
d. Evaluate the medications.
28. The nurse is auscultating cardiac tones. Where should the nurse listen to best hear a cardiac murmur related
to aortic regurgitation? A. Location A
b. Location B
c. Location C
d. Location D
MULTIPLE RESPONSE
1. A client with a history of renal insufficiency is
scheduled for a cardiac catheterization. What does the nurse
expect to do for this client before the catheterization?
(Select all that apply.) A. Insert a Foley catheter.
b. Administer IV fluids.
c. Assess for allergies to iodine.
d. Assess laboratory results.
e. Assess and mark pulses.
f. Insert a central venous catheter.
g. Have the client sign the consent.
2. A female client is admitted to the emergency department. Which symptoms cause the nurse to order an
electrocardiogram? (Select all that apply.) A. Hypertension
b. Fatigue despite adequate rest
System
MULTIPLE CHOICE
1. The nurse is caring for a client who has had a recent myocardial infarction involving the left ventricle. Which
assessment finding is expected? A. Faint S1 and S2 sounds
b. Decreased cardiac output
c. Increased blood pressure
d. Absent peripheral pulses
2. The nurse is caring for a client with coronary artery disease. What assessment finding does the nurse expect if
the client’s mean arterial blood pressure decreases below 60 mm Hg? A. Increased cardiac output
b. Hypertension
c. Chest pain
d. Decreased heart rate
3. The nurse is assessing a client following a myocardial infarction. The client is hypotensive. What
additional assessment finding does the nurse expect? A. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min
4. The nurse administers a beta blocker to a client after a myocardial infarction. What assessment finding does the
nurse expect?
a. Blood pressure increase of 10%
b. Increasing respiratory rate
c. Increased cardiac output
d. Pulse decrease from 100 to 80 beats/min
5. The nurse is assessing clients at a community health center. Which client does the nurse determine is at high
risk for cardiovascular disease?
a. Older adult man with a history of asthma
b. Asian-American man with colorectal cancer
c. American Indian woman with diabetes mellitus
d. Postmenopausal woman on hormone therapy
6. The nurse is obtaining a client’s health history. Which illness alerts the nurse to the possibility of
abnormal heart valves? A. Tuberculosis
b. Recurrent viral pneumonia
c. Rheumatic fever
d. Asthma
7. A nurse is performing an admission assessment on an older adult client with multiple chronic diseases.
The nurse assesses the heart rate to be 48 beats/min. What does the nurse do first? A.
Document the finding in the chart.
b. Evaluate for a pulse deficit.
,c. Assess the client’s medications.
d. Administer 1 mg of atropine.
8. The nurse is assessing clients at a clinic. Which activity takes priority?
a. Teaching smoking cessation to a middle-aged woman who smokes
b. Planning an exercise regimen with a woman with a sedentary lifestyle
c. Teaching an older man who is moderately obese to keep a fooddiary
d. Assessing a man with familial coronary artery disease for specific risk factors
9. The nurse is assessing a client in the emergency department. Which client statement alerts the nurse to the
occurrence of heart failure?
a. “I get short of breath when I climb stairs.”
b. “I see halos floating around my head.”
c. “I have trouble remembering things.”
d. “I have lost weight over the past month.”
10. The nurse is assessing a client newly admitted to the medical unit. Which statement made by the client
alerts the nurse to the presence of edema? A. “I wake up to go to the bathroom at night.”
b. “My shoes fit tighter by the end of the day.”
c. “I seem to be feeling more anxious lately.”
d. “I drink at least eight glasses of water a day.”
11. When obtaining a client’s vital signs, the nurse assesses a blood pressure of 134/88 mm Hg. What is the
nurse’s best intervention?
a. Call the health care provider and report the finding.
b. Reassess the client’s blood pressure at the next yearly physical.
c. Administer an additional antihypertensive medication to the client.
d. Teach the client lifestyle modifications to decrease blood pressure.
12. The nurse is performing a focused cardiac assessment. What assessment finding should be reported to the
health care provider?
a. Bruit heard on the side of the neck
b. Bounding peripheral pulses
c. Pulse rate of 90 beats/min
d. Blood pressure of 140/90 mm Hg
13. A client consistently reports feeling dizzy and lightheaded when moving from a supine position to a sitting
position. What nursing assessment takes priority at this time? A. Pulse oximetry
b. Blood pressure
c. Respiratory rate
d. Neurologic evaluation
14. The nurse is assessing an older adult client who is experiencing a myocardial infarction. What clinical
manifestation does the nurse expect in this client? A. Excruciating pain on inspiration
b. Left lateral chest wall pain
c. Disorientation and confusion
d. Numbness and tingling of the arm
15. A client is newly diagnosed with a heart murmur and asks the nurse to explain what this means. What is the
nurse’s best response?
a. “It is a rushing sound that blood makes moving through narrow places.”
b. “It’s the sound of the heart muscle stretching in an area of weakness.”
,c. “It’s a term doctors use to describe the efficiency of blood circulation.”
d. “It is the sound the heart makes when it is has an increased workload.”
16. A client has returned from a cardiac angiography via the left femoral artery. Two hours after the
procedure, the nurse notes that the left pedal pulse is weak. What is the nurse’s best action? A. Elevate the
leg and apply a sandbag to the entrance site.
b. Increase the flow rate of intravenous fluids.
c. Assess the color and temperature of the left leg.
d. Document the finding as left pedal pulse of +1/4.
17. The nurse is recovering a client after a left-sided cardiac catheterization. What assessment finding requires
immediate intervention?
a. Urinary output less than intake
b. Bruising at the insertion site
c. Slurred speech and confusion
d. Discomfort in the left leg
18. The nurse is preparing a client for a cardiac catheterization. What assessment is a priority before the
procedure?
a. Client’s level of anxiety
b. Ability to turn self in bed
c. Cardiac rhythm and heart rate
d. Allergies to iodine and shellfish
19. The client is scheduled for a resting electrocardiography. Which statement by the client indicates a good
understanding of the preprocedure teaching?
a. “I cannot eat or drink before the electrocardiography.”
b. “I must lie as still as possible during the procedure.”
c. “I am likely to feel warmth as the dye enters the heart.”
d. “I will increase my fluid intake on the day of the procedure.”
20. The nurse is monitoring a client undergoing an exercise electrocardiography (stress test). Which
assessment finding necessitates that the test be stopped? A. Heart rate increases to 140 beats/min
b. Blood pressure of 100/80 mm Hg
c. Respiratory rate exceeds 36 breaths/min
d. Significant ST-segment depression
21. A client who is scheduled for an echocardiography today asks why this test is being performed. What is the
nurse’s best response?
a. “This procedure is a noninvasive way to assess the structure of the heart.”
b. “This procedure assesses for abnormal electrical impulses within the heart.”
c. “This procedure will evaluate the oxygen saturation in your blood.”
d. “This procedure assesses for blockages within the coronary arteries.”
22. The nurse is caring for a client who is scheduled for magnetic resonance imaging (MRI) of the heart. The
client’s history includes a previous myocardial infarction and pacemaker implantation. Which action by the nurse
is most appropriate?
a. Schedule an electrocardiogram just before the MRI.
b. Notify the health care provider before scheduling the MRI.
c. Call the physician and request a laboratory draw for cardiac enzymes.
d. Instruct the client to increase fluid intake the day before the MRI.
, 23. The nurse obtains a pulmonary artery pressure reading of 25/12 mm Hg in a client recovering from a
myocardial infarction. What is the nurse’s first intervention? A. Compare the results with previous readings.
b. Increase the IV fluid rate because these readings are low.
c. Immediately notify the physician of the elevated pressures.
d. Document the finding and continue to monitor.
24. The nurse is preparing to measure a client’s pulmonary artery wedge pressure (PAWP). In what position
will the nurse place the client for the most accurate results? A. Supine, with the head elevated to 45 degrees
b. Supine, with the head elevated to 30 degrees
c. Reverse Trendelenburg position at 15 degrees
d. Supine, with the head of the bed flat
25. The nurse is caring for a client with an 80% blockage of the right coronary artery (RCA). While waiting
for bypass surgery, what is essential for the nurseto have available? A. Furosemide (Lasix)
b. External pacemaker
c. Lidocaine
d. Central venous access
26. The nurse is caring for a client with pericarditis. What assessment finding correlates with this disorder?
a. Pericardial friction rub
b. Systolic murmur
c. Ventricular gallop
d. Paradoxical splitting
27. The nurse is auscultating heart tones on an older client and hears the following sound. What is the nurse’s
best action? (Click the media button to hear the audio clip.) A. Administer a diuretic.
b. Document the finding.
c. Decrease the IV flow rate.
d. Evaluate the medications.
28. The nurse is auscultating cardiac tones. Where should the nurse listen to best hear a cardiac murmur related
to aortic regurgitation? A. Location A
b. Location B
c. Location C
d. Location D
MULTIPLE RESPONSE
1. A client with a history of renal insufficiency is
scheduled for a cardiac catheterization. What does the nurse
expect to do for this client before the catheterization?
(Select all that apply.) A. Insert a Foley catheter.
b. Administer IV fluids.
c. Assess for allergies to iodine.
d. Assess laboratory results.
e. Assess and mark pulses.
f. Insert a central venous catheter.
g. Have the client sign the consent.
2. A female client is admitted to the emergency department. Which symptoms cause the nurse to order an
electrocardiogram? (Select all that apply.) A. Hypertension
b. Fatigue despite adequate rest
