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Chapter 21: Assessment of Cardiovascular Function
1. A nurse is describing the process by which blood is ejected into circulation as the
chambers of the heart become smaller. The instructor categorizes this as what action?
A. Systole
B. Diastole
C. Repolarization
D. Ejection fraction
om
ANS: A
Rationale: Systole is the action of the chambers of the heart becoming smaller and
ejecting blood. This action of the heart is not diastole (relaxation), ejection fraction (the
.c
amount of blood expelled), or repolarization (electrical charging).
PTS: 1 REF: p. 651
ks
NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client
an
Needs: Physiological Integrity: Physiological Adaptation
TOP: Chapter 21: Assessment of Cardiovascular Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
tb
NOT: Multiple Choice
es
2. During a shift assessment, the nurse is identifying the client's point of maximum
impulse (PMI). Where should the nurse best palpate the PMI?
A. Left midclavicular line of the chest at the level of the nipple
bt
B. Left midclavicular line of the chest at the fifth intercostal space
C. Midline between the xiphoid process and the left nipple
D. Two to three centimeters to the left of the sternum
ANS: B
Rationale: The left ventricle is responsible for the apical beat or the point of maximum
impulse, which is normally palpated in the left midclavicular line of the chest wall at
the
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fifth intercostal space.
PTS: 1 REF: p. 653
NAT: Client Needs: Physiological Integrity: Physiological Adaptation
TOP: Chapter 21: Assessment of Cardiovascular Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice
3. The nurse is calculating a cardiac client's pulse pressure. If the client's blood pressure
is 122/76 mm Hg, what is the client's pulse pressure?
om
A. 46 mm Hg
B. 99 mm Hg
C. 198 mm Hg
D. 76 mm Hg
.c
ANS: A
ks
Rationale: Pulse pressure is the difference between the systolic and diastolic pressure. In
an
this case, this value is 46 mm Hg.
PTS: 1 REF: p. 665
tb
NAT: Client Needs: Physiological Integrity: Physiological Adaptation
TOP: Chapter 21: Assessment of Cardiovascular Function
es
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze
NOT: Multiple Choice
bt
4. A client has been admitted to the intensive care unit (ICU) after an ischemic stroke,
and a central venous pressure (CVP) monitoring line was placed. The nurse notes a low
CVP. Which condition is the most likely reason for a low CVP?
A. Hypovolemia
B. Myocardial infarction (MI)
C. Left-sided heart failure
D. Aortic valve regurgitation
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ANS: A
Rationale: CVP is a measurement of the pressure in the vena cava or right atrium. A low
CVP indicates a reduced right ventricular preload, most often from hypovolemia. An MI is
an unlikely cause of low CVP. CVP measures the right side of the heart, so left-sided
failure is unlikely to affect CVP. Aortic valve regurgitation is a less likely cause of low CVP.
PTS: 1 REF: p. 685
NAT: Client Needs: Physiological Integrity: Physiological Adaptation
om
TOP: Chapter 21: Assessment of Cardiovascular Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze
NOT: Multiple Choice
.c
5. While auscultating a client's heart sounds, the nurse hears an extra heart sound
immediately after the second heart sound (S2). An audible S3 would be considered an
expected finding in which client?
ks
A. A 47-year-old client
an
B. A 20-year-old client
C. A client who has undergone valve replacement
D. A client who takes a beta-adrenergic blocker
tb
ANS: B
es
Rationale: S3 represents a normal finding in children and adults up to 35 or 40 years of
age. In these cases, it is called a physiologic S3. It is an abnormal finding in a client with
bt
an artificial valve, an adult older than 40 years of age, or a client who takes a beta
blocker.
PTS: 1 REF: p. 669
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 21: Assessment of Cardiovascular Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice
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6. The physical therapist notifies the nurse that a client with coronary artery disease
(CAD) experienced a significant increase in heart rate during physical therapy. The nurse
recognizes that an increase in heart rate in a client with CAD may result in which
outcome?
A. Development of an atrial–septal defect
B. Myocardial ischemia
C. Formation of a pulmonary embolism
D. Release of potassium ions from cardiac cells
om
ANS: B
Rationale: Unlike other arteries, the coronary arteries are perfused during diastole. An
increase in heart rate shortens diastole and can decrease myocardial perfusion. Clients,
.c
particularly those with CAD, can develop myocardial ischemia. An increase in heart rate
will not usually result in a pulmonary embolism or create electrolyte imbalances.
Atrial-septal defects are congenital.
ks
an
PTS: 1 REF: p. 661
NAT: Client Needs: Physiological Integrity: Physiological Adaptation
TOP: Chapter 21: Assessment of Cardiovascular Function
tb
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice
es
7. The nurse is caring for a client who has a history of heart disease. What factor should
the nurse identify as possibly contributing to a decrease in cardiac output?
bt
A. A change in position from standing to sitting
B. A heart rate of 54 bpm
C. A pulse oximetry reading of 94%
D. An increase in preload related to ambulation
ANS: B
Rationale: Cardiac output is computed by multiplying the stroke volume by the heart
btestbanks.com
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Chapter 21: Assessment of Cardiovascular Function
1. A nurse is describing the process by which blood is ejected into circulation as the
chambers of the heart become smaller. The instructor categorizes this as what action?
A. Systole
B. Diastole
C. Repolarization
D. Ejection fraction
om
ANS: A
Rationale: Systole is the action of the chambers of the heart becoming smaller and
ejecting blood. This action of the heart is not diastole (relaxation), ejection fraction (the
.c
amount of blood expelled), or repolarization (electrical charging).
PTS: 1 REF: p. 651
ks
NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client
an
Needs: Physiological Integrity: Physiological Adaptation
TOP: Chapter 21: Assessment of Cardiovascular Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
tb
NOT: Multiple Choice
es
2. During a shift assessment, the nurse is identifying the client's point of maximum
impulse (PMI). Where should the nurse best palpate the PMI?
A. Left midclavicular line of the chest at the level of the nipple
bt
B. Left midclavicular line of the chest at the fifth intercostal space
C. Midline between the xiphoid process and the left nipple
D. Two to three centimeters to the left of the sternum
ANS: B
Rationale: The left ventricle is responsible for the apical beat or the point of maximum
impulse, which is normally palpated in the left midclavicular line of the chest wall at
the
btestbanks.com
Downloaded by CyberTestBanks Customer Service ()
, lOMoARcPSD|30158206
fifth intercostal space.
PTS: 1 REF: p. 653
NAT: Client Needs: Physiological Integrity: Physiological Adaptation
TOP: Chapter 21: Assessment of Cardiovascular Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice
3. The nurse is calculating a cardiac client's pulse pressure. If the client's blood pressure
is 122/76 mm Hg, what is the client's pulse pressure?
om
A. 46 mm Hg
B. 99 mm Hg
C. 198 mm Hg
D. 76 mm Hg
.c
ANS: A
ks
Rationale: Pulse pressure is the difference between the systolic and diastolic pressure. In
an
this case, this value is 46 mm Hg.
PTS: 1 REF: p. 665
tb
NAT: Client Needs: Physiological Integrity: Physiological Adaptation
TOP: Chapter 21: Assessment of Cardiovascular Function
es
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze
NOT: Multiple Choice
bt
4. A client has been admitted to the intensive care unit (ICU) after an ischemic stroke,
and a central venous pressure (CVP) monitoring line was placed. The nurse notes a low
CVP. Which condition is the most likely reason for a low CVP?
A. Hypovolemia
B. Myocardial infarction (MI)
C. Left-sided heart failure
D. Aortic valve regurgitation
btestbanks.com
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, lOMoARcPSD|30158206
ANS: A
Rationale: CVP is a measurement of the pressure in the vena cava or right atrium. A low
CVP indicates a reduced right ventricular preload, most often from hypovolemia. An MI is
an unlikely cause of low CVP. CVP measures the right side of the heart, so left-sided
failure is unlikely to affect CVP. Aortic valve regurgitation is a less likely cause of low CVP.
PTS: 1 REF: p. 685
NAT: Client Needs: Physiological Integrity: Physiological Adaptation
om
TOP: Chapter 21: Assessment of Cardiovascular Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze
NOT: Multiple Choice
.c
5. While auscultating a client's heart sounds, the nurse hears an extra heart sound
immediately after the second heart sound (S2). An audible S3 would be considered an
expected finding in which client?
ks
A. A 47-year-old client
an
B. A 20-year-old client
C. A client who has undergone valve replacement
D. A client who takes a beta-adrenergic blocker
tb
ANS: B
es
Rationale: S3 represents a normal finding in children and adults up to 35 or 40 years of
age. In these cases, it is called a physiologic S3. It is an abnormal finding in a client with
bt
an artificial valve, an adult older than 40 years of age, or a client who takes a beta
blocker.
PTS: 1 REF: p. 669
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 21: Assessment of Cardiovascular Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice
btestbanks.com
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, lOMoARcPSD|30158206
6. The physical therapist notifies the nurse that a client with coronary artery disease
(CAD) experienced a significant increase in heart rate during physical therapy. The nurse
recognizes that an increase in heart rate in a client with CAD may result in which
outcome?
A. Development of an atrial–septal defect
B. Myocardial ischemia
C. Formation of a pulmonary embolism
D. Release of potassium ions from cardiac cells
om
ANS: B
Rationale: Unlike other arteries, the coronary arteries are perfused during diastole. An
increase in heart rate shortens diastole and can decrease myocardial perfusion. Clients,
.c
particularly those with CAD, can develop myocardial ischemia. An increase in heart rate
will not usually result in a pulmonary embolism or create electrolyte imbalances.
Atrial-septal defects are congenital.
ks
an
PTS: 1 REF: p. 661
NAT: Client Needs: Physiological Integrity: Physiological Adaptation
TOP: Chapter 21: Assessment of Cardiovascular Function
tb
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice
es
7. The nurse is caring for a client who has a history of heart disease. What factor should
the nurse identify as possibly contributing to a decrease in cardiac output?
bt
A. A change in position from standing to sitting
B. A heart rate of 54 bpm
C. A pulse oximetry reading of 94%
D. An increase in preload related to ambulation
ANS: B
Rationale: Cardiac output is computed by multiplying the stroke volume by the heart
btestbanks.com
Downloaded by CyberTestBanks Customer Service ()
