Capillary refill of 3 seconds
A nurse has completed a cardiovascular Rationale:
assessment on a client. Which of the Capillary refill should be less than or equal to 2 seconds. This finding should be
following findings should the nurse report reported to the provider for further evaluation.
to the provider?
A client who has nausea and diaphoresis
Rationale:
A nurse has received change of shift A client who has nausea and diaphoresis should be assessed to evaluate the cause.
report. Which of the following clients Nausea with diaphoresis can be related to a cardiac event, such as a myocardial
should the nurse assess first? infarction, so the nurse should assess this client first.
Have the client lay supine with the head of bed at a 30° angle.
Rationale:
A nurse is assessing a client's jugular veins Having the client positioned supine with the head of their bed at a 30° to 45° angle
and carotid arteries. The nurse should assists the nurse in visualizing the pulsation of the carotid arteries and the jugular
assist the client into which of the following vein.
positions?
Discuss the benefits of meditation with the client
A nurse is assessing a client who reports Rationale:
an increase in their stress level related to The nurse can provide the client with information about meditation, which is a
the demands of their job. Which of the stress-reduction activity. The nurse may also discuss other stress-reduction
following interventions should the nurse activities, such as yoga, guided imagery, or hobbies.
recommend for the client to reduce their
stress?
A forceful chest movement at the midclavicular line in the fourth intercostal
space
Rationale:
A nurse is assessing the anterior chest of a A forceful thrusting movement of the chest at the point of maximal impulse (PMI) is
client. Which of the following findings termed a heave or lift. This finding is associated with an enlarged left ventricle. This
should the nurse report? is an unexpected finding and should be reported to the provider.
Rationale:
Elevate the head of the bed 30° and instruct the client to breath normally is the
first step. The nurse should instruct the client to breath normally and explain to
them that they'll be listening to the heart in several places. The nurse should then
position the client supine with the head of the bed elevated to a 30° angle.
Visualize the anatomy of the heart is the second step. The nurse should
visualize the anatomy of the heart as they auscultate to ensure they are listening in
the correct area.
Place the stethoscope to the right sternal border at the second intercostal
A nurse is auscultating a client's heart space is the third step. The nurse should place the stethoscope to the right sternal
sounds. Place the nursing actions for border at the second intercostal space to begin auscultation of the aortic valve.
auscultation of the heart in the correct Place the stethoscope close to the sternal border at the fourth intercostal
order. (Move the steps into the box on the space is the fourth step. This is the location for auscultation of the tricuspid valve.
right, placing them in the order of Auscultate the apical pulse for 1 min is the fifth step. The last heart sound is the
performance. Use all the steps.) mitral heart sound. This is where the apical pulse is heard and should be
auscultated for 1 min to note rate, rhythm, and presence of the S1 heart sound.
D is correct.
Rationale:
A nurse is auscultating heart sounds. This area, at the apex of the heart, is where sounds generated by the mitral valve
Identify the locations the nurse should between the left atrium and ventricle are best heard and is termed the apical
listen to determine the apical pulse rate. impulse or point of maximal impulse. The mitral heart sound is located at the fifth
(You will find hot spots a=to select on the intercostal space in the left midclavicular area. The nurse should auscultate in this
artwork below. Select only the hot spot that area for 1 min to determine the rate, rhythm and pitch of the apical pulse.
corresponds to your answer.)
A nurse has completed a cardiovascular Rationale:
assessment on a client. Which of the Capillary refill should be less than or equal to 2 seconds. This finding should be
following findings should the nurse report reported to the provider for further evaluation.
to the provider?
A client who has nausea and diaphoresis
Rationale:
A nurse has received change of shift A client who has nausea and diaphoresis should be assessed to evaluate the cause.
report. Which of the following clients Nausea with diaphoresis can be related to a cardiac event, such as a myocardial
should the nurse assess first? infarction, so the nurse should assess this client first.
Have the client lay supine with the head of bed at a 30° angle.
Rationale:
A nurse is assessing a client's jugular veins Having the client positioned supine with the head of their bed at a 30° to 45° angle
and carotid arteries. The nurse should assists the nurse in visualizing the pulsation of the carotid arteries and the jugular
assist the client into which of the following vein.
positions?
Discuss the benefits of meditation with the client
A nurse is assessing a client who reports Rationale:
an increase in their stress level related to The nurse can provide the client with information about meditation, which is a
the demands of their job. Which of the stress-reduction activity. The nurse may also discuss other stress-reduction
following interventions should the nurse activities, such as yoga, guided imagery, or hobbies.
recommend for the client to reduce their
stress?
A forceful chest movement at the midclavicular line in the fourth intercostal
space
Rationale:
A nurse is assessing the anterior chest of a A forceful thrusting movement of the chest at the point of maximal impulse (PMI) is
client. Which of the following findings termed a heave or lift. This finding is associated with an enlarged left ventricle. This
should the nurse report? is an unexpected finding and should be reported to the provider.
Rationale:
Elevate the head of the bed 30° and instruct the client to breath normally is the
first step. The nurse should instruct the client to breath normally and explain to
them that they'll be listening to the heart in several places. The nurse should then
position the client supine with the head of the bed elevated to a 30° angle.
Visualize the anatomy of the heart is the second step. The nurse should
visualize the anatomy of the heart as they auscultate to ensure they are listening in
the correct area.
Place the stethoscope to the right sternal border at the second intercostal
A nurse is auscultating a client's heart space is the third step. The nurse should place the stethoscope to the right sternal
sounds. Place the nursing actions for border at the second intercostal space to begin auscultation of the aortic valve.
auscultation of the heart in the correct Place the stethoscope close to the sternal border at the fourth intercostal
order. (Move the steps into the box on the space is the fourth step. This is the location for auscultation of the tricuspid valve.
right, placing them in the order of Auscultate the apical pulse for 1 min is the fifth step. The last heart sound is the
performance. Use all the steps.) mitral heart sound. This is where the apical pulse is heard and should be
auscultated for 1 min to note rate, rhythm, and presence of the S1 heart sound.
D is correct.
Rationale:
A nurse is auscultating heart sounds. This area, at the apex of the heart, is where sounds generated by the mitral valve
Identify the locations the nurse should between the left atrium and ventricle are best heard and is termed the apical
listen to determine the apical pulse rate. impulse or point of maximal impulse. The mitral heart sound is located at the fifth
(You will find hot spots a=to select on the intercostal space in the left midclavicular area. The nurse should auscultate in this
artwork below. Select only the hot spot that area for 1 min to determine the rate, rhythm and pitch of the apical pulse.
corresponds to your answer.)
