N125 Exam need to study Questions Solved
100% Correct |Verified Answers
What are the four techniques of assessment? Which are used for a cardiac and neck
vessel assessment? - ANSWER Inspection, Palpation, Auscultation, and Percussion
Inspection, palpation, and auscultation are used for a cardiac and neck vessel
assessment
The sac that surrounds and protects the heart is called the ___ - ANSWER pericardium
The component of the conduction system referred to as the pacemaker of the heart is
the ___ - ANSWER SA node
The electrical stimulus of the cardiac cycle follows which sequence: - ANSWER SA node -
AV node - bundle of his - bundle branches (aka Perkinje fibers)
The findings from an assessment of a 70-year old patient with swelling in his ankles
include jugular venous pulsations 5 cm above the sternal angle when the head of his bed
is elevated above 45 degrees. The nurse knows that this finding indicated: - ANSWER
elevated pressure related to heart failure
True or false: It is important to document the heart sounds in precisely the correct
locations to accurately correlate those sounds with particular valves - ANSWER false
What are the layers of the heart wall, from the outside to the inside of the heart? -
ANSWER pericardium, myocardium, endocardium
Where are each of the heart valves located? What controls their opening and closing? -
ANSWER Tricuspid is between right atrium and right ventricle
,Pulmonic valve is between right ventricle and pulmonary artery
Mitral is between left atrium and left ventricle
Aortic valve is between left ventricle and aorta
Opening and closing of valves is controlled by blood pressure changes
What are leaflets in the heart? What controls them? - ANSWER Flaps of tissue (2 or 3
per valve) that make up valves and keep the flow of blood in one direction. Chordae
tendineae control them.
What are the three kinds of circulation in the circulatory system? Where are they
located? - ANSWER Pulmonic circulation: the right side of the heart and the lungs
Systemic circulation: the left side of the heart and the rest of the body
Coronary circulation: outside of the heart (to nourish the heart itself)
Which valves close during S1? During S2? Where can you best hear this in the heart? -
ANSWER S1: closure of atrioventricular valves (mitral and tricuspid), heard loudest at
the apex
S2: closure of semilunar valves (aortic and pulmonary), heard loudest at the base
How would we clinically differentiate between preload and afterload? - ANSWER
Preload is the stretch associated with the volume that comes back to the heart, low in
someone with low blood volume
Afterload is the resistance that the ventricles have to pump against to get the blood out
to the body. Someone with high vasoconstriction would have high afterload.
Define "cardiac output" - ANSWER The amount of blood the heart pumps in one minute.
It can be found by multiplying the heart rate and the stroke volume.
, In the neck, where are the coronary arteries, internal jugular veins, and external jugular
veins found? - ANSWER Coronary arteries and internal jugular veins are found inside the
sternocleidomastoid muscle. The external jugular vein is found outside the
sternocleidomastoid muscle.
What is hemoptysis? - ANSWER Spitting or coughing up blood
What subjective data should be collected for a heart and neck vessel assessment? (11
things) - ANSWER 1. Chest pain: PQRSTU, had it before, associated symptoms
2. Dyspnea: after how much activity, change over time, positional, wake you up, ADLs
3. Orthopnea: how many pillows
4. Cough: OLDCART, associated factors, sputum characteristics
5. Fatigue: tire easily, onset, timing in day
6. Cyanosis or pallor
7. Edema (swelling in feet or legs): onset, changes, timing, symmetry, relief factors,
associated symptoms
8. Nocturia (frequently having to get up at night to pee)
9. Cardiac history: diseases and tests
10. Family cardiac history
11. Patient-centered care (nutrition, smoking, alcohol, exercise)
What is orthopnea? Why does it occur? - ANSWER Difficulty breathing when lying down.
Fluid moves down to the base of the lungs when sitting up. When laying down, the fluid
is covering a much larger surface area of the lung, impeding gas exchange.
What objective data should be collected for a heart and neck vessel assessment? (4
categories) - ANSWER 1) Carotid arteries (palpate, auscultate for bruit)
2) Jugular veins (inspect external jugular veins with a light)
100% Correct |Verified Answers
What are the four techniques of assessment? Which are used for a cardiac and neck
vessel assessment? - ANSWER Inspection, Palpation, Auscultation, and Percussion
Inspection, palpation, and auscultation are used for a cardiac and neck vessel
assessment
The sac that surrounds and protects the heart is called the ___ - ANSWER pericardium
The component of the conduction system referred to as the pacemaker of the heart is
the ___ - ANSWER SA node
The electrical stimulus of the cardiac cycle follows which sequence: - ANSWER SA node -
AV node - bundle of his - bundle branches (aka Perkinje fibers)
The findings from an assessment of a 70-year old patient with swelling in his ankles
include jugular venous pulsations 5 cm above the sternal angle when the head of his bed
is elevated above 45 degrees. The nurse knows that this finding indicated: - ANSWER
elevated pressure related to heart failure
True or false: It is important to document the heart sounds in precisely the correct
locations to accurately correlate those sounds with particular valves - ANSWER false
What are the layers of the heart wall, from the outside to the inside of the heart? -
ANSWER pericardium, myocardium, endocardium
Where are each of the heart valves located? What controls their opening and closing? -
ANSWER Tricuspid is between right atrium and right ventricle
,Pulmonic valve is between right ventricle and pulmonary artery
Mitral is between left atrium and left ventricle
Aortic valve is between left ventricle and aorta
Opening and closing of valves is controlled by blood pressure changes
What are leaflets in the heart? What controls them? - ANSWER Flaps of tissue (2 or 3
per valve) that make up valves and keep the flow of blood in one direction. Chordae
tendineae control them.
What are the three kinds of circulation in the circulatory system? Where are they
located? - ANSWER Pulmonic circulation: the right side of the heart and the lungs
Systemic circulation: the left side of the heart and the rest of the body
Coronary circulation: outside of the heart (to nourish the heart itself)
Which valves close during S1? During S2? Where can you best hear this in the heart? -
ANSWER S1: closure of atrioventricular valves (mitral and tricuspid), heard loudest at
the apex
S2: closure of semilunar valves (aortic and pulmonary), heard loudest at the base
How would we clinically differentiate between preload and afterload? - ANSWER
Preload is the stretch associated with the volume that comes back to the heart, low in
someone with low blood volume
Afterload is the resistance that the ventricles have to pump against to get the blood out
to the body. Someone with high vasoconstriction would have high afterload.
Define "cardiac output" - ANSWER The amount of blood the heart pumps in one minute.
It can be found by multiplying the heart rate and the stroke volume.
, In the neck, where are the coronary arteries, internal jugular veins, and external jugular
veins found? - ANSWER Coronary arteries and internal jugular veins are found inside the
sternocleidomastoid muscle. The external jugular vein is found outside the
sternocleidomastoid muscle.
What is hemoptysis? - ANSWER Spitting or coughing up blood
What subjective data should be collected for a heart and neck vessel assessment? (11
things) - ANSWER 1. Chest pain: PQRSTU, had it before, associated symptoms
2. Dyspnea: after how much activity, change over time, positional, wake you up, ADLs
3. Orthopnea: how many pillows
4. Cough: OLDCART, associated factors, sputum characteristics
5. Fatigue: tire easily, onset, timing in day
6. Cyanosis or pallor
7. Edema (swelling in feet or legs): onset, changes, timing, symmetry, relief factors,
associated symptoms
8. Nocturia (frequently having to get up at night to pee)
9. Cardiac history: diseases and tests
10. Family cardiac history
11. Patient-centered care (nutrition, smoking, alcohol, exercise)
What is orthopnea? Why does it occur? - ANSWER Difficulty breathing when lying down.
Fluid moves down to the base of the lungs when sitting up. When laying down, the fluid
is covering a much larger surface area of the lung, impeding gas exchange.
What objective data should be collected for a heart and neck vessel assessment? (4
categories) - ANSWER 1) Carotid arteries (palpate, auscultate for bruit)
2) Jugular veins (inspect external jugular veins with a light)
