Med Surge Success Test 1
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1. The 45-year old male client
diagnosed with essential
hypertension had decided not
to take his medications. The
client's BP is 178/94 indicating a
perfusion issue. Which question
should the nurse ask the client
first?
1. "Do you have the money to
buy your medication?"
2. "Does the medication give
unwanted side effects?"
3. "Did you quit taking the
medications because you don't
feel bad?"
4. Can you tell me why you
stopped taking the
medication?"
2. Along with persistent, crushing
chest pain, which
signs/symptoms would make
the nurse suspect that the client
is experiencing a myocardial
infarction?
1. Midepigastric pain and
pyrosis.
2. Diaphoresis and cool clammy
skin.
3. Intermittent claudication and
pallor.
4. Jugular vein distention and
dependent edema.
3. The charge nurse is making
assignments for clients on a
cardiac unit. Which client should
the charge nurse assign to a
new graduate nurse?
1. The 44-year-old client
diagnosed with a myocardial
infarction.
2. The 65-year-old client
admitted with unstable angina.
3. The 75-year-old client
scheduled for a cardiac
catheterization.
4. The 50-year-old client
complaining of chest pain.
2. "Does the medication
give unwanted side
effects?"
This is a mild way of
introducing the subject of
side effects to a client not
wishing to admit
medication causes
unwanted effects. It opens
the door to more probing
assessment questions.
2. Diaphoresis and cool
clammy skin.
Diaphoresis is a systemic
reaction to the MI. The
body vasoconstrics to
shunt blood from the
periphery to the trunk of
the body and causes cold,
clammy skin.
3. The 75-year-old client
scheduled for a cardiac
catheterization.
A new graduate should be
able to complete a pre
procedure checklist and
get this client to the cath
lab
4. The charge nurse is making shift 3. The client with an
assignments for the medical floor. apical pulse rate of
Which client should be assigned to 116, a respiratory rate
the most experienced registered of 26, and a blood
nurse? pressure of 94/62.
1. The client diagnosed with this client is is
congestive heart failure who is being exhibiting signs and
discharged in the symptoms of shock,
morning. the client is
2. The client who is having frequent becoming unstable &
incontinent liquid bowel movements needs an
and experienced nurse.
vomiting.
3. The client with an apical pulse rate
of 116, a respiratory rate of 26, and a
blood
pressure of 94/62.
4. The client who is complaining of
chest pain with inspiration and a
nonproductive
cough.
5. The client comes to the emergency 1. "Can you describe
department saying, "I am having a your chest pain?"
heart attack." Which question is most
pertinent when assessing the client?
1. "Can you describe your chest
pain?"
2. "What were you doing when the
pain started?"
3. "Did you have a high-fat meal
today?"
4. "Does the pain get worse when
you lie down?"
6. The client diagnosed with a 1. "Your heart is
myocardial infarction asks the nurse, damaged and needs
"Why do I have to rest and take it about four (4) to six
easy? My chest doesn't hurt (6) weeks to heal."
anymore." Which statement would
be the nurse's best response? The heart tissue is
dead, stress or
1. "Your heart is damaged and needs activity may cause
about four (4) to six (6) weeks to heart failure, and it
heal." does take about 6
2. "There is necrotic myocardial weeks for scar tissue
tissue that puts you at risk for to form.
dysrhythmias."
3. "Your doctor has ordered bedrest. #4 is incorrect
Therefore, you must stay in the bed." because this is a
4. "Just because your chest doesn't condescending
hurt anymore doesn't mean you are response, telling a
out of patient that they are
danger." in danger is
inappropriate.
7. The client diagnosed with a
myocardial infarction is on bedrest.
The unlicensed assistive personnel
(UAP) is encouraging the client to
move the legs. Which action should
the nurse implement?
1. Instruct the UAP to stop
encouraging the leg movements.
2. Report this behavior to the
charge nurse as soon as possible.
3. Praise the UAP for encouraging
the client to move legs.
4. Take no action concerning the
UAP's behavior.
8. The client diagnosed with a
myocardial infarction is six (6) hours
post-right femoral percutaneous
transluminal coronary angioplasty
(PTCA), also known as balloon
surgery. Which assessment data
would require immediate
intervention by the nurse?
1. The client is keeping the affected
extremity straight.
2. The pressure dressing to the
right femoral area is intact. 3. The
client is complaining of numbness
in the right foot. 4. The client's right
pedal pulse is 3+ and bounding.
9. The client diagnosed with a
myocardial infarction (MI) is being
discharged. Which discharge
instructions should the nurse teach
the client?
1. Call the health care provider if
any chest pain happens.
2. Discuss when the client can
resume sexual activity.
3. Explain the pharmacology of
nitroglycerin tablets.
4. Encourage the client to sleep
with the head of bed elevated.
3. Praise the UAP for 10.
encouraging the client
to move legs.
The nurse should
praise and encourage
UAP's to participate in
the client's care.
Clients on bedrest are
at risk for DVT and
moving the legs helps
prevent this from
occurring.
3. The client is
complaining of 11.
numbness in the right
foot.
2. Discuss when the
client can resume
sexual activity.
The nurse should make
sure the client is aware
of when sexual activity
can be safely resumed.
12.
The client diagnosed with an ST
elevation myocardial infarction
(STEMI) has developed 2+ edema
bilaterally of the lower
extremities and has crackles in
all lung fields. Which should the
nurse implement first?
1. Notify the healthcare provider.
2. Assess what the client ate at
the last meal.
3. Request a STAT 12 lead
echocardiogram.
4. Administer furosemide IVP.
The client diagnosed with
congestive heart failure is
complaining of leg cramps at
night. Which nursing
interventions should be
implemented?
1. Check the client for peripheral
edema and make sure the client
takes a diuretic
early in the day.
2. Monitor the client's potassium
level and assess the client's
intake of bananas and
orange juice.
3. Determine if the client has
gained weight and instruct the
client to keep the legs
elevated.
4. Instruct the client to ambulate
frequently and perform calf-
muscle stretching
exercises daily.
The client diagnosed with
pericarditis is being discharged
home. Which intervention should
the nurse include in the
discharge teaching?
1. Be sure to allow for
uninterrupted rest and sleep.
2. Refer client to outpatient
occupational therapy.
3. Maintain oxygen via nasal
cannula at two (2) L/min.
4. Discuss upcoming valve
replacement surgery.
1. Notify the healthcare
provider.
"Has developed"
indicates a new issue; the
nurse should notify the
HCP of the assessment
findings, which indicates
the patient is in heart
failure.
#4 is incorrect because it
is not what should be
done first, although
furosemide may be an
intervention.
2. Monitor the client's
potassium level and
assess the client's intake
of bananas and
orange juice.
The probable cause of
leg cramping is
potassium excretion as a
result of diuretic
medications. Bananas
and orange juice are high
in potassium for a patient
on diuretics.
1. Be sure to allow for
uninterrupted rest and
sleep.
Uninterrupted rest and
sleep help decrease the
workload of the heart
and help ensure the
restoration of physical
and emotional health.
13. The client diagnosed with
pericarditis is complaining
of increased pain. Which
intervention should the
nurse implement first?
1. Administer oxygen via
nasal cannula.
2. Evaluate the client's
urinary output.
3. Assess the client for
cardiac complications.
4. Encourage the client to
use the incentive
spirometer.
14. The client diagnosed with
pericarditis is experiencing
cardiac tamponade. Which
collaborative intervention
should the nurse anticipate
for this client?
1. Prepare for a
pericardiocentesis.
2. Request STAT cardiac
enzymes.
3. Perform a 12-lead
electrocardiogram.
4. Assess the client's heart
and lung sounds.
15. The client diagnosed with
rule-out myocardial
infarction is experiencing
chest pain while walking to
the bathroom. Which action
should the nurse implement
first?
1. Administer sublingual
nitroglycerin.
2. Obtain a STAT
electrocardiogram.
3. Have the client sit down
immediately.
4. Assess the client's vital
signs.
3. Assess the client for
cardiac complications.
The nurse must assess to
determine if pain is expected
secondary to pericarditis or if
the pain is indicative of a
complication that requires
intervention from the
healthcare provider.
1. Prepare for a
pericardiocentesis.
Pericardiocentesis removes
fluid from pericardial sac and
is an emergency treatment for
cardiac tamponade.
3. Have the client sit down
immediately.
16. The client has an 3. Carry the cell phone on the
implantable cardioverter opposite side of the ICD.
defibrillator (ICD). Which
discharge instructions Cell phones interfere with the
should the nurse teach the functioning of the ICD if they
client? are too close to it.
1. Do not lift or carry more
than 23 kg.
2. Have someone drive the
car for the rest of your
life.
3. Carry the cell phone on
the opposite side of the
ICD. 4. Avoid using the
microwave oven in the
home.
17. The client has chronic 1. Instruct the client to use a
atrial fibrillation. Which soft-bristle toothbrush.
discharge teaching should
the nurse discuss with the A client with chronic a-fib will
client? be taking anticoagulant therapy
to prevent clot formation.
1. Instruct the client to use Therefore, the client is at risk for
a soft-bristle toothbrush. bleeding and should use a soft-
2. Discuss the importance bristle tooth brush
of getting a monthly
partial thromboplastin
time (PTT). 3. Teach the
client about signs of
pacemaker malfunction.
4. Explain to the client the
procedure for
synchronized
cardioversion.
18. The client has just had a 1. Monitor vital signs every 15
pericardiocentesis. Which minutes for the first hour.
interventions should the 2. Assess the client's heart and
nurse implement? Select lung sounds.
all that apply. 3. Record the amount of fluid
removed as output.
1. Monitor vital signs every 4. Evaluate the client's cardiac
15 minutes for the first rhythm.
hour.
2. Assess the client's heart All of the above are necessary
and lung sounds. after a pericardiocentesis
3. Record the amount of except keeping the patient in a
fluid removed as output. supine position. Patient must be
4. Evaluate the client's semi-fowlers.
cardiac rhythm.
5. Keep the client in the
supine position.
19. The client has just returned
from a cardiac catheterization.
Which assessment data would
warrant immediate
intervention from the nurse?
1. The client's BP is 110/70 and
pulse is 90.
2. The client's groin dressing is
dry and intact.
3. The client refuses to keep
the leg straight.
4. The client denies any
numbness and tingling.
20. The client is admitted to the
emergency department, and
the nurse suspects a cardiac
problem. Which assessment
interventions should the nurse
implement? Select all that
apply.
1. Obtain a midstream urine
specimen.
2. Attach telemetry monitor
to the client.
3. Start a saline lock in the
right arm.
4. Draw a basal metabolic
panel (BMP).
5. Request an order for a
STAT 12-lead ECG.
21. The client is admitted to the
medical unit to rule out
carditis. Which question
should the nurse ask the
client during the admission
interview to support this
diagnosis?
1. "Have you had a sore throat
in the last month?"
2. "Did you have rheumatic
fever as a child?"
3. "Do you have a family
history of carditis?"
4. "What over-the-counter
(OTC) medications do you
take?"
3. The client refuses to keep
the leg straight.
If the client bends the leg, it
could cause the insertion
site to bleed. This is arterial
blood & the client could
bleed to death very quickly,
this requires immediate
intervention.
2. Attach telemetry monitor
to the client.
3. Start a saline lock in the
right arm.
5. Request an order for a
STAT 12-lead ECG
A saline lock is needed to
administer medications IV
so a saline lock in the right
arm is appropriate
2. "Did you have rheumatic
fever as a child?"
Rheumatic fever is an
autoimmune response that
can cause peridcarditis
22. The client is admitted to 1. Apical pulse rate of 110 and 4+
the telemetry unit pitting edema of feet.
diagnosed with acute
exacerbation of
congestive heart failure
(CHF). Which
signs/symptoms would
the nurse expect to find
when assessing this
client?
1. Apical pulse rate of 110
and 4+ pitting edema of
feet.
2. Thick white sputum and
crackles that clear with
cough.
3. The client sleeping with
no pillow and eupnea.
4. Radial pulse rate of 90
and capillary refill time <3
seconds.
23. The client is diagnosed 1. Muffled heart sounds.
with acute pericarditis.
Which sign/symptom Muffled heart sounds are
warrants immediate indicative to acute pericarditis
attention by the nurse?
1. Muffled heart sounds.
2. Nondistended jugular
veins.
3. Bounding peripheral
pulses.
4. Pericardial friction rub.
24. The client is diagnosed 3. Ask the client to lean forward
with pericarditis. When and listen again.
assessing the client, the
nurse is unable to Having the client lean forward
auscultate a friction rub. and to the left using gravity to
Which action should the force the heart nearer to the
nurse implement? chest wall, which allows the
1. Notify the health-care friction rub to be heard. The
provider. nurse should attempt to hear
2. Document that the the friction rub in multiple ways
pericarditis has resolved. before documenting that it is
3. Ask the client to lean not heard.
forward and listen again.
4. Prepare to insert a
unilateral chest tube.
25. The client is diagnosed with
pericarditis. Which are the
most common signs/symptoms
the nurse would expect to find
when assessing the client?
1. Pulsus paradoxus.
2. Complaints of fatigue and
arthralgias.
3. Petechiae and splinter
hemorrhages.
4. Increased chest pain with
inspiration.
26. The client is exhibiting sinus
bradycardia, is complaining of
syncope and weakness, and
has a BP of 98/60. Which
collaborative treatment
should the nurse anticipate
being implemented?
1. Administer a thrombolytic
medication.
2. Assess the client's
cardiovascular status.
3. Prepare for insertion of a
pacemaker.
4. Obtain a permit for
synchronized cardioversion.
27. The client is exhibiting
ventricular tachycardia. Which
intervention should the nurse
implement first?
1. Administer lidocaine, an
antidysrhythmic, IVP.
2. Prepare to defibrillate the
client.
3. Assess the client's apical
pulse and blood pressure.
4. Start basic cardiopulmonary
resuscitation.
28. The client is experiencing
multifocal premature
ventricular contractions.
Which antidysrhythmic
medication would the nurse
expect the health-care
provider to order for this
client?
1. Amiodarone.
2. Atropine.
3. Digoxin.
4. Adenosine.
4. Increased chest pain 29.
with inspiration.
Chest pain is the most
common symptom of
pericarditis, usually an
abrupt onset and is
aggravated by respiratory
movements (coughing,
change in movement, &
swallowing)
30.
3. Prepare for insertion of a
pacemaker.
31.
3. Assess the client's apical
pulse and blood pressure.
The nurse must assess
apical pulse and blood
pressure to determine if
patient is in cardiac arrest
and then treat ventricular
fibrillation .
32.
1. Amiodarone
Amiodarone is drug of
choice for ventricular
arrhythmias.
The client is in complete heart 2. Administer
block. Which intervention should the atropine, an
nurse implement first? antidysrhythmic.
1. Prepare to insert a pacemaker. Atropine will
2. Administer atropine, an decrease vagal
antidysrhythmic. stimulating and
3. Obtain a STAT electrocardiogram increase heart rate,
(ECG). therefore it is the first
4. Notify the health-care provider. intervention.
The client is in ventricular 1. Start
fibrillation. Which interventions cardiopulmonary
should the nurse implement? Select resuscitation.
all that apply. 3. Prepare to
defibrillate the client.
1. Start cardiopulmonary 4. Bring the crash
resuscitation. cart to the bedside.
2. Prepare to administer the 5. Prepare to
antidysrhythmic adenosine IVP. administer the
3. Prepare to defibrillate the client. antidysrhythmic
4. Bring the crash cart to the amiodarone IVP.
bedside.
5. Prepare to administer the
antidysrhythmic amiodarone IVP.
The client is one (1) day 2. Assess the client's
postoperative coronary artery chest dressing and
bypass surgery. The client complains vital signs.
of chest pain. Which intervention
should the nurse implement first? #4 is incorrect
because a nurse
1. Medicate the client with should assess the
intravenous morphine. patient first, not a
2. Assess the client's chest dressing machine
and vital signs.
3. Encourage the client to turn from
side to side.
4. Check the client's telemetry
monitor.
The client is scheduled for a right 2. Assess the client's
femoral cardiac catheterization. neurovascular status.
Which nursing intervention should
the nurse implement after the The nurse should
procedure? make sure blood is
circulating properly
1. Perform passive range-of-motion & check for the 6 P's.
exercises.
2. Assess the client's neurovascular
status.
3. Keep the client in high Fowler's
position.
4. Assess the gag reflex prior to
feeding the client.
33. The client is three (3)
hours post-myocardial
infarction. Which data
would warrant immediate
intervention by the
nurse?
1. Bilateral peripheral
pulses 2+.
2. The pulse oximeter
reading is 96%.
3. The urine output is 240
mL in the last four (4)
hours.
4. Cool, clammy,
diaphoretic skin.
34. The client shows
ventricular fibrillation on
the telemetry at the
nurse's station. Which
action should the
telemetry nurse
implement first?
1. Administer epinephrine
IVP.
2. Prepare to defibrillate
the client.
3. Call a STAT code.
4. Start cardiopulmonary
resuscitation.
35. The client's telemetry
reading shows a P wave
before each QRS
complex and the rate is
78. Which action should
the nurse implement?
1. Document this as
normal sinus rhythm.
2. Request a 12-lead
electrocardiogram.
3. Prepare to administer
the cardiotonic digoxin
PO.
4. Assess the client's
cardiac enzymes.
4. Cool, clammy, diaphoretic 36.
skin.
Cold clammy skin is an indicator
of carcinogenic shock which is a
complication of MI and warrants
immediate intervention
37.
3. Call a STAT code.
The nurse must call a code that
activates the crash cart being
brought to the room and a team
of health-care providers that will
care for the client according to
an established protocol.
38.
1. Document this as normal sinus
rhythm.
The client who has had a 3. Cardiac rehabilitation.
myocardial infarction is admitted
to the telemetry unit from
intensive care. Which referral
would be most appropriate for
the client?
1. Social worker.
2. Physical therapy.
3. Cardiac rehabilitation.
4. Occupational therapy.
The client who is one (1) day 4. Determine if the client
postoperative coronary artery is having pain.
bypass surgery is exhibiting sinus
tachycardia. Which intervention Sinus tach means the
should the nurse implement? sinoatrial node is the
main pacemaker and the
1. Assess the apical heart rate for rate is greater than 100
one (1) full minute. because of pain, anxiety,
2. Notify the client's cardiac or fever.
surgeon.
3. Prepare the client for
synchronized cardioversion.
4. Determine if the client is
having pain.
The client with coronary artery 1. "Chest pain is caused
disease asks the nurse, "Why do by decreased oxygen to
I get chest pain?" Which the heart muscle."
statement would be the most
appropriate response by the #1 is correct because it is
nurse? in layman's terms, #2 is
incorrect because it is in
1. "Chest pain is caused by medical terms
decreased oxygen to the heart
muscle."
2. "There is ischemia to the
myocardium as a result of
hypoxemia."
3. "The heart muscle is unable to
pump effectively to perfuse the
body."
4. "Chest pain occurs when the
lungs cannot adequately
oxygenate the blood."
39. The client with coronary
artery disease is prescribed a
Holter monitor. Which
intervention should the nurse
implement?
1. Instruct client to keep a
diary of activity, especially
when having chest pain.
2. Discuss the need to
remove the Holter monitor
during a.m. care and
showering.
3. Explain that all medications
should be withheld while
wearing a Holter monitor.
4. Teach the client the
importance of decreasing
activity while wearing the
monitor.
40. The client with coronary
artery disease is prescribed
transdermal nitroglycerin, a
coronary vasodilator. Which
behavior indicates the client
understands the discharge
teaching concerning this
medication?
1. The client places the
medication under the tongue.
2. The client removes the old
patch before placing the new.
3. The client applies the patch
to a hairy area.
4. The client changes the
patch every 36 hours.
41. The client with pericarditis is
prescribed a nonsteroidal
anti-inflammatory drug
(NSAID). Which teaching
instruction should the nurse
discuss with the client?
1. Explain the importance of
tapering off the medication.
2. Discuss that the medication
will make the client drowsy.
3. Instruct the client to take
the medication with food.
4. Tell the client to take the
medication when the pain
level is around "8."
1. Instruct client to keep a 42.
diary of activity, especially
when having chest pain.
The holter monitor is a 24-
hour electrocardiogram and
the client must keep an
accurate record of activity
so that the health-care
provider can compare the
ECG recordings with
different levels of activity.
#2 is not the answer
43.
because the monitor should
not come off for any reason
2. The client removes the
old patch before placing
the new.
44.
3. Instruct the client to take
the medication with food.
NSAIDS must be taken with
food, milk, or antacids to
reduce gastric distress
#1 is incorrect because only
steroids are tapered slowly,
not NSAIDS
The elderly client has 3. "Are you sexually
coronary artery disease. active?"
Which question should the
nurse ask the client during the Sexual activity is a risk
client teaching? factor for angina resulting
from coronary artery
1. "Do you have a daily bowel disease. The client's being
movement?" elderly should not affect
2. "Do you get yearly chest x- the nurse's assessment of
rays?" the clients concerns about
3. "Are you sexually active?" sexual activity.
4. "Have you had any weight
change?"
The health-care provider has 2. Teach the client how to
ordered an angiotensin- prevent orthostatic
converting enzyme (ACE) hypotension.
inhibitor for the client
diagnosed with congestive
heart failure. Which discharge
instructions should the nurse
include?
1. Instruct the client to take a
cough suppressant if a cough
develops.
2. Teach the client how to
prevent orthostatic
hypotension.
3. Encourage the client to eat
bananas to increase
potassium level.
4. Explain the importance of
taking the medication with
food.
The home health nurse is 1. Request a dietary consult
assigned a client diagnosed for a sodium-restricted diet.
with heart failure. Which 2. Instruct the client to
should the nurse implement? elevate the feet during the
Select all that apply: day.
3. Teach the client to weigh
1. Request a dietary consult every morning wearing the
for a sodium-restricted diet. same type of clothing.
2. Instruct the client to 4. Assess for edema in
elevate the feet during the dependent areas of the
day. body.
3. Teach the client to weigh 6. Have the client repeat
every morning wearing the back instructions to the
same type of clothing. nurse.
4. Assess for edema in
dependent areas of the body. #5 is incorrect because
5. Encourage the client to although fluids are
drink at least 3,000 mL of encouraged, 3,000is
fluid per day. excessive
6. Have the client repeat back
instructions to the nurse.
45. The intensive care department
nurse is assessing the client who is
12 hours post-myocardial
infarction. The nurse assesses an
S3 heart sound. Which
intervention should the nurse
implement?
1. Notify the health-care provider
immediately.
2. Elevate the head of the client's
bed.
3. Document this as a normal and
expected finding.
4. Administer morphine
intravenously.
46. The male client is diagnosed with
coronary artery disease (CAD)
and is prescribed sublingual
nitroglycerin. Which statement
indicates the client needs more
teaching?
1. "I should keep the tablets in the
dark-colored bottle they came in."
2. "If the tablets do not burn
under my tongue, they are not
effective."
3. "I should keep the bottle with
me in my pocket at all times."
4. "If my chest pain is not gone
with one tablet, I will go to the
ER."
47. The nurse and an unlicensed
assistive personnel (UAP) are
caring for four clients on a
telemetry unit. Which nursing task
would be best for the nurse to
delegate to the UAP?
1. Assist the client to go down to
the smoking area for a cigarette.
2. Transport the client to the
intensive care unit via a stretcher.
3. Provide the client going home
discharge-teaching instructions.
4. Help position the client who is
having a portable x-ray done.
1. Notify the health-care 48.
provider immediately.
Notifying the health
care provider
immediately is
necessary because S3
indicates left
ventricular failure and
is potentially life
threatening
49.
4. "If my chest pain is
not gone with one
tablet, I will go to the
ER."
The client should take
one tablet every 5
minutes and if no relief
occurs after the third
tablet, they need to be
50.
driven to the ER or call
911.
#3 is incorrect because
they should carry nitro
with them at all times
4. Help position the
client who is having a
portable x-ray done.
51.
The nurse enters the client's room 4. Push the code blue
and notes an unconscious client button.
with an absence of respirations
and no pulse or blood pressure. The first action is to
THe concept of perfusion is immediately notify the
identified by the nurse. Which code team and initiate
should the nurse implement first? CPR per protocol.
1. Notify the health care provider
2. Call a rapid response team (RRT)
3. Determine the telemetry
monitor reading.
4. Push the code blue button.
The nurse enters the room of the 4. Assist the client to a
client diagnosed with congestive sitting position
heart failure. The client is lying in
bed gasping for breath, is cool and
clammy, and has buccal cyanosis.
Which intervention would the
nurse implement first?
1. Sponge the client's forehead.
2. Obtain a pulse oximetry reading.
3. Take the client's vital signs.
4. Assist the client to a sitting
position.
The nurse has received shift report. 1. The client diagnosed
Which client should the nurse with coronary artery
assess first disease complaining
of severe indigestion.
1. The client diagnosed with
coronary artery disease A complaint of
complaining of severe indigestion. indigestion could be
2. The client diagnosed with CHF cardiac chest pain. The
who has 3+ pitting edema. nurse should assess
3. The client diagnosed with atrial this client because of
fibrillation whose apical rate is 100 the diagnosis of CAD
and irregular. and the word "severe"
4. The client diagnosed with sinus in the option.
bradycardia who is complaining of
being constipated.
The nurse has written an outcome 4. Plan for frequent
goal "demonstrates tolerance for rest periods.
increased activity" for a client
diagnosed with congestive heart Scheduling rest
failure. Which intervention should periods allows the
the nurse implement to assist the client to participate in
client to achieve this outcome? his or her own care
and addresses a
1. Measure intake and output. desired outcome.
2. Provide two (2)-g sodium diet.
3. Weigh client daily.
4. Plan for frequent rest periods.
52. The nurse identifies the
concept of altered tissue
perfusion related to a client
admitted with atrial
fibrillation. Which
interventions should the
nurse implement? Select all
that apply:
1. Monitor the clients blood
pressure and apical rate
every 4 hours.
2. Place the client on intake
and output every shift.
3. Require the client to sleep
with the head of the bed
elevated.
4. Teach the patient to
perform Buerger Allen
exercises daily.
5. Determine if the client is
on anti platelet or
anticoagulant medication.
6. Assess the clients
neurological status every
shift and prn.
53. The nurse identifies the
concept of perfusion for a
client diagnosed with
congestive heart failure.
Which assessment data
support this concept?
1. The client has a lard
abdomen and a positive
tympanic wave.
2. The client has paroxysmal
nocturnal dyspnea.
3. The client has 2+ glucose
in the urine
4. The client has a comorbid
condition of MI
1. Monitor the clients blood 54.
pressure and apical rate
every 4 hours.
2. Place the client on intake
and output every shift.
5. Determine if the client is
on anti platelet or
anticoagulant medication.
6. Assess the clients
neurological status every
shift and prn.
The client should be
monitored for any
cardiovascular changes.
55.
THe client should be
monitored for the
development of heart failure
as a result of increased
strain on the heart from the
atria not functioning as it
should.
Clients diagnosed with afib
are at risk for developing
emboli from the stasis of
blood in the atria. If an
emboli breaks loose from
the lining of the atria it can
travel to the lungs or brain
56.
2. The client has paroxysmal
nocturnal dyspnea.
Dyspnea occurring at night
when the client is in
recumbent position indicates
that cardiac muscle is not
able to compensate for
extra fluid returning to the
heart during sleep.
The nurse identifies the concept 1. The client has a history
of tissue perfusion as a client of CAD
problem. Which is an
antecedent of tissue perfusion? CAD narrows the arteries
of the heart, causing the
1. The client has a history of tissues not to be
CAD perfused, especially
2. The client has a history of when an embolus or
diabetes insidipidus thrombus occurs.
3. The client has a history of
chronic obstructive pulmonary
disease.
4. The client has multiple
fractures from a motor-vehicle
accident.
The nurse is administering a 4. The client's blood
calcium channel blocker to the pressure is 90/62.
client diagnosed with a
myocardial infarction. Which the clients BP is low, and
assessment data would cause a calcium channel
the nurse to question blocker would lower the
administering this medication? pressure more.
1. The client's apical pulse is 64.
2. The client's calcium level is
elevated.
3. The client's telemetry shows
occasional PVCs.
4. The client's blood pressure is
90/62.
The nurse is administering 3. Enalapril orally to a
morning medications to clients client whose BP is 86/64
on a telemetry unit. Which and apical pulse 65.
medication would the nurse
question? Enalopril an ACE
inhibitor, will lower the
1. Furosemide IVP to a client blood pressure even
with a potassium level of 3.6 more. The nurse should
mEq/L. hold the medication and
2. Digoxin orally to a client notify the HCP that the
diagnosed with rapid atrial medication is being held.
fibrillation.
3. Enalapril orally to a client
whose BP is 86/64 and apical
pulse 65.
4. Morphine IVP to a client
complaining of chest pain and
who is diaphoretic.
57. The nurse is admitting 4. Perfusion 60. The nurse is assisting with a 1. Wait until the machine
a client diagnosed synchronized cardioversion on discharges.
with coronary artery The cardiac muscle is not perfused a client in atrial fibrillation.
disease (CAD) and when there is a narrowing of the When the machine is activated,
angina. Which concept arteries caused by CAD or when there is a pause. What action
is priority? an embolus or thrombosis should the nurse take?
occludes the artery. Adequate 1. Wait until the machine
1. Sleep, rest, activity. perfusion will supply oxygen to the discharges.
2. Comfort. cardiac muscle, allow for increased 2. Shout "all clear" and don't
3. Oxygenation. activity, and decrease pain. touch the bed.
4. Perfusion 3. Make sure the client is all
#1 Is incorrect because it is not a right.
priority 4. Increase the joules and
redischarge.
58. The nurse is assessing 1. An elevated B-type natriuretic
the client diagnosed peptide (BNP). 61. The nurse is caring for a client 2. Administer an aspirin
with congestive heart diagnosed with a myocardial orally.
failure. Which infarction who is experiencing 3. Apply oxygen via a
laboratory data would chest pain. Which interventions nasal cannula.
indicate that the client should the nurse implement?
is in severe congestive Select all that apply. #1 is incorrect because
heart failure? morphine is administered
1. An elevated B-type 1. Administer morphine IV not IM
natriuretic peptide intramuscularly.
(BNP). 2. Administer an aspirin orally. #5 Is incorrect because
2. An elevated 3. Apply oxygen via a nasal nitro is given sublingually,
creatine kinase (CK- cannula. not subcutaneously
MB). 4. Place the client in a supine
3. A positive D-dimer. position.
4. A positive 5. Administer nitroglycerin
ventilation/perfusion subcutaneously.
(V/Q) scan.
62. The nurse is caring for a client 1. Carry your nitroglycerin
59. The nurse is assessing 3. The client is able to perform diagnosed with coronary artery tablets in a brown bottle.
the client diagnosed ADLs without dyspnea. disease. Which should the nurse
with congestive heart teach the client prior to
failure. Which discharge?
signs/symptoms would
indicate that the 1. Carry your nitroglycerin
medical treatment has tablets in a brown bottle.
been effective? 2. Swallow a nitroglycerin
1. The client's tablet at the first sign of angina.
peripheral pitting 3. If one nitroglycerin tablet
edema has gone from does not work in 10 minutes,
3+ to 4+. take another.
2. The client is able to 4. Nitroglycerin tablets have a
take the radial pulse fruity odor if they are potent.
accurately.
63. The nurse is caring for a client 2. Assess the client for a
3. The client is able to
who goes into ventricular pulse.
perform ADLs without
tachycardia. Which intervention
dyspnea.
should the nurse implement The nurse must first
4. The client has
first? determine if the client has
minimal jugular vein
1. Call a code immediately. a pulse. Pulseless catch is
distention.
2. Assess the client for a pulse. treated with defibrillation.
3. Begin chest compressions. Vtach with a pulse is
4. Continue to monitor the treated with
client. cardioversion.
64. The nurse is caring for a client who 4. Have the client sit 67. The nurse is developing a nursing care 2. Have an audible
suddenly complains of crushing down. plan for a client diagnosed with S1 and S2 with no
substernal pain while ambulating in congestive heart failure. A nursing S3 heard by end
the hall. Which nursing action should diagnosis of "decreased cardiac output of shift.
the nurse implement first? related to inability of the heart to
pump effectively" is written. Which Reason: Audible S1
1. Call a code blue. short-term goal would be best for the & S2 are normal
2. Assess the telemetry reading. client? The client will: for a heart with
3. Take the client's apical pulse. 1. Be able to ambulate in the hall by adequate output,
4. Have the client sit down. date of discharge. an audible S3 may
2. Have an audible S1 and S2 with no indicate left
65. The nurse is caring for clients on a 3. The client
S3 heard by end of shift. ventricular heart
cardiac floor. Which client should the diagnosed with
3. Turn, cough, and deep breathe failure
nurse assess first? mitral valve
every two (2) hours.
1. The client with three (3) unifocal prolapse with an
4. Have a pulse oximeter reading of
PVCs in one (1) minute. audible S3.
98% by day two (2) of care.
2. The client diagnosed with
coronary artery disease who wants An audible S3 68. The nurse is discussing angina with a 2. Stop the activity
to ambulate. indicates left-sided client who is diagnosed with coronary immediately and
3. The client diagnosed with mitral heart failure and artery disease. Which action should rest.
valve prolapse with an audible S3. needs to be the client take first when experiencing
4. The client diagnosed with assessed angina?
pericarditis who is in normal sinus immediately.
rhythm. 1. Put a nitroglycerin tablet under the
tongue.
66. The nurse is developing a discharge- 2. Teach client how
2. Stop the activity immediately and
teaching plan for the client to count the radial
rest.
diagnosed with congestive heart pulse when taking
3. Document when and what activity
failure. Which interventions should digoxin, a cardiac
caused angina.
be included in the plan? Select all glycoside.
4. Notify the health-care provider
that apply.
immediately.
1. Notify health-care provider of a 3. Instruct client to
weight gain of more than one (1) remove the 69. The nurse is discussing the importance 3. Do not walk
pound in a week. saltshaker from the of exercise with the client diagnosed outside if it is less
2. Teach client how to count the dinner table. with coronary artery disease. Which than 40 ̊F.
radial pulse when taking digoxin, a intervention should the nurse
cardiac glycoside. #4 is not a choice implement? When it is cold
3. Instruct client to remove the because the patient outside,
saltshaker from the dinner table. should be on a 1. Perform isometric exercises daily. vasoconstriction
4. Encourage client to monitor urine diuretic and urine 2. Walk for 15 minutes three (3) times a occurs, and this
output for change in color to should be more week. decreases oxygen
become dark. frequent & lighter 3. Do not walk outside if it is less than to the heart
5. Discuss the importance of taking 40 ̊F. muscle, therefore
the loop diuretic furosemide at 4. Wear open-toed shoes when the client should
bedtime. ambulating. not exercise in the
cold.
70. The nurse is functioning in the role of 1. Mix the 73. The nurse on the 1. The client diagnosed with
medication nurse during a code. Which medication in telemetry unit has just myocardial infarction who has an
should the nurse implement when 100mL of fluid & received the a.m. shift audible S3 heart
administering amiodarone for ventricular administer report. Which client sound.
tachycardia? rapidly. should the nurse
assess first? An audible S3 indicates left
1. Mix the medication in 100mL of fluid & Amiodarone is ventricular heart failure and the
administer rapidly. administered 1. The client diagnosed nurse must assess this client first
2. Push the amiodarone directly into the during a code with myocardial because it is an emergency
nearest IV port and raise the arm. rapidly after infarction who has an situation
3. Question the physicians order because being mixed in audible S3 heart
it is not ACLS recommended. 100 mL of fluid. sound.
4. Administer via an IV pump based on 2. The client diagnosed
mg/kg/min. #2 is incorrect with congestive heart
because it is not failure who has 4+
pushed sacral pitting
edema.
71. The nurse is preparing to administer a 2. The client has
3. The client diagnosed
beta blocker to the client diagnosed an apical pulse
with pneumonia who
with coronary artery disease. Which of 56.
has a pulse oximeter
assessment data would cause the nurse
reading of 94%.
to question administering the
4. The client with
medication?
chronic renal failure
who has an elevated
1. The client has a BP of 110/70.
creatinine level.
2. The client has an apical pulse of 56.
3. The client is complaining of a 74. The telemetry nurse is 3. Contact the client on the client
headache. unable to read the call system.
4. The client's potassium level is 4.5 telemetry monitor at
mEq/L. the nurse's station. If the client is answering the call
Which intervention light and is not experiencing chest
72. The nurse is transcribing the doctor's 1. Discuss the
should the telemetry pain, then there is probably a
orders for a client with congestive heart order with the
nurse implement first? monitor artifact, which is not a life-
failure. The order reads 2.5 mg of health-care
threatening emergency. After
Lanoxin daily. Which action should the provider.
1. Go to the client's talking with the client send a nurse
nurse implement?
room to check the to the room to check the monitor.
This dosage is
client.
1. Discuss the order with the health-care 10x the normal
2. Instruct the primary
provider. dose for a client
nurse to assess the
2. Take the client's apical pulse rate with CHF and is
client.
before administering. potentially
3. Contact the client
3. Check the client's potassium level lethal.
on the client call
before giving the medication.
system.
4. Determine if a digoxin level has been
4. Request the nursing
drawn.
assistant to take the
crash cart to the
client's room.
75. The telemetry nurse notes a peaked 4. Potassium 79. Which client teaching should 1. Encourage a low-fat, low-
T wave for the client diagnosed with the nurse implement for the cholesterol diet.
congestive heart failure. Which Hyperkalemia will client diagnosed with 2. Instruct client to walk 30
laboratory data should the nurse cause an elevated T coronary artery disease? minutes a day.
assess? wave therefore the Select all that apply. 4. Refer to counselor for
1. CK-MB. nurse should check stress reduction techniques.
2. Troponin. these laboratory 1. Encourage a low-fat, low- 5. Teach the client to
3. BNP. data. cholesterol diet. increase fiber in the diet.
4. Potassium. 2. Instruct client to walk 30
minutes a day. Low-fat/cholesterol diet
76. The unlicensed assistive personnel 4. Go to the room
3. Decrease the salt intake to helps prevent
(UAP) tells the primary nurse that the and assess the
two (2) g a day. atherosclerosis
client diagnosed with coronary client's chest pain.
4. Refer to counselor for
artery disease is having chest pain.
stress reduction techniques. Walking increases
Which action should the nurse take Assessment is the
5. Teach the client to increase circulation
first? first step in the
fiber in the diet.
1. Tell the UAP to go take the client's nursing process and
Stress reduction is
vital signs. should be
encouraged
2. Ask the UAP to have the telemetry implemented first,
nurse read the strip. 3. Notify the chest pain is a
Increasing fiber in the diet
client's health-care provider. priority.
will help remove
4. Go to the room and assess the
cholesterol via GI system
client's chest pain.
80. Which client would most 3. A 40-year-old Hispanic
77. Which cardiac enzyme would the 3. Troponin
likely be misdiagnosed for female with a normal
nurse expect to elevate first in a
having a myocardial electrocardiogram.
client diagnosed with a myocardial
infarction?
infarction?
1. A 55-year-old Caucasian Misdiagnosed clients often
male with crushing chest pain present atypical symptoms,
1. Creatine kinase (CK-MB).
and diaphoresis. they tend to be female,
2. Lactate dehydrogenase (LDH).
2. A 60-year-old Native younger than 55, and in a
3. Troponin.
American male with an minority group.
4. White blood cells (WBCs).
elevated troponin level.
78. Which client problem has priority for 2. Decreased 3. A 40-year-old Hispanic
the client with a cardiac cardiac output. female with a normal
dysrhythmia? electrocardiogram.
4. An 80-year-old Peruvian
1. Alteration in comfort. female with a normal CK-MB
2. Decreased cardiac output. at 12 hours.
3. Impaired gas exchange.
81. Which data would cause the 1. The potassium level is 3.2
4. Activity intolerance.
nurse to question mEq/L.
administering digoxin to a
client diagnosed with The potassium level is
congestive heart failure? below normal levels.
1. The potassium level is 3.2 hypokalemia can potentiate
mEq/L. digoxin toxicity and lead to
2. The digoxin level is 1.2 cardiac dysrhythmias.
mcg/mL.
3. The client's apical pulse is
64.
4. The client denies yellow
haze.
82. Which intervention should the nurse 2. Assess the client's 86. Which statement by the client diagnosed with 2. "I should
implement when administering a loop serum potassium coronary artery disease indicates that the bake or
diuretic to a client diagnosed with level. client understands the discharge teaching grill any
coronary artery disease? concerning diet? meats I
eat."
1. Assess the client's radial pulse. 1. "I will not eat more than six (6) eggs a
2. Assess the client's serum potassium week."
level. 2. "I should bake or grill any meats I eat."
3. Assess the client's glucometer 3. "I will drink eight (8) ounces of whole milk a
reading. day."
4. Assess the client's pulse oximeter 4. "I should not eat any type of pork
reading. products."
83. Which intervention should the nurse 4. Shout "all clear"
implement when defibrillating a prior to
client who is in ventricular defibrillating the
fibrillation? client.

1. Defibrillate the client at 50, 100,

and 200 joules.
2. Do not remove the oxygen source
during defibrillation.
3. Place petroleum jelly on the
defibrillator pads.
4. Shout "all clear" prior to
defibrillating the client.
84. Which population is at a higher risk 4. African American
for dying from a myocardial Females
infarction?
1. Caucasian males. African Americans
2. Hispanic females. are more likely to
3. Asian males. die from MIs than
4. African American females. any other
populations
85. Which preprocedure information 3. Do not eat
should be taught to the female client anything for four (4)
having an exercise stress test in the hours.
morning?
1. Wear open-toed shoes to the NPO decreases
stress test. aspiration in case of
2. Inform the client not to wear a bra. emergency.
3. Do not eat anything for four (4)
hours.
4. Take the beta blocker one (1) hour
before the test.