Which findings should receive the highest priority?
1. BP 110/62, atrial fi brillation with HR 82,bibasilar crackles.
2. Confusion, urine output 15 mL over the last 2 hours, orthopnea.
3. SpO2 92 on 2 liters nasal cannula, respirations 20, 1+ edema of lower extremities.
4. Weight gain of 1 kg in 3 days, BP 130/80,mild dyspnea with exercise.
2. When administering a thrombolytic drug to the client experiencing a myocardial infarction (MI),
the nurse explains that the purpose of the drug is to:
1. Help keep him well hydrated.
2. Dissolve clots that he may have.
3. Prevent kidney failure.
4. Treat potential cardiac arrhythmias.
3. The nurse notices that a client’s heart rate decreases from 63 to 50 beats per minute on the
monitor. The nurse should fi rst:
1. Administer Atropine 0.5 mg I.V. push.
2. Auscultate for abnormal heart sounds.
3. Prepare for transcutaneous pacing.
4. Take the client’s blood pressure.
4. If the client who was admitted for myocardial infarction (MI) develops cardiogenic shock,
which characteristic sign should the nurse expect to observe?
1. Oliguria.
2. Bradycardia.
3. Elevated blood pressure.
4. Fever.
5. A client is admitted with a myocardial infarction and new onset atrial fi brillation.
While auscultating the heart, the nurse notes an irregular heart rate
and hears an extra heart sound at the apex after the S2 that remains constant throughout
the respiratory cycle. The nurse should document these fi ndings as:
a. Heart rate irregular with S3.
b. Heart rate irregular with S4.
c. Heart rate irregular with aortic regurgitation.
d. Heart rate irregular with mitral stenosis.
6. The physician orders continuous I.V. nitroglycerin infusion for the client with myocardial
infarction. Essential nursing actions include which of the following?
a. Obtaining an infusion pump for the medication.
b. Monitoring blood pressure every 4 hours.
c. Monitoring urine output hourly.
d. Obtaining serum potassium levels daily.
7. Crackles heard on lung auscultation indicate which of the following?
a. Cyanosis.
b. Bronchospasm.
c. Airway narrowing.
d. Fluid-fi lled alveoli.
8. Which of the following symptoms should the nurse teach the client with unstable
angina to report immediately to her physician?
a. A change in the pattern of her pain.
b. Pain during sexual activity.
c. Pain during an argument with her husband.
d. Pain during or after an activity such as lawn-mowing.
9. A client with chronic heart failure has atrial fi brillation and a left ventricular ejection
fraction of 15%. The client is taking warfarin (Coumadin).
The expected outcome of this drug is to:
a. Decrease circulatory overload.
b. Improve the myocardial workload.
c. Prevent thrombus formation.
d. Regulate cardiac rhythm.
10. The major goal of therapy for a client with heart failure and pulmonary edema should be to:
a. Increase cardiac output.
b. Improve respiratory status.
c. Decrease peripheral edema.
d. Enhance comfort.
11. The nurse should teach the client that signs of digoxin toxicity include which of the following?
a. Rash over the chest and back.
b. Increased appetite.
c. Visual disturbances such as seeing yellow spots.
d. Elevated blood pressure.
12. The nurse should be especially alert for signs and symptoms of digoxin toxicity if serum levels
indicate that the client has a:
a. Low sodium level.
b. High glucose level.
c. High calcium level.
d. Low potassium level.
13. The nurse fi nds the apical impulse below the fi fth intercostal space. The nurse suspects:
a. Left atrial enlargement.
b. Left ventricular enlargement.
c. Right atrial enlargement.
d. Right ventricular enlargement.
14. The nurse’s discharge teaching plan for the client with heart failure should stress
the importance of which of the following?
a. Maintaining a high-fi ber diet.
b. Walking 2 miles every day.
c. Obtaining daily weights at the same time each day.
d. Remaining sedentary for most of the day.
15. A client has returned to the medical-surgical unit after a cardiac catheterization.
Which is the most important initial postprocedure nursing assessment for this client?
a. Monitor the laboratory values.
b. Observe neurologic function every 15 minutes.
c. Observe the puncture site for swelling and bleeding.
d. Monitor skin warmth and turgor.
16. The most effective measure the nurse can use to prevent wound infection
when changing a client’s dressing after coronary artery bypass surgery is to:
a. Observe careful hand-washing procedures.
b. Clean the incisional area with an antiseptic.
c. Use prepackaged sterile dressings to cover the incision.
d. Place soiled dressings in a waterproof bag before disposing of them.
17. The nurse should teach the client who is receiving warfarin sodium that:
a. Partial thromboplastin time values determine the dosage of warfarin sodium.
b. Protamine sulfate is used to reverse the effects of warfarin sodium.
c. International Normalized Ratio (INR) is used to assess effectiveness.
d. Warfarin sodium will facilitate clotting of the blood.
18. The most important long-term goal for a client with hypertension would be to:
a. Learn how to avoid stress.
b. Explore a job change or early retirement.
c. Make a commitment to long-term therapy.
d. Lose weight.
19. The nurse is developing a care plan with an older adult and is instructing
the client that hypertension can be a silent killer. The nurse should instruct
the client to be aware of signs and symptoms of other system failures and
encourage the client to report signs of which of the following diseases that
are often a result of undeteced high blood pressure?
a. Cerebrovascular accidents (CVAs).
b. Liver disease.
c. Myocardial infarction.
d. Pulmonary disease.
20. A client treated for hypertension with furosemide (Lasix), atenolol (Tenormin),
and ramipril (Altace) develops a second degree heart block Mobitz type 1. Which of
the following actions should the nurse take?
a. Administer a 250 mL fl uid bolus.
b. Withhold the atenolol.
c. Prepare for cardioversion.
d. Set up for an arterial line.
Answers And Rationals
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