Exam 1 Iggy Questions

Question 1

A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be
disoriented to person, place, and time. What action by the nurse is best?
a. Assess the clients pupillary responses.
b. Request a neurologic consultation.
c. Stop the infusion and call the provider.
d. Take and document a full set of vital signs.

Answer 1

C

Question 2

A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an
intravenous infusion of heparin. The clients spouse asks why the client needs this medication. What response by the nurse is best?
a. The t-PA didnt dissolve the entire coronary clot.
b. The heparin keeps that artery from getting blocked again.
c. Heparin keeps the blood as thin as possible for a longer time.
d. The heparin prevents a stroke from occurring as the t-PA wears off

Answer 2

B

Question 3

A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse
assists the client to the bathroom and notes the clients O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best?
a. Administer oxygen at 2 L/min.
b. Allow continued bathroom privileges.
c. Obtain a bedside commode.
d. Suggest the client use a bedpan.

Answer 3

ANS: B
This clients physiologic parameters did not exceed normal during and after activity, so it is safe for the client to
continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan.

Question 4

A nursing student is caring for a client who had a myocardial infarction. The student is confused because the
client states nothing is wrong and yet listens attentively while the student provides education on lifestyle
changes and healthy menu choices. What response by the faculty member is best?
a. Continue to educate the client on possible healthy changes.
b. Emphasize complications that can occur with noncompliance.
c. Tell the client that denial is normal and will soon go away.
d. You need to make sure the client understands this illness.

Answer 4

A

Question 5

5. A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5mm Hg. What action by the nurse is most appropriate?
   a. Level the transducer at the phlebostatic axis.
   b. Lay the client in the supine position.
   c. Prepare to administer diuretics.
   d. Prepare to administer a fluid bolus

Answer 5

D

Question 6

A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the
clients heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to
100/60 mm Hg. What action by the nurse is most appropriate?
a. Allow the client to rest quietly.
b. Assess the client for bleeding.
c. Document the findings in the chart.
d. Medicate the client for pain.

Answer 6

B

Question 7

A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The
client is yelling at family members and tells the doctor to just get this over with when asked to sign the consent form. What action by the nurse is best?
a. Ask the family members to wait in the waiting area.
b. Inform the client that this behavior is unacceptable.
c. Stay out of the room to decrease the clients stress levels.
d. Tell the client that anxiety is common and that you can help.

Answer 7

D

Question 8

A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and
vomiting. What action by the nurse takes priority?
a. Administer an aspirin.
b. Call for an electrocardiogram (ECG).
c. Maintain airway patency.
d. Notify the provider.

Answer 8

C

Question 9

An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent
dysrhythmias. What action by the nurse is most appropriate?
a. Assess for any hemodynamic effects of the rhythm.
b. Prepare to administer antidysrhythmic medication. c. Notify the provider or call the Rapid Response Team.
d. Turn the alarms off on the cardiac monitor.

Answer 9

A

Question 10

A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on the clients
sheets. What action should the nurse perform first?
a. Assess the insertion site. b. Change the clients sheets.
c. Put on a pair of gloves.
d. Assess blood pressure.

Answer 10

C

Question 11

A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first?
a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours
b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg
c. Client who is 1 day post percutaneous coronary intervention, going home this morning
d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking

Answer 11

B

Question 12

A client has presented to the emergency department with an acute myocardial infarction (MI). What action
by the nurse is best to meet The Joint Commissions Core Measures outcomes?
a. Obtain an electrocardiogram (ECG) now and in the morning.
b. Give the client an aspirin. c. Notify the Rapid Response Team.
d. Prepare to administer thrombolytics.

Answer 12

B

Question 13

A nurse is caring for four clients. Which client should the nurse assess first?
a. Client with an acute myocardial infarction, pulse 102 beats/min
b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety
c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr
d. Client who is post coronary artery bypass, potassium 4.2 mEq/L

Answer 13

B

Question 14

A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless
and agitated. What action should the nurse perform first for comfort?
a. Allow family members to remain at the bedside.
b. Ask the family if the client would like a fan in the room.
c. Keep the television tuned to the clients favorite channel.
d. Speak loudly to the client in case of hearing problems.

Answer 14

A

Question 15

The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows
significantly. What action by the nurse is most important?
a. Increase the setting on the suction.
b. Notify the provider immediately.
c. Re-position the chest tube.
d. Take the tubing apart to assess for clots.

Answer 15

B

Question 16

A home health care nurse is visiting an older client who lives alone after being discharged from the hospital
after a coronary artery bypass graft. What finding in the home most causes the nurse to consider additional
referrals?
a. Dirty carpets in need of vacuuming
b. Expired food in the refrigerator
c. Old medications in the kitchen
d. Several cats present in the home

Answer 16

B

Question 17

A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety?
a. Assess the IV site hourly. b. Monitor the pedal pulses. c. Monitor the clients vital signs.
d. Obtain consent for a central line.

Answer 17

A

Question 18

A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred?
a. Blood pressure that is 20 mm Hg below baseline
b. Oxygen saturation of 94% on room air
c. Poor peripheral pulses and cool skin
d. Urine output of 1.2 mL/kg/hr for 4 hours

Answer 18

C

Question 19

A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commissions Core Measures
set, by what time should the client have a percutaneous coronary intervention performed?
a. 1530 (3:30 PM)
b. 1600 (4:00 PM)
c. 1630 (4:30 PM)
d. 1700 (5:00 PM)

Answer 19

C

Question 20

The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse?
a. It constricts vessels, improving blood flow.
b. It dilates vessels, which lessens the work of the heart.
c. It increases the force of the hearts contractions.
d. It slows the heart rate down for better filling.

Answer 20

C
A positive inotrope is a medication that increases the strength of the hearts contractions. The other options are
not correct.

Question 21

A nurse is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the nurse
hears the following sound. What action by the nurse is most appropriate?
(Click the media button to hear the audio clip.)
a. Assess for further chest pain.
b. Call the Rapid Response Team.
c. Have the client sit upright. d. Listen to the clients lung sounds.

Answer 21

D

Question 22

A client had an inferior wall myocardial infarction (MI). The nurse notes the clients cardiac rhythm as
shown below:
What action by the nurse is most important?
a. Assess the clients blood pressure and level of consciousness.
b. Call the health care provider or the Rapid Response Team.
c. Obtain a permit for an emergency temporary pacemaker insertion.
d. Prepare to administer antidysrhythmic medication.

Answer 22

A

Question 23

A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this
include? (Select all that apply.)
a. Age
b. Hypertension
c. Obesity
d. Smoking
e. Stress

Answer 23

B, C, D, E

Question 24

A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the
nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Assist the client to the chair for meals and to the bathroom.
b. Encourage the client to use the spirometer every 4 hours.
c. Ensure the client wears TED hose or sequential compression devices.
d. Have the client rate pain on a 0-to-10 scale and report to the nurse. e. Take and record a full set of vital signs per hospital protocol.

Answer 24

A C E

Question 25

A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI)
differs from stable angina in what ways? (Select all that apply.)
a. Accompanied by shortness of breath
b. Feelings of fear or anxiety
c. Lasts less than 15 minutes
d. No relief from taking nitroglycerin
e. Pain occurs without known cause

Answer 25

A, B, D, E

Question 26

A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would
include which topics? (Select all that apply.)
a. Advanced age
b. Diabetes
c. Ethnic background
d. Medication use
e. Smoking

Answer 26

A, B, C, E

Question 27

The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3
hours of the client being identified as being at risk? (Select all that apply.)
a. Administer antibiotics.
b. Draw serum lactate levels. c. Infuse vasopressors.
d. Measure central venous pressure.
e. Obtain blood cultures.

Answer 27

A, B, E

Question 28

A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the
nursing student? (Select all that apply.)
a. Bringing the client warm blankets
b. Giving the client hot tea to drink
c. Massaging the clients painful legs
d. Reorienting the client as needed
e. Sitting with the client for reassurance

Answer 28

A, D, E

Question 29

The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher
risk for shock. For what factors would the nurse assess? (Select all that apply.)
a. Altered mobility/immobility
b. Decreased thirst response
c. Diminished immune response
d. Malnutrition
e. Overhydration

Answer 29

A, B, C, D

Question 30

The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility
of the clients developing shock? (Select all that apply.)
a. Assessing and identifying clients at risk
b. Monitoring the daily white blood cell count
c. Performing proper hand hygiene
d. Removing invasive lines as soon as possible
e. Using aseptic technique during procedures

Answer 30

A, C, D, E

Question 31

The student nurse studying shock understands that the common manifestations of this condition are directly
related to which problems? (Select all that apply.)
a. Anaerobic metabolism
b. Hyperglycemia
c. Hypotension
d. Impaired renal perfusion
e. Increased perfusion

Answer 31

A,C

Question 32

A client is being discharged home after a large myocardial infarction and subsequent coronary artery
bypass grafting surgery. The clients sternal wound has not yet healed. What statement by the client most
indicates a higher risk of developing sepsis after discharge?
a. All my friends and neighbors are planning a party for me.
b. I hope I can get my water turned back on when I get home.
c. I am going to have my daughter scoop the cat litter box.
d. My grandkids are so excited to have me coming home!

Answer 32

B

Question 33

A client in shock is apprehensive and slightly confused. What action by the nurse is best?
a. Offer to remain with the client for awhile.
b. Prepare to administer antianxiety medication.
c. Raise all four siderails on the clients bed.
d. Tell the client everything possible is being done.

Answer 33

A

Question 34

A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to
communicate with the health care provider?
a. Creatinine: 0.9 mg/dL
b. Lactate: 6 mmol/L
c. Sodium: 150 mEq/L
d. White blood cell count: 11,000/mm3

Answer 34

B

Question 35

A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly
amputated leg that is bleeding profusely. What action by the nurse takes priority?
a. Apply direct pressure to the bleeding.
b. Ensure the client has a patent airway.
c. Obtain consent for emergency surgery.
d. Start two large-bore IV catheters.

Answer 35

B

Question 36

A nurse works at a community center for older adults. What self-management measure can the nurse teach
the clients to prevent shock?
a. Do not get dehydrated in warm weather.
b. Drink fluids on a regular schedule.
c. Seek attention for any lacerations.
d. Take medications as prescribed.

Answer 36

B

Question 37

A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood
glucose level 198 mg/dL, and temperature 96.2 F (35.6 C). What action by the nurse takes priority?
a. Document the findings in the clients chart.
b. Give the client warmed blankets for comfort.
c. Notify the health care provider immediately.
d. Prepare to administer insulin per sliding scale.

Answer 37

C
This client has several indicators of sepsis with systemic inflammatory response. The nurse should notify the
health care provider immediately. Documentation needs to be thorough but does not take priority. The client
may appreciate warm blankets, but comfort measures do not take priority. The client may or may not need
insulin.

Question 38

A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous
readings. What action does the nurse delegate next to the UAP?
a. Assess the client for pain or discomfort.
b. Measure urine output from the catheter.
c. Reposition the client to the unaffected side.
d. Stay with the client and reassure him or her.

Answer 38

B

Question 39

The nurse gets the hand-off report on four clients. Which client should the nurse assess first?
a. Client with a blood pressure change of 128/74 to 110/88 mm Hg
b. Client with oxygen saturation unchanged at 94%
c. Client with a pulse change of 100 to 88 beats/min
d. Client with urine output of 40 mL/hr for the last 2 hours

Answer 39

A

Question 40

A nurse is caring for a client after surgery. The clients respiratory rate has increased from 12 to 18
breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best?
a. Ask if the client needs pain medication.
b. Assess the clients tissue perfusion further.
c. Document the findings in the clients chart.
d. Increase the rate of the clients IV infusion.

Answer 40

B

Question 41

A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate
the blood loss with the clients mean arterial pressure (MAP)?
a. It causes vasoconstriction and increased MAP.
b. Lower blood volume lowers MAP.
c. There is no direct correlation to MAP.
d. It raises cardiac output and MAP.

Answer 41

B

Question 42

A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is
possible without pain. What question asked next by the nurse will give the best information?
a. Could you walk further than that a few months ago?
b. Do you walk mostly uphill, downhill, or on flat surfaces?
c. Have you ever considered swimming instead of walking?
d. How much pain medication do you take each day?

Answer 42

A

Question 43

An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the
family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care?
a. I nearly always wear comfy sweatpants and house shoes.
b. Im glad I get energy assistance so my house isnt so cold.
c. My daughter makes sure I have plenty of lotion for my feet.
d. My hands shake when I try to do things requiring coordination.

Answer 43

D

Question 44

A client is taking warfarin (Coumadin) and asks the nurse if taking St. Johns wort is acceptable. What
response by the nurse is best?
a. No, it may interfere with the warfarin.
b. There isnt any information about that.
c. Why would you want to take that?
d. Yes, it is a good supplement for you.

Answer 44

A

Question 45

A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires
the registered nurse to intervene?
a. Assesses the client for back pain
b. Auscultates over abdominal bruit
c. Measures the abdominal girth
d. Palpates the abdomen in four quadrants

Answer 45

D

Question 46

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a
priority outcome has been met?
a. Ambulates with assistance
b. Oxygen saturation of 98%
c. Pain of 2/10 after medication
d. Verbalizing risk factors

Answer 46

B

Question 47

A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the
unlicensed assistive personnel (UAP)?
a. Ambulate the client.
b. Apply a warm moist pack. c. Massage the clients leg. d. Provide an ice pack.

Answer 47

B

Question 48

A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding
about self-management activities?
a. I can use a heating pad on my legs if its set on low.
b. I should not cross my legs when sitting or lying down.
c. I will go out and buy some warm, heavy socks to wear
d. Its going to be really hard but I will stop smoking.

Answer 48

A

Question 49

A client has been bedridden for several days after major abdominal surgery. What action does the nurse
delegate to the unlicensed assistive personnel (UAP) for deep vein thrombosis (DVT) prevention? (Select all
that apply.)
a. Apply compression stockings.
b. Assist with ambulation.
c. Encourage coughing and deep breathing.
d. Offer fluids frequently.
e. Teach leg exercises.

Answer 49

A B D

Question 50

A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the clients
plan of care? (Select all that apply.)
a. Assess the client for bleeding.
b. Monitor the daily activated partial thromboplastin time (aPTT) results.
c. Stop the IV for aPTT above baseline.
d. Use an IV pump for the infusion.
e. Weigh the client daily on the same scale.

Answer 50

A B D

Question 51

A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should the nurse expect? (Select all that apply.)
a. Weight gain
b. Night sweats
c. Cardiac murmur
d. Abdominal bloating
e. Oslers nodes

Answer 51

B C E

Question 52

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert
the nurse to the possibility of heart transplant rejection? (Select all that apply.)
a. Shortness of breath
b. Abdominal bloating
c. New-onset bradycardia
d. Increased ejection fraction
e. Hypertension

Answer 52

A B C

Question 53

A nurse prepares to discharge a client who has heart failure. Which questions should the nurse ask to ensure
this clients safety prior to discharging home? (Select all that apply.)
a. Are your bedroom and bathroom on the first floor?
b. What social support do you have at home?
c. Will you be able to afford your oxygen therapy?
d. What spiritual beliefs may impact your recovery?
e. Are you able to accurately weigh yourself at home?

Answer 53

A B D

Question 54

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client with
congestive heart failure. Which instructions should the nurse provide to the UAP when delegating care for this
client? (Select all that apply.)
a. Reposition the client every 2 hours.
b. Teach the client to perform deep-breathing exercises.
c. Accurately record intake and output.
d. Use the same scale to weigh the client each morning.
e. Place the client on oxygen if the client becomes short of breath.

Answer 54

A C D

Question 55

A nurse assesses clients on a cardiac unit. Which clients should the nurse identify as at greatest risk for the
development of acute pericarditis? (Select all that apply.)
a. A 36-year-old woman with systemic lupus erythematosus (SLE)
b. A 42-year-old man recovering from coronary artery bypass graft surgery
c. A 59-year-old woman recovering from a hysterectomy
d. An 80-year-old man with a bacterial infection of the respiratory tract
e. An 88-year-old woman with a stage III sacral ulcer

Answer 55

A B D

Question 56

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse
assess? (Select all that apply.)
a. Pulmonary crackles
b. Confusion, restlessness
c. Pulmonary hypertension
d. Dependent edema
e. Cough that worsens at night

Answer 56

A, B, E

Question 57

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the
nurse assess?
a. Preventricular contractions
b. Atrial fibrillation
c. Symptomatic bradycardia
d. Sinus tachycardia

Answer 57

B

Question 58

A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to
the left side of the neck. Which nonpharmacologic comfort measure should the nurse implement?
a. Apply an ice pack to the clients chest.
b. Provide a neck rub, especially on the left side.
c. Allow the client to lie in bed with the lights down.
d. Sit the client up with a pillow to lean forward on.

Answer 58

D

Question 59

A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears
depressed and states, I know a transplant is my last chance, but I dont want to become a vegetable. How should
the nurse respond?
a. Would you like to speak with a priest or chaplain?
b. I will arrange for a psychiatrist to speak with you. c. Do you want to come off the transplant list?
d. Would you like information about advance directives?

Answer 59

D

Question 60

A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find?
a. Heart rate that speeds up and slows down
b. Friction rub at the left lower sternal border
c. Presence of a regular gallop rhythm
d. Coarse crackles in bilateral lung bases

Answer 60

B

Question 61

. A nurse cares for a client with infective endocarditis. Which infection control precautions should the nurse
use?
a. Standard Precautions
b. Bleeding precautions
c. Reverse isolation
d. Contact isolation

Answer 61

A

Question 62

After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse
assesses the clients understanding. Which client statement indicates a need for additional teaching?
a. I’ll be able to carry heavy loads after 6 months of rest.
b. I will have my teeth cleaned by my dentist in 2 weeks.
c. I must avoid eating foods high in vitamin K, like spinach.
d. I must use an electric razor instead of a straight razor to shave

Answer 62

B

Question 63

A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, Why will I
need to take anticoagulants for the rest of my life? How should the nurse respond?
a. The prosthetic valve places you at greater risk for a heart attack.
b. Blood clots form more easily in artificial replacement valves.
c. The vein taken from your leg reduces circulation in the leg.
d. The surgery left a lot of small clots in your heart and lungs.

Answer 63

B

Question 64

A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to
the possibility that the clients stenosis has progressed?
a. Oxygen saturation of 92%
b. Dyspnea on exertion
c. Muted systolic murmur
d. Upper extremity weakness

Answer 64

B

Question 65

A nurse cares for a client with right-sided heart failure. The client asks, Why do I need to weigh myself
every day? How should the nurse respond?
a. Weight is the best indication that you are gaining or losing fluid.
b. Daily weights will help us make sure that you’re eating properly.
c. The hospital requires that all inpatients be weighed daily.
d. You need to lose weight to decrease the incidence of heart failure.

Answer 65

A

Question 66

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action
should the nurse take next?
a. Assess for symptoms of left-sided heart failure.
b. Document this as a normal finding.
c. Call the health care provider immediately.
d. Transfer the client to the intensive care unit.

Answer 66

A

Question 67

A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for
the development of left-sided heart failure?
a. A 36-year-old woman with aortic stenosis
b. A 42-year-old man with pulmonary hypertension
c. A 59-year-old woman who smokes cigarettes daily
d. A 70-year-old man who had a cerebral vascular accident

Answer 67

A

Question 68

A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.)
a. Decrease in cardiac output
b. Increase in cardiac output
c. Decrease in blood pressure
d. Increase in blood pressure
e. Decrease in urine output
f. Increase in urine output

Answer 68

A, D, E

Question 69

A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure?
a. Clean the skin and clip hairs if needed.
b. Add gel to the electrodes prior to applying them.
c. Place the electrodes on the posterior chest.
d. Turn off oxygen prior to monitoring the client.

Answer 69

A

Question 70

The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client
asks, Why do you want to know if I use cocaine? How should the nurse respond?
a. Substance abuse puts clients at risk for many health issues.
b. The hospital requires that I ask you about cocaine use. c. Clients who use cocaine are at risk for fatal dysrhythmias.
d. We can provide services for cessation of substance abuse.

Answer 70

C

Question 71

A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by
the nurse?
a. Mid-sternal chest pain
b. Increased urine output
c. Mild orthostatic hypotension
d. P wave touching the T wave

Answer 71

A

Question 72

A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care
services. Which priority information should be communicated to the home health nurse upon discharge?
a. Medication reconciliation
b. Immunization history
c. Religious beliefs
d. Nutrition preferences

Answer 72

A

Question 73

A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should
the nurse take prior to the initiation of cardioversion?
a. Administer intravenous adenosine.
b. Turn off oxygen therapy.
c. Ensure a tongue blade is available.
d. Position the client on the left side.

Answer 73

B

Question 74

A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily
living. What interventions should the nurse implement to address this clients concerns?
a. Administer oxygen therapy at 2 liters per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask unlicensed assistive personnel to help bathe the client

Answer 74

C

Question 75

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should
the nurse perform prior to defibrillating this client?
a. Make sure the defibrillator is set to the synchronous mode.
b. Administer 1 mg of intravenous epinephrine.
c. Test the equipment by delivering a smaller shock at 100 joules.
d. Ensure that everyone is clear of contact with the client and the bed

Answer 75

D

Question 76

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the
presence of a pacing spike but no QRS complex on the clients electrocardiogram. Which action should the
nurse take next?
a. Administer intravenous diltiazem (Cardizem).
b. Assess vital signs and level of consciousness.
c. Administer sublingual nitroglycerin.
d. Assess capillary refill and temperature.

Answer 76

B

Question 77

A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart
rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next?
a. Pulmonary auscultation
b. Pulse strength and amplitude
c. Level of consciousness
d. Mobility and gait stability

Answer 77

C

Question 78

A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this clients medication administration record to prevent a common complication of this
condition?
a. Sotalol (Betapace)
b. Warfarin (Coumadin)
c. Atropine (Sal-Tropine)
d. Lidocaine (Xylocaine)

Answer 78

B

Question 79

A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility
of a serious complication from this condition?
a. Sinus tachycardia
b. Speech alterations
c. Fatigue
d. Dyspnea with activity

Answer 79

B

Question 80

A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at
greatest risk for atrial fibrillation?
a. A 45-year-old who takes an aspirin daily
b. A 50-year-old who is post coronary artery bypass graft surgery
c. A 78-year-old who had a carotid endarterectomy
d. An 80-year-old with chronic obstructive pulmonary disease

Answer 80

B

Question 81

A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which
activity modification should the nurse suggest to avoid further slowing of the heart rate?
a. Make certain that your bath water is warm.
b. Avoid straining while having a bowel movement. c. Limit your intake of caffeinated drinks to one a day.
d. Avoid strenuous exercise such as running.

Answer 81

B

Question 82

A nurse assesses a clients electrocardiograph tracing and observes that not all QRS complexes are preceded
by a P wave. How should the nurse interpret this observation?
a. The client has hyperkalemia causing irregular QRS complexes.
b. Ventricular tachycardia is overriding the normal atrial rhythm.
c. The clients chest leads are not making sufficient contact with the skin.
d. Ventricular and atrial depolarizations are initiated from different sites.

Answer 82

D