Unit H-Cardiovascular

Question 1

nurse assesses a client who had a myocardial infarction and has a blood pressure of 88/58
mm Hg. Which additional assessment finding would the nurse expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min

Answer 1

ANS: A
When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure
decrease in the vessels. The parasympathetic system responds by lessening the inhibitory
effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This
tachycardia is an early response and is seen even when blood pressure is not critically low. An
increased heart rate and respiratory rate will compensate for the low blood pressure and
maintain oxygen saturation and perfusion. The client may not be able to compensate for long
and decreased oxygenation and cool, clammy skin will occur later.

Question 2

A nurse assesses a client after administering a prescribed beta blocker. Which assessment
would the nurse expect to find?
a. Blood pressure increased from 98/42 to 132/60 mm Hg.
b. Respiratory rate decreased from 25 to 14 breaths/min.
c. Oxygen saturation increased from 88% to 96%.
d. Pulse decreased from 100 to 80 beats/min

Answer 2

ANS: D
Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic
(fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR
and blood pressure, increasing ventricular filling time. It usually does not have effects on
beta2-adrenergic receptor sites. Cardiac output may drop because of decreased HR, but
slowing the rate may allow for better filling and better cardiac output.

Question 3

A nurse assesses clients on a medical-surgical unit. Which client would the nurse identify as
having the greatest risk for cardiovascular disease?
a. An 86-year-old man with a history of asthma.
b. A 32-year-old man with colorectal cancer.
c. A 65-year-old woman with diabetes mellitus.
d. A 53-year-old postmenopausal woman who takes bisphosphonates

Answer 3

ANS: C
Of the options, the client with diabetes has a two- to four-fold increase in risk for death due to
cardiovascular disease. Advancing age also increases risk, but not as much. Asthma,
colorectal cancer, and bisphosphonate therapy do not increase the risk for cardiovascular
disease.

Question 4

A nurse assesses an older adult client who has multiple chronic diseases. The client’s heart
rate is 48 beats/min. What action would the nurse take first?
a. Document the finding in the chart.
b. Initiate external pacing.
c. Assess the client’s medications.
d. Administer 1 mg of atropine.

Answer 4

ANS: C
Pacemaker cells in the conduction system decrease in number as a person ages, potentially
resulting in bradycardia. However, the nurse would first check the medication reconciliation
for medications that might cause such a drop in heart rate, and then would inform the primary
health care provider. Documentation is important, but it is not the first action. The heart rate is
not low enough for atropine or an external pacemaker to be needed unless the client is
symptomatic, which is not apparent

Question 5

An emergency department nurse obtains the health history of a client. Which statement by the
client would alert the nurse to the occurrence of heart failure?
a. “I get short of breath when I climb stairs.”
b. “I see halos floating around my head.”
c. “I have trouble remembering things.”
d. “I have lost weight over the past month.”

Answer 5

ANS: A
Dyspnea on exertion is an early manifestation of heart failure and is associated with an
activity such as stair climbing. The other findings are not specific to early occurrence of heart
failure.

Question 6

A nurse obtains the health history of a client who is newly admitted to the medical unit.
Which statement by the client would alert the nurse to the presence of edema?
a. “I wake up to go to the bathroom at night.”
b. “My shoes fit tighter by the end of the day.”
c. “I seem to be feeling more anxious lately.”
d. “I drink at least eight glasses of water a day.”

Answer 6

ANS: B
Weight gain can result from fluid accumulation in the interstitial spaces. This is known as
edema. The nurse would note whether the client feels that his or her shoes or rings are tight,
and would observe, when present, an indentation around the leg where the socks end. The
other answers do not describe edema.

Question 7

A nurse assesses female client who is experiencing a myocardial infarction. Which clinical
manifestation would the nurse expect?
a. Excruciating pain on inspiration
b. Left lateral chest wall pain
c. Fatigue and shortness of breath
d. Numbness and tingling of the arm

Answer 7

ANS: C
In women, fatigue, shortness of breath, and indigestion may be the major symptoms of
myocardial infarction caused by poor cardiac output. Chest pain is the classic symptom of
myocardial infarction and can be present in women. Pain on inspiration may be related to a
pleuropulmonary cause. Numbness and tingling of the arm could also be related to the
myocardial infarction, but are not known to be specific symptoms for women having and MI.

Question 8

A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The
nurse notes that the left pedal pulse is weak. What action would the nurse take next?
a. Elevate the leg and apply a sandbag to the entrance site.
b. Increase the flow rate of intravenous fluids.
c. Assess the color and temperature of the left leg.
d. Document the finding as “left pedal pulse of +1/4.”

Answer 8

ANS: C
Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial
obstruction. The left pulse would be compared with the right, and pulses would be compared
with previous assessments, especially before the procedure. Assessing color (pale, cyanosis)
and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and
vascular assessment data are acquired, the primary health care provider would be notified.
Simply documenting the findings is inappropriate. The leg would be positioned below the
level of the heart to increase blood flow to the distal portion of the leg. Increasing intravenous
fluids will not address the client’s problem.

Question 9

A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which
assessment finding requires immediate intervention?
a. Urinary output less than intake
b. Bruising at the insertion site
c. Slurred speech and confusion
d. Discomfort in the left leg

Answer 9

ANS: C
A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular
accident. A change in neurologic status needs to be acted on immediately. Discomfort and
bruising are not unexpected at the site. Urinary output less than intake may or may not be
significant.

Question 10

A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment
would the nurse complete as the priority prior to this procedure?
a. Client’s level of anxiety
b. Ability to turn self in bed
c. Cardiac rhythm and heart rate
d. Allergies to iodine-based agents

Answer 10

ANS: D
Before the procedure, the nurse would ascertain whether the client has an allergy to
iodine-containing preparations, such as seafood or local anesthetics. The contrast medium
used during the procedure is iodine based. This allergy can cause a life-threatening reaction,
so it is a high priority. It is important for the nurse to assess anxiety, mobility, and baseline
cardiac status, but allergies take priority for client safety.

Question 11

A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart.
The client’s health history includes a previous myocardial infarction and pacemaker
implantation. What action would the nurse take?
a. Schedule an electrocardiogram just before the MRI.
b. Notify the primary health care provider before scheduling the MRI.
c. Request lab for cardiac enzymes from the primary health care provider.
d. Instruct the client to increase fluid intake the day before the MRI.

Answer 11

ANS: B
The magnetic fields of the MRI can deactivate the pacemaker. The nurse would call the
primary health care provider and report that the client has a pacemaker so that he or she can
order other diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes,
or increased fluids. Some newer MRI scanners have eliminated the possibility of
complications due to implants, but the nurse needs to notify the primary health care provider.

Question 12

A nurse assesses a client who is recovering from a myocardial infarction. The client’s blood
pressure is 140/88 mm Hg. What action would the nurse take first?
a. Compare the results with previous blood pressure readings.
b. Increase the intravenous fluid rate because these readings are low.
c. Immediately notify the primary health care provider of the elevated blood pressure.
d. Document the finding in the client’s chart as the only action.

Answer 12

ANS: A
The most recent range for normal blood pressure is less than 140 mm Hg systolic and less
than 90mm Hg diastolic. This client’s blood pressure is at the upper range of acceptable, so
the nurse would compare the client’s current reading with those previously recorded before
doing anything else. The reading is not low, so the nurse would not increase IV fluids, nor
would the nurse necessarily notify the primary health care provider. Documentation is
important, but the nurse first checks previous readings

Question 13

A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is
scheduled for bypass surgery. Which intervention would the nurse be prepared to implement
while this client waits for surgery?
a. Administration of IV furosemide
b. Initiation of an external pacemaker
c. Assistance with endotracheal intubation
d. Placement of central venous access

Answer 13

ANS: B
The RCA supplies the right atrium, right ventricle, inferior portion of the left ventricle, and
atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the client
totally occludes the RCA, the AV node would not function and the client would go into heart
block, so emergency pacing would be available for the client. Furosemide, intubation, and
central venous access will not address the primary complication of RCA occlusion, which is
AV node (and possibly SA node) malfunction.

Question 14

A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk
for coronary artery disease. Which statement related to nutrition would the nurse include in
this client’s teaching?
a. “The best way to lose weight is a high-protein, low-carbohydrate diet.”
b. “You should balance weight loss with consuming necessary nutrients.”
c. “A nutritionist will provide you with information about your new diet.”
d. “If you exercise more frequently, you won’t need to change your diet.”

Answer 14

ANS:B
Clients at risk for cardiovascular diseases should follow the American Heart Association
guidelines to combat obesity and improve cardiac health. The nurse would encourage the
client to eat vegetables, fruits, unrefined whole-grain products, and fat-free dairy products
while losing weight. High-protein food items are often high in fat and calories. Although the
nutritionist can assist with client education, the nurse would include nutrition education and
assist the client to make healthy decisions. Exercising and eating nutrient-rich foods are both
important components in reducing cardiovascular risk.

Question 15

A nurse cares for a client who has advanced cardiac disease and states, “I am having trouble
breathing while I’m sleeping at night.” What is the nurse’s best response?
a. “I will consult your primary health care provider to prescribe a sleep study.”
b. “You become hypoxic while sleeping; oxygen therapy via nasal cannula will
help.”
c. “A continuous positive airway pressure, or CPAP, breathing mask will help you
breathe at night.”
d. “Use pillows to elevate your head and chest while you are sleeping.”

Answer 15

ANS: D
The client is experiencing orthopnea (shortness of breath while lying flat). The nurse would
teach the client to elevate the head and chest with pillows or sleep in a recliner. A sleep study
is not necessary to diagnose this client. Oxygen and CPAP will not help a client with
orthopnea.

Question 16

A nurse cares for a client who is recovering from a myocardial infarction. The client states, “I
will need to stop eating so much chili to keep that indigestion pain from returning.” What is
the nurse’s best response?
a. “Chili is high in fat and calories; it would be a good idea to stop eating it.”
b. “The primary health care provider has prescribed an antacid every morning.”
c. “What do you understand about what happened to you?”
d. “When did you start experiencing this indigestion?”

Answer 16

ANS: C
Clients who experience myocardial infarction often respond with denial, which is a defense
mechanism. The nurse would ask the client what he or she thinks happened, or what the
illness means to him or her. The other responses do not address the client’s misconception
about recent pain and the cause of that pain.

Question 17

A nurse prepares a client for cardiac catheterization. The client states, “I am afraid I might

die. ” What is the nurse’s best response?
a. “This is a routine test and the risk of death is very low.”
b. “Would you like to speak with a chaplain prior to test?”
c. “Tell me more about your concerns about the test.”
d. “What support systems do you have to assist you?”

Answer 17

ANS: C
The nurse would discuss the client’s feelings and concerns related to the cardiac
catheterization. The nurse would not provide false hope or push the client’s concerns off on
the chaplain. The nurse would address support systems after addressing the client’s current
issue.

Question 18

An emergency department nurse triages clients who present with chest discomfort. Which
client would the nurse plan to assess first?
a. Client who describes pain as a dull ache.
b. Client who reports moderate pain that is worse on inspiration.
c. Client who reports cramping substernal pain.
d. Client who describes intense squeezing pressure across the chest.

Answer 18

ANS: D
All clients who have chest pain would be assessed more thoroughly. To determine which
client would be seen first, the nurse must understand common differences in pain descriptions.
Intense stabbing and viselike (squeezing) substernal pain or pressure that spreads through the
client ’s chest, arms, jaw, back, or neck are indicatives of a myocardial infarction. The nurse
would plan to see this client first to prevent cardiac cell death. A dull ache, pain that gets
worse with inspiration, and cramping pain are not usually associated with myocardial
infarction.

Question 19

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a
cardiac catheterization. What actions would the nurse take prior to the catheterization? (Select
all that apply.)
a. Assess for allergies to iodine.
b. Administer intravenous fluids.
c. Assess blood urea nitrogen (BUN) and creatinine results.
d. Insert a Foley catheter.
e. Administer a prophylactic antibiotic.
f. Insert a central venous catheter

Answer 19

ANS: A, B, C
If the client has kidney disease, fluids may be given 12 to 24 hours before the procedure for
renal protection. Hydration would continue after the procedure. The client would be assessed
for allergies to iodine, including shellfish; the contrast medium used during the catheterization
contains iodine. Baseline renal labs would be assessed. A Foley catheter and central venous
catheter are not required for the procedure and would only increase the client’s risk for
infection. Prophylactic antibiotics are not administered prior to a cardiac catheterization

Question 20

An emergency department nurse assesses a female client. Which assessment findings would
alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.)
a. Hypertension
b. Fatigue despite adequate rest
c. Indigestion
d. Abdominal pain
e. Shortness of breath

Answer 20

ANS: B, C, E
Women may not have chest pain with myocardial infarction, but may feel discomfort or
indigestion. They often present with a triad of symptoms—indigestion or feeling of abdominal
fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their
breath. Frequently, women are not diagnosed and therefore are not treated adequately.
Hypertension and abdominal pain are not associated with acute coronary syndrome

Question 21

A nurse assesses a client who is recovering after a coronary catheterization. Which assessment
findings in the first few hours after the procedure require immediate action by the nurse?
(Select all that apply.)
a. Blood pressure of 140/88 mm Hg
b. Serum potassium of 2.9 mEq/L (2.9 mmol/L)
c. Warmth and redness at the site
d. Expanding groin hematoma
e. Rhythm changes on the cardiac monitor
f. Oxygen saturation 93% on room air

Answer 21

ANS: B, D, E
After a cardiac catheterization, the nurse monitors vital signs, entry site, cardiac function, and
distal circulation. The potassium is very low which can lead to dysrhythmias. An expanding
hematoma signifies bleeding. Rhythm changes on the monitor are a known complication.
These findings would require prompt action. The client’s blood pressure is slightly elevated
but does not need immediate action. Warmth and redness at the site would indicate an
infection, but this would not be present in the first few hours. The oxygen saturation is slightly
low but not critical and there is no baseline to compare it to.

Question 22

A nurse reviews a client’s laboratory results. Which findings would alert the nurse to the
possibility of atherosclerosis? (Select all that apply.)
a. Total cholesterol: 280 mg/dL (7.3 mmol/L)
b. High-density lipoprotein cholesterol: 50 mg/dL (1.3 mmol/L)
c. Triglycerides: 200 mg/dL (2.3 mmol/L)
d. Serum albumin: 4 g/dL (5.8 mcmol/L)
e. Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L)

Answer 22

ANS: A, C, E
A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides,
and low-density lipoprotein cholesterol levels are all high, indicating higher risk for
cardiovascular disease. High-density lipoprotein cholesterol is within the normal range for
both males and females. Serum albumin is not assessed for atherosclerosis.

Question 23

A nurse prepares a client for a pharmacologic stress echocardiogram. What actions would the
nurse take when preparing this client for the procedure? (Select all that apply.)
a. Assist the primary health care provider to place a central venous access device.
b. Prepare for continuous blood pressure and pulse monitoring.
c. Administer the client’s prescribed beta blocker.
d. Give the client nothing by mouth 3 to 6 hours before the procedure.
e. Explain to the client that dobutamine will simulate exercise for this examination.

Answer 23

ANS: B, D, E
Clients receiving a pharmacologic stress echocardiogram will need peripheral venous access
and continuous blood pressure and pulse monitoring. The client must be NPO 3 to 6 hours
prior to the procedure. Education about dobutamine, which will be administered during the
procedure, would be performed. Beta blockers are often held prior to the procedure as they
lower the heart rate and may result in inaccurate results

Question 24

A nurse cares for a client who is recovering from a right-sided heart catheterization. For which
complications of this procedure would the nurse assess? (Select all that apply.)
a. Thrombophlebitis
b. Stroke
c. Pulmonary embolism
d. Myocardial infarction
e. Cardiac tamponade
f. Dysrhythmias

Answer 24

ANS: A, C, E
Complications from a right-sided heart catheterization include thrombophlebitis, pulmonary
embolism, and vagal response. Cardiac tamponade is a risk of both right- and left-sided heart
catheterizations. Stroke, myocardial infarction, and dysrhythmias are complications of
left-sided heart catheterizations.

Question 25

A nurse assesses clients on a cardiac unit. Which client would 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 25

ANS: A
Causes of left ventricular failure include mitral or aortic valve disease, coronary artery
disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk
factors for right ventricular failure. A cerebral vascular accident does not increase the risk of
heart failure.

Question 26

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the
possibility of left-sided heart failure?
a. “I have been drinking more water than usual.”
b. “I am awakened by the need to urinate at night.”
c. “I must stop halfway up the stairs to catch my breath.”
d. “I have experienced blurred vision on several occasions.”

Answer 26

ANS: C
Clients with left-sided heart failure report weakness or fatigue while performing normal
activities of daily living, as well as difficulty breathing, or “catching their breath.” This occurs
as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and
blurred vision are not related to heart failure.

Question 27

A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the
nurse to the possibility of right-sided heart failure?
a. “I sleep with four pillows at night.”
b. “My shoes fit really tight lately.”
c. “I wake up coughing every night.”
d. “I have trouble catching my breath.”

Answer 27

ANS:B
Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure
builds in the venous system, and peripheral edema develops. Left-sided heart failure
symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all
could be results of left-sided heart failure.

Question 28

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

Answer 28

ANS: A
The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left
ventricular pressure and left ventricular failure. The other actions are not warranted.

Question 29

A nurse cares for a client with right-sided heart failure. The client asks, “Why do I need to
weigh myself every day?” How would 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 clients be weighed daily.”
d. “You need to lose weight to decrease the incidence of heart failure.”

Answer 29

ANS: A
Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals
2.2 lb (1 kg). Weight changes are the most reliable indicator of fluid loss or gain. The other
responses do not address the importance of monitoring fluid retention or loss.

Question 30

A nurse is teaching a client with heart failure who has been prescribed enalapril. Which
statement would the nurse include in this client’s teaching?
a. “Avoid using salt substitutes.”
b. “Take your medication with food.”
c. “Avoid using aspirin-containing products.”
d. “Check your pulse daily.”

Answer 30

ANS:A
Angiotensin-converting enzyme (ACE) inhibitors such as enalapril inhibit the excretion of
potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to
limit potassium intake. Salt substitutes are composed of potassium chloride. ACE inhibitors
do not need to be taken with food and have no impact on the client’s pulse rate. Aspirin is
often prescribed in conjunction with ACE inhibitors and is not contraindicated

Question 31

After administering the first dose of captopril to a client with heart failure, the nurse
implements interventions to decrease complications. Which intervention is most important for
the nurse to implement?
a. Provide food to decrease nausea and aid in absorption.
b. Instruct the client to ask for assistance when rising from bed.
c. Collaborate with assistive personnel to bathe the client.
d. Monitor potassium levels and check for symptoms of hypokalemia.

Answer 31

ANS: B
Hypotension is a side effect of ACE inhibitors such as captopril. Clients with a fluid volume
deficit should have their volume replaced or start at a lower dose of the drug to minimize this
effect. The nurse would instruct the client to seek assistance before arising from bed to
prevent injury from postural hypotension. ACE inhibitors do not need to be taken with food.
Collaboration with assistive personnel to provide hygiene is not a priority. The client would
be encouraged to complete activities of daily living as independently as possible. The nurse
would monitor for hyperkalemia, not hypokalemia, especially if the client has renal
insufficiency secondary to heart failure.

Question 32

A nurse assesses a client after administering the first dose of a nitrate. The client reports a

headache. What action would the nurse take?
a. Initiate oxygen therapy.
b. Hold the next dose.
c. Instruct the client to drink water.
d. Administer PRN acetaminophen

Answer 32

ANS: D
The vasodilating effects of nitrates frequently cause clients to have headaches during the
initial period of therapy. The nurse would inform the client about this side effect and offer a
mild analgesic, such as acetaminophen. The client’s headache is not related to hypoxia or
dehydration; therefore, applying oxygen and drinking water would not help. The client needs
to take the medication as prescribed to prevent angina; the medication would not be held.

Question 33

A nurse teaches a client who is prescribed digoxin therapy. Which statement would the nurse
include in this client’s teaching?
a. “Avoid taking aspirin or aspirin-containing products.”
b. “Increase your intake of foods that are high in potassium.”
c. “Hold this medication if your pulse rate is below 80 beats/min.”
d. “Do not take this medication within 1 hour of taking an antacid.”

Answer 33

ANS: D
Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids,
interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart
rate of 80 beats/min is too high for this cutoff. Potassium and aspirin have no impact on
digoxin absorption.

Question 34

A nurse teaches a client who has a history of heart failure. Which statement would the nurse
include in this client’s discharge teaching?
a. “Avoid drinking more than 3 quarts (3 L) of liquids each day.”
b. “Eat six small meals daily instead of three larger meals.”
c. “When you feel short of breath, take an additional diuretic.”
d. “Weigh yourself daily while wearing the same amount of clothing.”

Answer 34

ANS: D
Clients with heart failure are instructed to weigh themselves daily to detect worsening heart
failure early, and thus avoid complications. Other signs of worsening heart failure include
increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload
increases symptoms of heart failure. The client would be taught to eat a heart-healthy diet,
balance intake and output to prevent dehydration and overload, and take medications as
prescribed. The most important discharge teaching is daily weights as this provides the best
data related to fluid retention.

Question 35

A nurse admits a client who is experiencing an exacerbation of heart failure. What action
would the nurse take first?
a. Assess the client’s respiratory status.
b. Draw blood to assess the client’s serum electrolytes.
c. Administer intravenous furosemide.
d. Ask the client about current medications.

Answer 35

ANS: A
Assessment of respiratory and oxygenation status is the most important nursing intervention
for the prevention of complications. Monitoring electrolytes, administering diuretics, and
asking about current medications are important but do not take precedence over assessing
respiratory status.

Question 36

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

Answer 36

ANS: B
Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs
increases. The other signs and symptoms do not relate to the progression of mitral valve
stenosis.

Question 37

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?” What is the best
response by the nurse?
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 37

ANS: B
Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate
easily and initiate the formation of blood clots. The other responses are inaccurate.

Question 38

After teaching a client who is being discharged home after mitral valve replacement surgery,
the nurse assesses the client’s 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 38

ANS: B
Clients who have defective or repaired valves are at high risk for endocarditis. The client who
has had valve surgery should avoid dental procedures for 6 months because of the risk for
endocarditis. When undergoing a mitral valve replacement surgery, the client needs to be
placed on anticoagulant therapy to prevent vegetation forming on the new valve. Clients on
anticoagulant therapy would be instructed on bleeding precautions, including using an electric
razor. If the client is prescribed warfarin, the client should avoid foods high in vitamin K.
Clients recovering from open-heart valve replacements should not carry anything heavy for 6
months while the chest incision and muscle heal

Question 39

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

Answer 39

ANS: A
The client with infective endocarditis does not pose any specific threat of transmitting the
causative organism. Standard Precautions would be used. Bleeding Precautions, reverse
isolation, or Contact Precautions are not necessary.

Question 40

A nurse assesses a client with pericarditis. Which assessment finding would 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 40

ANS: B
The client with pericarditis may present with a pericardial friction rub at the left lower sternal
border. This sound is the result of friction from inflamed pericardial layers when they rub
together. The other assessments are not related.

Question 41

After teaching a client who is recovering from a heart transplant to change positions slowly,
the client asks, “Why is this important?” How would the nurse respond?
a. “Rapid position changes can create shear and friction forces, which can tear out
your internal vascular sutures.”
b. “Your new vascular connections are more sensitive to position changes, leading to
increased intravascular pressure and dizziness.”
c. “Your new heart is not connected to the nervous system and is unable to respond to
decreases in blood pressure caused by position changes.”
d. “While your heart is recovering, blood flow is diverted away from the brain,
increasing the risk for stroke when you stand up

Answer 41

ANS:C
Because the new heart is denervated, the baroreceptor and other mechanisms that compensate
for blood pressure drops caused by position changes do not function. This allows orthostatic
hypotension to persist in the postoperative period. The other options are false statements and
do not correctly address the client’s question.

Question 42

A nurse is providing discharge teaching to a client recovering from a heart transplant. Which
statement would the nurse include?
a. “Use a soft-bristled toothbrush and avoid flossing.”
b. “Avoid large crowds and people who are sick.”
c. “Change positions slowly to avoid hypotension.”
d. “Check your heart rate before taking the medication.”

Answer 42

ANS: B
Clients who have had heart transplants must take immunosuppressant therapy for the rest of
their lives. The nurse would teach this client to avoid crowds and sick people to reduce the
risk of becoming ill him- or herself. These medications do not place clients at risk for
bleeding, orthostatic hypotension, or changes in heart rate. Orthostatic hypotension from the
denervated heart is generally only a problem in the immediate postoperative period.

Question 43

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 don’t want to
become a vegetable.” How would 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 43

ANS: D
The client is verbalizing a real concern or fear about negative outcomes of the surgery. This
anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic
stimulation. The best action is to allow the client to verbalize the concern and work toward a
positive outcome without making the client feel as though the concerns are not valid. The
client needs to feel that he or she has some control over the future. The nurse personally
provides care to address the client’s concerns instead of immediately calling for the chaplain
or psychiatrist. The nurse would not jump to conclusions and suggest taking the client off the
transplant list, which is the best treatment option.

Question 44

A nurse assesses a client who has a history of heart failure. Which question would the nurse
ask to assess the extent of the client’s heart failure?
a. “Do you have trouble breathing or chest pain?”
b. “Are you still able to walk upstairs without fatigue?”
c. “Do you awake with breathlessness during the night?”
d. “Do you have new-onset heaviness in your legs?”

Answer 44

ANS:B
Clients with a history of heart failure generally have negative findings, such as shortness of
breath and fatigue. The nurse needs to determine whether the client’s activity is the same or
worse, or whether the client identifies a decrease in activity level. Trouble breathing, chest
pain, breathlessness at night, and peripheral edema are symptoms of heart failure, but do not
provide data that can determine the extent of the client’s heart failure.

Question 45

A nurse cares for an older adult client with heart failure. The client states, “I don’t know what
to do. I don’t want to be a burden to my daughter, but I can’t do it alone. Maybe I should die.”
What is the best response by the nurse?
a. “I can stay if you would you like to talk more about this.”
b. “You are lucky to have such a devoted daughter.”
c. “It is normal to feel as though you are a burden.”
d. “Would you like to meet with the chaplain?”

Answer 45

ANS: A
Depression can occur in clients with heart failure, especially older adults. Having the client
talk about his or her feelings will help the nurse focus on the actual problem. Open-ended
statements allow the client to respond safely and honestly. The other options minimize the
client’s concerns and do not allow the nurse to obtain more information to provide
client-centered care.

Question 46

A nurse teaches a client with heart failure about energy conservation. Which statement would
the nurse include in this client’s teaching?
a. “Walk until you become short of breath, and then walk back home.”
b. “Begin walking 200 feet a day three times a week.”
c. “Do not lift heavy weights for 6 months.”
d. “Eat plenty of protein to build your strength.”

Answer 46

ANS: B
A client who has heart failure would be taught to conserve energy and given an exercise plan.
The client should begin walking 200-400 feet a day at home three times a week. The client
should not walk until becoming short of breath because he or she may not make it back home.
The lifting restriction is specifically for clients after valve replacements. Protein does help
build strength, but this direction is not specific to heart failure.

Question 47

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 would the
nurse implement?
a. Apply an ice pack to the client’s 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 47

ANS: D
Pain from acute pericarditis may worsen when the client lays supine. The nurse would
position the client in a comfortable position, which usually is upright and leaning slightly
forward. An ice pack and neck rub will not relieve this pain. Dimming the lights will also not
help the pain.

Question 48

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

Answer 48

ANS: B
Atrial fibrillation is a clinical manifestation of mitral valve regurgitation and stenosis.
Preventricular contractions and bradycardia are not associated with valvular problems. These
are usually identified in clients with electrolyte imbalances, myocardial infarction, and sinus
node problems. Sinus tachycardia is a manifestation of aortic regurgitation due to a decrease
in cardiac output.

Question 49

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

Answer 49

ANS: A, B, E
Left-sided heart failure occurs with a decrease in contractility of the heart or an increase in
afterload. Most of the signs will be noted in the respiratory system. These include crackles,
confusion (due to decreased oxygenation), and cough. Right ventricular failure is associated
with pulmonary hypertension, edema, and jugular venous distention.

Question 50

A nurse evaluates laboratory results for a client with heart failure. Which results would the
nurse expect? (Select all that apply.)
a. Hematocrit: 32.8%
b. Serum sodium: 130 mEq/L (130 mmol/L)
c. Serum potassium: 4.0 mEq/L (4.0 mmol/L)
d. Serum creatinine: 1.0 mg/dL (88.4 mcmol/L)
e. Proteinuria
f. Microalbuminuria

Answer 50

ANS: A, B, E, F
A hematocrit of 32.8% is low (should be 42.6%), indicating a dilutional ratio of red blood
cells to fluid. A serum sodium of 130 mEq/L (130 mmol/L) is low because of hemodilution.
Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. These
are early warning signs of decreased compliance of the heart. The potassium level is normal
and the serum creatinine level is normal.

Question 51

A nurse assesses clients on a cardiac unit. Which clients would 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 51

ANS: A, B, D
Acute pericarditis is most commonly associated with acute exacerbations of systemic
connective tissue disease, including SLE; with Dressler syndrome, or inflammation of the
cardiac sac after cardiac surgery or a myocardial infarction; and with infective organisms,
including bacterial, viral, and fungal infections. Abdominal and reproductive surgeries and
pressure injuries do not increase clients’ risk for acute pericarditis

Question 52

After teaching a client with congestive heart failure (CHF), the nurse assesses the client’s
understanding. Which client statements indicate a correct understanding of the teaching
related to nutritional intake? (Select all that apply.)
a. “I’ll read the nutritional labels on food items for salt content.”
b. “I will drink at least 3 L of water each day.”
c. “Using salt in moderation will reduce the workload of my heart.”
d. “I will eat oatmeal for breakfast instead of ham and eggs.”
e. “Substituting fresh vegetables for canned ones will lower my salt intake.”
f. “Salt substitutes are a good way to cut down on sodium in my diet.”

Answer 52

ANS:A,D,E
Nutritional therapy for a client with CHF is focused on decreasing sodium and water retention
to decrease the workload of the heart. The client would be taught to read nutritional labels on
all food items, omit table salt and foods high in sodium (e.g., ham and canned foods), and
limit water intake to a normal 2 L/day. Salt substitutes typically contain potassium, so
although they are not strictly banned, clients would have to have their renal function and
serum potassium monitored while using them. It would be safer to avoid them.

Question 53

A nurse collaborates with assistive personnel (AP) to provide care for a client with congestive
heart failure. Which instructions would the nurse provide to the AP 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 53

ANS: A, C, D
The AP should reposition the client every 2 hours to improve oxygenation and prevent
atelectasis. The AP can also accurately record intake and output, and use the same scale to
weigh the client each morning before breakfast. APs are not qualified to teach clients or assess
the need for and provide oxygen therapy.

Question 54

A nurse prepares to discharge a client who has heart failure. Based on national quality
measures, what actions would the nurse complete prior to discharging this client? (Select all
that apply.)
a. Teach the client about energy conservation techniques.
b. Ensure that the client is prescribed a beta blocker.
c. Document a discussion about advanced directives.
d. Confirm that a postdischarge nurse visit has been scheduled.
e. Consult a social worker for additional resources.
f. Care transition record transmitted to next level of care within 7 days of discharge.
ANS:

Answer 54

ANS:B, C, D, F
National quality measures aim to decrease heart failure readmission by proper preparation for
discharge. These measures include :(1) beta blocker prescribed for left ventricular dysfunction
at discharge, (2) postdischarge follow-up appointment scheduled within 7 days of discharge
with documentation of location, date, and time. (3) care transition record transmitted to next
level of care within 7 days of discharge. (4) documentation of discussion of advance
directives/advance care planning with a health care provider, (5) documentation of execution
of advance directives within the medical record, and (6) postdischarge evaluation of patient
for symptom assessment and treatment adherence within 72 hours of discharge (this can occur
by phone, scheduled office visit, or home visit)

Question 55

A nurse prepares to discharge a client who has heart failure. Which questions would the nurse
ask to ensure this client’s 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 55

ANS: A, B, D
To ensure safety upon discharge, the nurse would assess for structural barriers to functional
ability, such as stairs. The nurse would also assess the client’s available social support, which
may include family, friends, and home health services. The client’s beliefs about and ability to
adhere to medication and treatments, including daily weights, would also be reviewed. The
other questions do not specifically address the client’s safety upon discharge

Question 56

A nurse assesses a client who is recovering from a heart transplant. Which assessment
findings would 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
f. Fatigue

Answer 56

ANS: A, B, C, F
Clinical findings of heart transplant rejection include shortness of breath, fatigue, fluid gain,
abdominal bloating, new-onset bradycardia, hypotension, atrial fibrillation or flutter,
decreased activity tolerance, and decreased ejection fraction

Question 57

A nurse is caring for a client who was admitted with hypertrophic cardiomyopathy (HCM).
What interprofessional care does the nurse anticipate providing? (Select all that apply.)
a. Administering beta blockers
b. Administering high-dose furosemide
c. Preparing for a cardiac catheterization
d. Loading the client on digitalis
e. Instructing the client to avoid strenuous exercise
f. Teaching the client how to use the CardioMEMS™

Answer 57

ANS:A,C,E
Management of obstructive HCM includes administering negative inotropic agents such as
beta-adrenergic blocking agents (carvedilol) and calcium antagonists (verapamil).
Vasodilators, diuretics, nitrates, and cardiac glycosides are contraindicated in patients with
obstructive HCM. Strenuous exercise is also prohibited. Echocardiography, radionuclide
imaging, and angiocardiography during cardiac catheterization are performed to diagnose and
differentiate cardiomyopathies. The CardioMEMS™ device is used with clients who have
heart failure

Question 58

A nurse is assessing the peripheral vascular system of an older adult. What action by the nurse
would cause the supervising nurse to intervene?
a. Assessing blood pressure in both upper extremities
b. Auscultating the carotid arteries for any bruits
c. Classifying capillary filling of 4 seconds as normal
d. Palpating both carotid arteries at the same time

Answer 58

ANS: D
The nurse would not compress both carotid arteries at the same time to avoid brain ischemia.
Blood pressure would be taken and compared in both arms. Prolonged capillary filling is
considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as
normal would not require intervention. Bruits would be auscultated.

Question 59

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel.
What meal selection indicates that the client is managing this condition well with diet?
a. A 4-ounce steak, French fries, iceberg lettuce
b. Baked chicken breast, broccoli, tomatoes
c. Fried catfish, cornbread, peas
d. Spaghetti with meat sauce, garlic bread

Answer 59

ANS: B
The diet recommended for this client would be low in saturated fats and red meat, high in
vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is the
chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg
lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no
vegetables.

Question 60

A nurse is working with a client who takes clopidogrel. The client’s recent laboratory results
include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action
by the nurse is best?
a. Ask if the client eats grapefruit.
b. Assess the client for dehydration.
c. Facilitate admission to the hospital.
d. Obtain a random urinalysis.

Answer 60

ANS:A
There is a drug–food interaction between clopidogrel and grapefruit that can lead to acute
kidney failure. This client has elevated renal laboratory results, indicating some degree of
kidney involvement. The nurse would assess if the client eats grapefruit or drinks grapefruit
juice. Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more
specific for a kidney injury. The client does not necessarily need to be admitted. A urinalysis
may or may not be ordered.

Question 61

A client has been diagnosed with hypertension but does not take the antihypertensive
medications because of a lack of symptoms. What response by the nurse is best?
a. “Do you have trouble affording your medications?”
b. “Most people with hypertension do not have symptoms.”
c. “You are lucky; most people get severe morning headaches.”
d. “You need to take your medicine or you will get kidney failure.”

Answer 61

ANS: B
Most people with hypertension are asymptomatic, although a small percentage do have
symptoms such as headache. The nurse would explain this to the client. Asking about paying
for medications utilizes closed-ended questioning and is not therapeutic. Threatening the
client with possible complications will not increase compliance.

Question 62

A client asks what “essential hypertension” is. What response by the registered nurse is best?

a. “It means it is caused by another disease.”
b. “It means it is ‘essential’ that it be treated.”
c. “It is hypertension with no specific cause.”
d. “It refers to severe and life-threatening hypertension.”

Answer 62

ANS: C
Essential hypertension is the most common type of hypertension and has no specific cause
such as an underlying disease process. Hypertension that is due to another disease process is
called secondary hypertension. A severe, life-threatening form of hypertension is malignant
hypertension.

Question 63

A nurse is interested in providing community education and screening on hypertension. In
order to reach a priority population, to what target audience would the nurse provide this
service?
a. African-American churches
b. Asian-American groceries
c. High school sports camps
d. Women’s health clinics

Answer 63

ANS: A
African Americans in the United States have one of the highest rates of hypertension in the
world. The nurse has the potential to reach this priority population by providing services at
African-American churches. Although hypertension education and screening are important for
all groups, African Americans are the priority population for this intervention

Question 64

A client has hypertension and high risk factors for cardiovascular disease. The client is
overwhelmed with the recommended lifestyle changes. What action by the nurse is best?
a. Assess the client’s support system.
b. Assist in finding one change the client can control.
c. Determine what stressors the client faces in daily life.
d. Inquire about delegating some of the client’s obligations.

Answer 64

ANS: B
All options are appropriate when assessing stress and responses to stress. However, this client
feels overwhelmed by the suggested lifestyle changes. Instead of looking at all the needed
changes, the nurse would assist the client in choosing one the client feels optimistic about
controlling. Once the client has mastered that change, he or she can move forward with
another change. Determining support systems, daily stressors, and delegation opportunities
does not directly impact the client’s feelings of control.

Question 65

The nurse is caring for four hypertensive clients. Which drug–laboratory value combination
would the nurse report immediately to the health care provider?
a. Furosemide/potassium: 2.1 mEq/L
b. Hydrochlorothiazide/potassium: 4.2 mEq/L
c. Spironolactone/potassium: 5.1 mEq/L
d. Torsemide/sodium: 142 mEq/L

Answer 65

ANS: A
Furosemide is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is
quite low and would be reported immediately. Spironolactone is a potassium-sparing diuretic
that can cause hyperkalemia. A potassium level of 5.1 mEq/L is on the high side, but it is not
as critical as the low potassium with furosemide. The other two laboratory values are normal

Question 66

A nurse is assessing a client with peripheral artery disease (PAD). The client states that
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 66

ANS: A
As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on
activity to be pain free indicates that the client’s disease is worsening. The other questions are
useful, but not as important.

Question 67

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. “I’m glad I get energy assistance so my house isn’t 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 67

ANS: D
Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and
cut straight across. The client whose hands shake may cause injury when trimming toenails.
The nurse would refer this client to a podiatrist. Comfy sweatpants and house shoes are
generally loose and not restrictive, which is important for clients with PVD. Keeping the
house at a comfortable temperature makes it less likely the client will use alternative heat
sources, such as heating pads, to stay warm. The client should keep the feet moist and soft
with lotion.

Question 68

A client is taking warfarin and asks the nurse if taking St. John’s wort is acceptable. What
response by the nurse is best?
a. “No, it may interfere with the warfarin.”
b. “There isn’t any information about that.”
c. “Why would you want to take that?”
d. “Yes, it is a good supplement for you.”

Answer 68

ANS: A
Many foods and drugs interfere with warfarin, St. John’s wort being one of them. The nurse
would advise the client against taking it. The other answers are not accurate.

Question 69

A nurse is teaching a female client about alcohol intake and how it affects hypertension. The
client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is
best?
a. “No, women should only have one beer a day as a general rule.”
b. “No, you should not drink any alcohol with hypertension.”
c. “Yes, since you are larger, you can have more alcohol.”
d. “Yes, two beers per day is an acceptable amount of alcohol.”

Answer 69

ANS: A
Alcohol intake should be limited to two drinks a day for men and one drink a day for women.
A “drink” is classified as one beer, 1.5 ounces of hard liquor, or 5 ounces of wine. Limited
alcohol intake is acceptable with hypertension. The woman’s size does not matter.

Question 70

A nurse is caring for four clients. Which one would the nurse see first?

a. Client who needs a beta blocker, and has a blood pressure of 98/58 mm Hg.
b. Client who had a first dose of captopril and needs to use the bathroom.
c. Hypertensive client with a blood pressure of 188/92 mm Hg.
d. Client who needs pain medication prior to a dressing change of a surgical wound

Answer 70

ANS: B
Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially
after the first dose. The nurse would see this client first to prevent falling if the client decides
to get up without assistance. The two blood pressure readings are abnormal but not critical.
The nurse would check on the client with higher blood pressure next to assess for problems
related to the reading. The nurse can administer the beta blocker as standards state to hold it if
the systolic blood pressure is below 90 to 100 mm Hg. The client who needs pain medication
prior to the dressing change is not a priority over client safety and assisting the other client to
the bathroom.

Question 71

A client had a percutaneous angioplasty for renovascular hypertension 3 months ago. What
assessment finding by the nurse indicates that an important outcome for this client has been
met?
a. Client is able to decrease blood pressure medications.
b. Insertion site has healed without redness or tenderness.
c. Most recent lab data show BUN: 19 mg/dL and creatinine 1.1 mg/dL.
d. Verbalizes understanding of postprocedure lifestyle changes.

Answer 71

ANS: A
Hypertension can be caused by renovascular disease. Opening up a constricted renal artery
can lead to decreased blood pressure, manifested by the need for less blood pressure
medication. The other findings are normal and desired, but not specifically related to
hypertension caused by renal disease

Question 72

A client is 4 hours postoperative after a femoral-popliteal bypass. The client reports throbbing
leg pain on the affected side, rated as 7/10. What action by the nurse is most important?
a. Administer pain medication as ordered.
b. Assess distal pulses and skin color.
c. Document the findings in the client’s chart.
d. Notify the surgeon immediately.

Answer 72

ANS: B
Once perfusion has been restored or improved to an extremity, clients can often feel a
throbbing pain due to the increased blood flow. However, it is important to differentiate this
pain from ischemia. The nurse would assess for other signs of perfusion, such as distal pulses
and skin color/temperature. Administering pain medication is done once the nurse determines
that the client’s perfusion status is normal. Documentation needs to be thorough. Notifying the
surgeon is not necessary.

Question 73

A client had a femoral-popliteal bypass graft with a synthetic graft. What action by the nurse
is most important to prevent wound infection?
a. Appropriate hand hygiene before giving care
b. Assessing the client’s temperature every 4 hours
c. Clean technique when changing dressings
d. Monitoring the client’s daily white blood cell count

Answer 73

ANS: A
Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes
would be done with sterile technique. Assessing vital signs and white blood cell count will not
prevent infection.

Question 74

A client is receiving an infusion of alteplase for an intra-arterial clot. The client begins to
mumble and is disoriented. What action by the nurse is most important?
a. Assess the client’s neurologic status.
b. Notify the Rapid Response Team.
c. Prepare to administer vitamin K.
d. Turn down the infusion rate.

Answer 74

ANS: B
Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of neurologic
signs may indicate that the client is having a hemorrhagic stroke. The nurse does need to
complete a thorough neurologic examination, but would first call the Rapid Response Team
based on the client’s manifestations. Vitamin K is not the antidote for this drug. Turning down
the infusion rate will not be helpful if the client is still receiving any of the drug.

Question 75

A new nurse is caring for a client with an abdominal aneurysm. What action by the new nurse
requires the nurse’s mentor 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 75

ANS: D
Abdominal aneurysms should never be palpated as this increases the risk of rupture. The nurse
mentoring the new nurse would intervene when the new nurse attempts to do this. The other
actions are appropriate.

Question 76

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment
indicates that an important 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 76

ANS: B
A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates
that this has not occurred. The other assessments are also positive, but not as important.

Question 77

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

Answer 77

ANS: B
Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure.
Massaging the client’s legs is contraindicated to prevent complications such as pulmonary
embolism. Ice packs are not recommended for DVT.

Question 78

A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein
thrombosis. The client has lost 20 lb (9.09 Kg) since the last visit. What action by the nurse is
best?
a. Ask if the weight loss was intended.
b. Encourage a high-protein, high-fiber diet.
c. Measure for new compression stockings.
d. Review a 3-day food recall diary.

Answer 78

ANS: C
Compression stockings must fit correctly in order to work. After losing a significant amount
of weight, the client would be remeasured and new stockings ordered if needed. The other
options are appropriate, but not the most important

Question 79

A nurse wants to provide community service that helps meet the goals of Healthy People 2020
(HP2020) related to cardiovascular disease and stroke. What activity would best meet this
goal?
a. Teach high school students heart-healthy living.
b. Participate in blood pressure screenings at the mall.
c. Provide pamphlets on heart disease at the grocery store.
d. Set up an “Ask the nurse” booth at the pet store

Answer 79

ANS: B
An important goal of HP2020 is to increase the proportion of adults who have had their blood
pressure measured within the preceding 2 years and can state whether their blood pressure
was normal or high. Participating in blood pressure screening in a public spot will best help
meet that goal. The other options are all appropriate but do not specifically help meet a goal.

Question 80

A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin.
The client is adamant about refusing the drug because “it’s dangerous.” What action by the
nurse is best?
a. Assess the reason behind the client’s fear.
b. Remind the client about laboratory monitoring.
c. Tell the client that drugs are safer today than before.
d. Warn the client about consequences of noncompliance.

Answer 80

ANS: A
The first step is to assess the reason behind the client’s fear, which may be related to the
experience of someone the client knows who took warfarin or misinformation. If the nurse
cannot address the specific rationale, teaching will likely be unsuccessful. Laboratory
monitoring once every few weeks may not make the client perceive the drug to be safe.
General statements like “drugs are safer today” do not address the root cause of the problem.
Warning the client about possible consequences of not taking the drug is not therapeutic and is
likely to lead to an adversarial relationship.

Question 81

A client with a history of heart failure and hypertension is in the clinic for a follow-up visit.
The client is on lisinopril and warfarin. The client reports new-onset cough. What action by
the nurse is most appropriate?
a. Assess the client’s lung sounds and oxygenation.
b. Instruct the client on another antihypertensive.
c. Obtain a set of vital signs and document them.
d. Remind the client that cough is a side effect of lisinopril.

Answer 81

ANS: A
This client could be having an exacerbation of heart failure or experiencing a side effect of
lisinopril (and other angiotensin-converting enzyme inhibitors). The nurse would assess the
client’s lung sounds and other signs of oxygenation first. The client may or may not need to
switch antihypertensive medications. Vital signs and documentation are important, but the
nurse would assess the respiratory system first. If the cough turns out to be a side effect,
reminding the client is appropriate, but then more action needs to be taken.

Question 82

A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the
nurse is best?
a. Consult with the wound care nurse.
b. Give pain medication prior to dressing changes.
c. Maintain sterile technique for dressing changes.
d. Prepare the client for eventual amputation

Answer 82

ANS: A
A nonhealing wound needs the expertise of the wound care nurse. Premedicating prior to
painful procedures and maintaining sterile technique are helpful, but if the wound is not
healing, more needs to be done. The client may need an amputation, but other options need to
be tried first.

Question 83

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 it’s 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. “It’s going to be really hard but I will stop smoking.”

Answer 83

ANS: A
Clients with PAD should never use heating pads as skin sensitivity is diminished and burns
can result. The other statements show good understanding of self-management.

Question 84

What nonpharmacologic comfort measures would the nurse include in the plan of care for a
client with severe varicose veins? (Select all that apply.)
a. Administering mild analgesics for pain
b. Applying elastic compression stockings
c. Elevating the legs when sitting or lying
d. Reminding the client to do leg exercises
e. Teaching the client about surgical options
f. Encouraging participation in high impact aerobic activity

Answer 84

ANS: B,C,D
The three Es of care for varicose veins include elastic compression hose, exercise, and
elevation. Mild analgesics are not a nonpharmacologic measure. Teaching about surgical
options is not a comfort measure. High impact aerobics is not encouraged and is not a comfort
measure

Question 85

A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the
nurse delegate to the assistive personnel (AP)? (Select all that apply.)
a. Administering preoperative medication
b. Ensuring that the consent is signed
c. Marking pulses with a pen
d. Raising the side rails on the bed
e. Recording baseline vital signs

Answer 85

ANS: D, E
The AP can raise the side rails of the bed for client safety and take and record the vital signs.
Administering medications, ensuring that a consent is on the chart, and marking the pulses for
later comparison would be done by the registered nurse. This is also often done by the
postanesthesia care nurse and is part of the hand-off report.

Question 86

A client has been bedridden for several days after major abdominal surgery. What action does
the nurse delegate to the assistive personnel (AP) 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 86

ANS: A, B, D
The AP can apply compression stockings, assist with ambulation, and offer fluids frequently
to help prevent DVT. The AP can also encourage the client to do pulmonary exercises, but
these do not decrease the risk of DVT. Teaching is a nursing function

Question 87

A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include
in the client’s 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 87

ANS: A, B, D
Assessing for bleeding, monitoring aPTT, and using an IV pump for the infusion are all
important safety measures for heparin to prevent injury from bleeding. The aPTT needs to be
1.5 to 2.5 times normal in order to demonstrate that the heparin is therapeutic. Weighing the
client is not related

Question 88

A client is being discharged on warfarin therapy. What discharge instruction is the nurse
required to provide? (Select all that apply.)
a. Dietary restrictions
b. Driving restrictions
c. Follow-up laboratory monitoring
d. Possible drug–drug interactions
e. Reason to take medication
f. Wearing a Medic Alert bracelet

Answer 88

ANS: A, C, D, E
Best practices state that clients being discharged on warfarin need instruction on follow-up
monitoring, dietary restrictions, drug–drug interactions, using a Medic Alert bracelet or
necklace, and reason for compliance. Driving is typically not restricted.

Question 89

Which statements by the client indicate good understanding of foot care in peripheral vascular
disease? (Select all that apply.)
a. “A good abrasive pumice stone will keep my feet soft.”
b. “I’ll always wear shoes if I can buy cheap flip-flops.”
c. “I will keep my feet dry, especially between the toes.”
d. “Lotion is important to keep my feet smooth and soft.”
e. “Washing my feet in room-temperature water is best.”
f. “I will inspect my feet daily.”

Answer 89

ANS: C, D, E
Good foot care includes appropriate hygiene and injury prevention. Keeping the feet dry;
wearing good, comfortable shoes; using lotion; washing the feet in room-temperature water;
cutting the nails straight across; and inspecting the feet daily are all important measures.
Abrasive material such as pumice stones would not be used. Cheap flip-flops may not fit well
and won’t offer much protection against injury.

Question 90

A nurse is caring for a client with a nonhealing arterial ulcer. The primary health care provider
has informed the client about possibly needing to amputate the client’s leg. The client is
crying and upset. What actions by the nurse are best? (Select all that apply.)
a. Ask the client to describe his or her current emotions.
b. Assess the client for support systems and family.
c. Offer to stay with the client if he or she desires.
d. Relate how smoking contributed to this situation.
e. Tell the client that many people have amputations.
f. Arrange for an amputee to come visit the client.

Answer 90

ANS: A, B, C
When a client is upset, the nurse would offer self by remaining with the client if desired.
Other helpful measures include determining what and whom the client has for support systems
and asking the client to describe what he or she is feeling. Telling the client how smoking has
led to this situation will only upset the client further and will damage the therapeutic
relationship. Telling the client that many people have amputations belittles the client’s
feelings. It is too early to send an amputee to visit the client as the decision to amputate has
not yet been made.

Question 91

The nurse working in the emergency department knows that which factors are commonly
related to aneurysm formation? (Select all that apply.)
a. Atherosclerosis
b. Down syndrome
c. Frequent heartburn
d. History of hypertension
e. History of smoking
f. Hyperlipidemia

Answer 91

ANS: A, D, E, F
Atherosclerosis, hypertension, hyperlipidemia, hyperlipidemia, and smoking are the most
commonly related factors. Down syndrome and heartburn have no relation to aneurysm
formation.

Question 92

A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal
pain. The nurse assesses the client’s blood pressure at 82/40 mm Hg. What actions by the
nurse are most important? (Select all that apply.)
a. Administer pain medication.
b. Assess distal pulses every 10 minutes.
c. Have the client sign a surgical consent.
d. Notify the Rapid Response Team.
e. Take vital signs every 10 minutes.

Answer 92

ANS: B, D, E
This client may have a ruptured/rupturing aneurysm. The nurse would notify the Rapid
Response team and perform frequent client assessments. Giving pain medication will lower
the client’s blood pressure even further. The nurse cannot have the client sign a consent until
the surgeon has explained the procedure.

Question 93

A client presents to the emergency department with a thoracic aortic aneurysm. Which
findings are most consistent with this condition? (Select all that apply.)
a. Abdominal tenderness
b. Difficulty swallowing
c. Changes in bowel habits
d. Shortness of breath
e. Hoarseness

Answer 93

ANS: B, E
Signs of a thoracic aortic aneurysm include shortness of breath, hoarseness, and difficulty
swallowing. Pain is often rated as a 10 on a 10-point scale. Bowel habits are not related

Question 94

The nurse is reviewing risk factors in a client who has atherosclerosis. Which findings are
most concerning? (Select all that apply.)
a. Elevated low-density lipoprotein (LDL-C)
b. Decreased levels of high-density lipoprotein cholesterol (HDL-C)
c. Asian ethnicity
d. History of smoking
e. Blood pressure: 142/92 mm Hg on one occasion

Answer 94

ANS: A, B, D
Elevated levels of lipids (fats) such as low-density lipoprotein cholesterol (LDL-C) and
decreased levels of high-density lipoprotein cholesterol can cause chemical damage to blood
vessel walls. Smoking can cause endothelial damage in addition to increasing a client’s
carbon monoxide levels. African American and Hispanic ethnicities carry an increased risk for
atherosclerosis. Hypertension does increase atherosclerosis risk, but an elevated reading on
one occasion is not classified as hypertension.